Medical ForumWA 0618 Public Edn

Beginnings & Endings Oil on Preterms End-of-Life Choices Diabetes; Dengue; Hernias; Hep C

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June 2018

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2258.6 03/18 (0811)

EDITORIAL Dr Rob McEvoy, Medical Editor

‘In-fill’ health leads to personalised medicine A wandering mind and seeing the wood for the trees is the journalist’s lot. A residents’ association meeting sparked this one!

Let’s face it. It is hard to stay across all the health effects of these social changes, mainly because there are so many. It was interesting to hear the Health Minister Roger Cook say at the last Doctors Drum that his colleagues in parliament repeatedly put forward brilliant policy for their portfolios but policy that will create more ill health in the community.

With urban sprawl predicted to outstrip available land in Perth, the “in-fill” town planners are on the loose. This means the death of the four-by-two as the oldies sell to developers and move to a more tightly built retirement village and then onto a nursing home (euphemistically called a ‘residential aged care facility’).

He definitely thinks a “public health approach” is required but here’s the rub – he cannot ignore people who have ill health today, even though he believes that underlying causes need attention, if the community is to move forward.

The RACFs are short of beds in WA and they are pretty full already with elderly demented patients.

So where does this leave the younger family with elderly parents? While the elderly parents are well, all is good. They perform their baby sitting duties on cue, and look after the grandchildren. But if one of them gets sick or has a fall, they can no longer serve any useful function in the paddy fields of life, which means they become a drain on the ‘system’.

With both younger parents often working these days, the job of looking after the infirmed elderly may fall to Medicare and all its attenders.

Hang on to your local park or greenbelt as “in-fill” progresses.

You may no longer see the grandchildren playing with the oldies there (those who are fit enough, that is), or the oldies taking their dog for a walk.

The suburban sprawl is already happening. You have all seen the suburbs – devoid of trees; closed communities without walkways; squeezy single storey developments (because two storey is less profitable) – offering affordable housing for younger families but at what price?

With the Perth population set to outstrip available land along the coast, the rezoning of medium-to-high density and the appearance of accommodation like apartment blocks will mean that ‘down-sizing’ by older citizens will occur. Here’s hoping they stay well too!

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

MEDICAL FORUM

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

And doing the financial report (P25) you have to ask whether the profession is part of the problem or part of the solution.

Where the money is, the doctors will follow.

Federal and state politicians know this story all too well. When it comes to GPs and Medicare, both the carrot and the stick are used. If our efforts are consumed by chasing compensation for whatever each of us does to help people – be that community medicine, procedural work, specialist care, or research – then the hungry beast of customer care may get in the road of seeing the big picture. This is where system thinkers with a soul are needed!

Looking at the editing of Clinical Updates that Dr Joe Kosterich and I have done, you have to marvel at the rapid pace of developments and how things are becoming more specific.

The DG of Health Dr David Russell-Weisz (Russ) feels we are heading towards more personalised medicine where diseases and treatments are predicted and mapped out in our DNA or some other test.

The two big questions are: 1. Can we do this more cost-effectively and with the current resources we have at present?

2. Is this good for the art of medicine as a ‘calling’?

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

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

JUNE 2018 | 1

CONTENTS JUNE 2018

INSIDE 10 14 16 22

Close-Up: Dr Tobias Strunk Heart-Stopping: Dr Corinne Jones Type 1 Diabetes Family Centre End-of-Life Choices

16

22

NEWS & VIEWS 1 Editorial: In-fill’ Health & Personalised Medicine Dr Rob McEvoy 4 Letters to the Editor

14

10 MAJOR PARTNER 2 | JUNE 2018

8 9 13 19 20 22 25

Bulk-Billing: Counting the Cost - Dr Rohan Gay BB a Disgrace - Dr Colin Hughes Consumers, Mesh & Consent - Ms Pip Brennan STI Red Alert - Dr Paul Armstrong Calling GPs for Study - Ms Kristen Seaman Have you Heard?

Beneath the Drapes Invest in Health, Not Illness Single Touch Payroll Tax Tips End-of-life Inquiry Digs Deep Watch the Pennies, or Lash Out?

LIFESTYLE 41 Wine Review: House of Cards - Dr Craig Drummond MW 42 Funny Side 42 Wine Winner: Dr Theresa John 43 Opera: Carmen 44 Competitions 45 Music: David Helfgott & Rhodri Clarke

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MEDICAL FORUM

CONTENTS JUNE 2018 CLINICALS

5 Navigating Cervical Screening Test Dr Bridget Cooke

27 Testing Blood Sugars in DM2 Dr Timothy Welborn

31

32

Managing Chronic Kidney Disease Dr Wai Lim

Dengue Vaccine Disappointment?

Dr Astrid Arellano

29 Hiatus Hernia Surgery Dr Krishna Epari

33 Heart Failure in 2018 Dr Andrew Klimaitis

37 Ketoacidosis in T2 DM Dr Paul Grolman

GUEST COLUMNS

7 Let’s Get Together Dr Andy Carr

21 Healthy Finances When You’re Not Nada Maticevic

23 Case for Voluntary Assisted Dying Dr Peter Beahan

30 Hepatitis C Update Dr Wendy Cheng

35 Ten Diverticulitis Misconceptions Dr Nigel Barwood

39 Allergens in Natural Supplements Dr Meilyn Hew

40 Balint Groups – What are They?

Judy Griffiths

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

MEDICAL FORUM

JUNE 2018 | 3

LETTERS TO THE EDITOR Bulk-billing counting the cost

It has been thus for decades yet the focus of Medicare is forever on compliance to an increasingly ludicrous schedule. Never has the annual “interpretation of the schedule” roadshow sought grassroots feedback.

As the subject of review myself, it was made clear that no feedback would be taken, only a determination made of my compliance (what makes for “normal” rates of spirometry makes for very interesting reading indeed) and an implicit warning to maintain the status quo.

Dear Editor, I was sitting on a panel discussing the future of medicine recently when the bulkbilling rate having reached 85% was raised again. The implication being that the high rate signalled contentment in the profession.

It occurred to me how irrelevant the bulk-billing rate was as a measure of not only contentment but of the quality and effectiveness of health care provision. It reminded me of the US fixation on the body count as a supposed measure of military success during the Vietnamese war that was ultimately lost at the cost up to three million Vietnamese lives.

GPs are often blamed for the high bulkbilling rate, however, unlike specialists, we have no outpatients for those who cannot afford our private fees. We also tend to be more emotionally invested in the lives and socio-economic circumstances of our patients than other branches of medicine, a force for cost containment not appreciated by the policy makers.

Many of us do our best to keep our patients out of the emergency department, however, on the meagre MBS offerings, and where mere sustainable practice is at stake, don’t expect automatic value for money. Most of us are forced to provide the least for our “standard” level B, an item that values 10 to 19 minutes as no more valuable than 0-9 minutes.

We do not have national standardised primary care data collection on smoking, alcohol, obesity, or physical exercise yet we have detailed statistics on bulk billing.

We use these statistics to catch outliers without ever questioning the legitimacy of the norms with which we are all compared in regards to quality or effectiveness.

We need to ditch bulk-billing; not so much as a practice but as a measure of medical funding and quality medical care provision.

GPs have realised that $38 is about what a five-minute consultation is worth. They know they are not practising the medicine they were taught and what I am teaching to second year medical students.

Maybe they can justify it to themselves that it’s OK to ask a patient to come back for a second visit when they dare to ask for a second item such as referral? Or is it more sinister when Overseas Trained Doctors have asked me whether they have to sign a contract that commits them to six-minute consultations of 10 per hour?

Dr Colin Hughes, Greenmount

Dr Rohan Gay, GP, Bayswater

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Consumers, mesh & consent

BB a disgrace

Dear Editor,

Dear Editor, I have asked but not received an answer to the questions: Is the 85% bulk billing rate for services or visits to GPs? Is the government double dipping by counting the Medicare incentive for pensioners as two items instead of one visit?

Anecdotally GPs in WA, especially in rural WA, are charging a gap fee of between $30 and $50 including for children in 45% of all consultations.

The issue is not just the Medicare rebate but rather the relative value of a 15-minute consultation with a specialist at a common fee of $300 or the bulk-billed GP of a mere $38.

Until we address the issue of productivity and rewarding longer consultations, clinics will continue to offer a one issue, one consultation type of practice instead of holistic care. How is it that a normal GP consultation in Norway is 25 minutes yet a GP visit in Australia is barely six minutes?

The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts.

Re: TV Mesh Update (Letters, May, 2018) It seems no one is very happy. Dr Jessica Yin noted a “seismic shift” in the field of urology and gynaecology, while women impacted by the permanent, life-altering consequences of mesh implants were disappointed that the inquiry did not call for a ban on the use of mesh.

They take little comfort from the wording of the inquiry’s Recommendation 7 noting that mesh should be used “as a last resort” as there is little transparency for consumers as to how this will be monitored and implemented. The sad reality for women in the WA Pelvic Mesh Support Group is they know that despite their best efforts, mesh will continue to be used, and women will continue to be poorly consented to its insertion.

It is a case for reflection that a Senate Inquiry included specific instructions on how to gain informed consent (Recommendation 6). We know that lack of truly informed consent is not unique to this area of medicine. Consent is a difficult process to get right, but the Senate Inquiry hearing was rife with reports of consent conversations that went along the lines of “it’s a simple operation, we can fit you in next week. You’ll be like a 16-year-old again.”

Bertrand Russell (1872-1970) continued on Page 6 SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

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

4 | JUNE 2018

The support of all advertisers, sponsors and contributors is welcome.

Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

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MEDICAL FORUM

Major Partner: Clinipath Pathology

Dr Bridget Cooke MB BS FRCPA FIAC

Navigating the New Cervical Screening Test (CST)

BACK TO CONTENTS

On December 1, 2017, we commenced a new era in cervical screening in Australia with major changes in the way we test, interpret and follow up women in the screening program. The HPV test is now the primary screening test with cervical cytology moving into a supportive diagnostic role.

The change has mostly been smooth sailing but here at Clinipath Pathology, a few issues have come to light and are discussed below.

those women requiring lifelong follow-up e.g. post hysterectomy for endometrial carcinoma, a role often taken over by the patient’s GP. Provided that there are no symptoms, no abnormality is seen on speculum examination at specimen collection and the annual LBC is negative, this should constitute appropriate gynaecological review and referral to a gynaecologist is not required unless there are symptoms or concern.

Pap smear replaced by LBC The conventional Pap smear (sample smeared onto slide) is no longer used and is not supported as a suitable test by the new screening program. There is no longer a Medicare rebate for the Pap smear and it has been replaced by Liquid Base Cytology (LBC) where the cells collected with a broom or brush from a well visualised cervix are vigorously rinsed into a liquid base e.g. ThinPrep vial. From this one vial, HPV testing can be done and a co-test performed if HPV is detected.

LBC samples can also be scanned by an automated imaging system.

Sonic Healthcare network and we will inform referrers.

Screening of symptomatic women Finally, screening in the new program caters for symptomatic women. Women with any abnormal vaginal bleeding (post coital, intermenstrual, postmenopausal) require co-testing (i.e. HPV and LBC) and gynaecological follow up. Unexplained persistent unusual vaginal discharge especially if offensive or bloodstained, should also be investigated with a co-test and referral.

What about screening under 25s?

There has been confusion about the under 25 age group. The new program does not provide routine screening for asymptomatic women less than 24yrs and 9mths in age except for: • Women who have had a previous abnormality and have not completed the appropriate testing to return to normal screening; • Young women with early sexual debut (prior to age 14) and prior to vaccination; in this case, one HPV test is permitted between the ages of 20 and 25 (for reasons of privacy, a clinical history of ‘’Meets criteria for early screening” is adequate); • Younger women with symptoms such as abnormal bleeding who may have a co-HPV test at any time.

What about women requiring life-long follow-up?

There has also been confusion surrounding the recommendation for appropriate gynaecological/oncological review for

About the Author Clinipath Pathology welcomes Dr Bridget Cooke as Head of Cytology. Bridget studied medicine at the University of NSW and held appointments as a Staff Specialist Pathologist at the Royal Prince Alfred and Prince of Wales Hospitals.

Dr Cooke has a broad base of experience in most aspects of pathology, but her particular interests include breast, ophthalmic and respiratory pathology as well as cytology, especially fine needle aspiration cytology.

What about self-collected vaginal samples?

The new cervical screening program includes the option of a self-collected vaginal HPV sample when the following strict criteria are met: • Asymptomatic women • 30 yrs of age or over • declined a clinician collected sample • more than 4 yrs since last Pap test or have never been screened.

Due to the requirement for each individual laboratory to validate the use of the collection swab, this test is not yet available in most Australian states. The test can be offered by referral to the Victorian Cytology Service who will only test those patients meeting the strict Medicare criteria above.

Testing should soon be available through

From May 1, to clarify the issue, Clinipath Pathology will introduce an additional risk category – SYMPTOMATIC - for women with symptoms who on co-test are HPV negative, have HPV (not 16/18) detected and have either PLSIL or negative cytology.

The recommendation will clarify risk for cervical cancer (Low/ Intermediate) as well as recommending appropriate follow-up of symptoms.

Symptomatic women who are HPV 16 and /or 18 positive will continue to be reported as High Risk and will be referred for colposcopy.

Acknowledgements: Adele Richards, Sonic Project Manager – Cervical Screening Renewal Program

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

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au

MEDICAL FORUM

JUNE 2018 | 5

LETTERS TO THE EDITOR continued from Page 4 The person who has to live with persistent pelvic pain at rest, the person whose sex life is annihilated, and their marriage with it, the person whose livelihood is destroyed, they need to make that call. They cannot make that call with the kind of consent conversations they have been having.

The issue of lack of skills in full removal impacts very badly on women. There are the inevitable conversations about evidence, but I have seen women return from America who have had full removal, and their lives are back on track. I have seen women who have had removal in WA who have a sequelae of distressing postoperative complications, and no end of relief in sight.

An honest appraisal of what we can offer women needs to be undertaken. I believe it is the least we can do.

Recommendation 11 – “to undertake an audit of transvaginal mesh procedures undertaken and their outcomes since the introduction of transvaginal mesh devices for use in the Australian market.”

This continues to be a complex area with thousands of Australian women stranded with mesh implants which have caused permanent, life-altering impacts and now cannot be easily removed. The Health Consumers’ Council looks to our health

system to both protect our consumers into the future against having implant procedures which are not properly consented. We also look to you to support consumers who have been impacted by these treatments.

ever reported that are resistant to all antibiotics used in routine treatment for gonorrhoea. This has serious public health implications, as treatment can be complex and infections may ultimately become untreatable with currently available drugs.

Ms Pip Brennan, CEO, Health Consumers Council of WA

How does this change the management of cases of suspected gonorrhoea?

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• The initial approach to the testing, treatment, follow-up and contact tracing of gonorrhoea remains unchanged – please refer to the WA guidelines for managing sexually transmitted infections and blood-borne viruses (the ‘Silver Book’) http://ww2.health.wa.gov.au/ Silver-book

STI red alert Dear Editor, In March 2018, two unlinked cases of highly antibioticresistant gonorrhoea were diagnosed in WA and Queensland.

One case was acquired in South East Asia and the source of the other case is under investigation.

The Neisseria gonorrhoeae strains of these cases, and a recent case in the UK, have high level resistance to ceftriaxone and azithromycin, the first line antibiotic treatment in WA (apart from remote regions).

These strains also showed the more commonly seen resistance to penicillin and ciprofloxacin, making them the first

• Have a high index of suspicion for antibiotic-resistant strains if the patient has recently travelled in South East and East Asia.

• Take a sexual and travel history and take appropriate samples from all potentially infected sites: dry swabs for PCR testing as well as swabs on all symptomatic patients for culture and antimicrobial susceptibility (note PCR samples are not suitable for susceptibility testing).

• Ensure a swab for culture is taken as a ‘test of cure’ for all cases infected in South East and East Asia (note PCR is not valid for ‘test of cure’ if taken <14

continued on Page 7

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MEDICAL FORUM

INCISIONS

Let’s Get Together

General Practice is heading down the wrong road, says Dr Andy Carr and it’s time to pool resources.

BACK TO CONTENTS

The WHO Sustainable Development goals seek to provide universal health coverage by 2030. Unfortunately, the current narrative is that services are more constrained than ever and costs of holistic healthcare are skyrocketing.

The elderly are surviving diseases that would previously have killed them so they’re acquiring more complex comorbidities that require expensive sociomedical solutions. The young ‘worriedwell’ is tech-savvy and engages in DIY medicine. All they need you, the doctor, for is to order the test or see the specialist they’ve already decided they need.

with your patients there will be gaps and weaknesses. There’ll be over-referral in some areas, and under-referral in others.

We all do it.

And I think it terrifies some patients that we call what we do, ‘Practice’.

We are continually buffing up our armour.

That requires spending some of the precious hours the universe gives us at a seminar or in front of an online learning module instead of spending them with family. Yes, CPD is important, but when is enough, enough?

Let’s think about how two practices in close proximity respond to each in relation to market share:

Okay, perhaps it’s not all like that!

pooled resources? It could be wonderful!

We could be sensitive to each other’s way of working yet still focus on stewardship.

Imagine a day’s work where you can do both your core GP work and a special interest clinic within the co-op your practice belongs to?

A co-op recognises the value of the ‘time saved’ as well as ‘dollars earned’, allowing the creation of solutions to more complex problems, picking that hard-to-reach fruit that nobody wants to pick. Remuneration models in such a system go way beyond ‘see patient/get paid’.

Why not go further? Imagine joining forces with our secondary colleagues in designing holistic health fund products that keep people out of hospital, and are cheaper and more comprehensive. These are health services that are not limited to disease management. We might even be able to choose where to send patients for colonoscopies!

But ‘burnout’ is at an all-time high and the sheer breadth and depth expected of a primary care physician is beyond what we can deliver without enormous consumption of resources.

How do we address the risk of DENs (Doctor’s Educational Needs) becoming PUNs (Patient Unmet Needs)?

Surely, the secret to the future of sustainable healthcare lies in collaboration and camaraderie, not consumption and competition? Every professional industry recognises that collaboration yields fruit far beyond what any one individual can produce. Yet we seem to both believe and behave differently.

Practice A: Bulk-bills everyone. Practice B: follows.

If we don’t like the road medicine seems to be headed down, then let’s get off it.

A: Opens in the evening. B: Follows.

Maybe it starts with a coffee and meeting the practice owner across the road?

Perhaps you’ll find that you both have services, resources and ideas you’d like to share with each other.

My worldview and yours is not identical, and within such differences are solutions.

While you can achieve wonderful things

A: Offers free flu shots. B: Follows.

A: Results over the phone. B: Follows.

How much energy and resources could be saved if each practice had some level of interest in the success of the other?

What if, instead of racing to the bottom, we

Perhaps it’ll be the start of something beautiful?

continued from Page 6 days from start of treatment).

• Seek specialist advice for all cases where (i) first line treatment fails; and/ or (ii) the antibiotic sensitivity report indicates resistance to ceftriaxone and/ or azithromycin.

Specialist advice can be found at (Royal Perth Hospital Sexual Health Clinic, 9224 2178, or South Terrace Clinic at Fremantle Hospital, 9431 2149).

Further information about this health alert can be found at the www.health.gov.au/ internet/main/publishing.nsf/Content/ohpgonorrhoea.htm Dr Paul Armstrong, Director, WA Communicable Disease Control Directorate

MEDICAL FORUM

Calling GPs for study Dear Editor, Breast cancer is the most commonly diagnosed women’s cancer worldwide. In Australia, there is a strong emphasis on population-based screening mammography targeting asymptomatic women with the aim of detecting breast cancer before it is otherwise identified.

General Practitioners are one of the most cited sources of women’s information about breast screening. We are seeking GPs to participate in one-on-one, face-to-face interviews to better understand how GPs discuss breast screening with patients.

Interviews are estimated to take 25 minutes to one hour and can be conducted in a mutually convenient time and location.

Participants will be reimbursed for their time with a $50 Myer gift card.

This study is part of a PhD (Clinical Psychology) being conducted at Curtin University. If you are interested, please contact Kristen Seaman on kristen. seaman@student.curtin.edu.au.

Kristen Seaman, PhD Candidate, Curtin University We welcome your letters and leads for stories.

Please keep them short.

Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month.

Letters, especially those over 300 words, may be edited for legal issues, space or clarity.

You can also leave a message. www.medicalhub.com.au.

JUNE 2018 | 7

HAVE YOU HEARD?

Dr Mary Theophilus, Dr Palon Thirunavakkarasu and Dr Amanda Boudville

Curtin Pro-Vice Chancellor Prof Archie Clements and SJG Midland CEO Michael Hogan, dean of the Curtin Medical School Prof William Hart and SJG Midland medical director Dr Sayanta Jana Dr Ruwan Wijesuriya and Dr Kalindu Muthucumarana

Midland signs on Curtin students Curtin medical students now have training certainty with the signing of an agreement between Curtin University and St John of God Health Care which will provide clinical placements at St John of God Midland Public Hospital. The hospital will begin receiving medical students from next year. Curtin’s Midland campus, which will run medical, nursing, allied health and business courses, will open in 2020 and when that is in full swing, SJG Midland CEO Michael Hogan said the hospital would initially provide 60 student placements, though that number was expected to increase over the years.

Lymphoma and breast implants

Translational research funded

Perhaps hyper alert after the vaginal mesh issue, the TGA has updated its figures on breast implants and anaplastic large cell lymphoma, which has reached 72 cases, an increase of 16 since its last update in September 2017. This update followed an article in the MJA, in which the authors said the cancer effect was causal and were pushing for more resources for the Australian Breast Device Registry. The FDA in the US had 414 cases of this lymphoma (Sept, 2017) which it pointed out was a lymphoma and not a breast cancer. It first reported this association in 2011 (but poor registry details made it difficult to be more specific); about 50% of cases were diagnosed within eight years of implantation with a median age at diagnosis of 53 years. (www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/).

In our April 18 edition we explored the hopes and aspirations of the Western Australian Health Translation Network (WAHTN) and the views of its outgoing ED Prof John Challis. With Prof Gary Geelhoed now in the chair, he is in the happy place of welcoming $6.1 million of funding (over three years) from the Commonwealth Medical Research Future Fund (MRFF). It is WAHTN’s biggest single funding input since it was established in 2014 and it is expected to help “fast-track research results into disease prevention, better treatments and improved patient health” according to the relevant minister, Mr Ken Wyatt. Making the announcement at the recent Science on the Swan conference in Perth, he said this investment was additional to the $222,222 already provided this financial year. The MRFF is set to reach $20 billion by 2020-21.

Radiology and The Record My Health Record (MHR)’s three-month opt-out period starts 16 July unlike organ donation which is still non-compulsory opt-in. In Western Australia, health businesses are busy preparing themselves.

Perth Radiological Clinic’s Booragoon practice has become the first radiology practice in Australia to send Digital Imaging reports to the My Health Record. The PRC chairman Dr Martin Blake, described this as a “significant step forward for the community” and plans were to have PRC’s 19 other practices online by the end of June. AHPRA has just sent around a promo for MHR to all doctors.

8 | JUNE 2018

Consumers at the table Still on research, narratives are starting to radically alter. Prof Ian Frazer, chair of the Translational Research Institute, in an opinion piece in the Consumers Health Forum journal has called on Australians to consider what they want of their future health care given the rapid development of ever more powerful and expensive treatments. He says optimal health care for chronic diseases is more expensive, raising questions of how we control health costs.

“All Australians can, and should, get involved in the discussion and debate around what we want the healthcare revolution to deliver.” Perth health consumer leader Anne McKenzie says that while there remains

Dr Jeremy Chong, Dr Amit Banerjee and Tara Peters

a lack of comprehensive requirement for consumer and community involvement in research, there had been “massive changes” in attitudes with consumer involvement in a variety of areas.

Aged Care waitlist too long Aged care is causing a few headaches despite the enormous hard work and commitment of the Minister for Aged Care, Ken Wyatt. At the Doctors Drum in late March we heard of the inordinately long wait (300 days by some people’s reckoning) for people to receive Level 3 and 4 home care packages. That’s too long for many vulnerable, elderly people hoping to stay in their homes for as long as possible; the very thing the government wants them to do. In mid-May, Minister Wyatt had consultations over two weeks to help determine where the most need was. Aged care funding increased by $5 billion (over four years) in the latest Budget and before the 2018-19 Aged Care Approvals Round started he wanted industry input. We hope he got it and can do something to keep the aged care reform process on track.

How am I doing, coach?

In our Cardiovascular Health edition (April 18), the GPs we interviewed bemoaned the fact that it often took the first cardiovascular ‘event’, such as a heart attack or stroke, to motivate people to make lifestyle changes.

Well, HBF has introduced the Coach Program to do its own spot of motivating.

HBF sources names of members from the private hospital, then invites them to join the Program for the “one-on-one

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Health Minister Roger Cook, SJG Midland CEO Michael Hogan, Curtin Provost Prof John Cordery and medical students Jayde Frank and James Leigh

drapes beneath the

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service that complements the care of your general practitioner”. This happens if the patient reads and returns the HBF Privacy Statement (which mentions using patient information for “conducting market research” and disclosing “the information to any service provider and/or health care professional that is relevant to this service”.

The Program Declaration letter talks of obtaining copies of pathology tests, and sending a copy of the coaching report to the patient’s nominated doctor. According to their website, the program was developed in Australia in 1995, along with the claim it is “the world’s only evidence-based coaching program for the prevention of chronic disease” – meaning diabetes, CVD and COPD. We talked to someone in the early stages of the CVD program. The initial letter was “take it or leave it”. The first call from the Coach Program’s dietitian was mainly information gathering – medications, what was done, blood results, lifestyle factors (exercise and weight loss mainly), and agreed targets for lifestyle changes. A letter and a measuring tape followed. Five more monthly calls to go!

will transform rural medical school training, with the obvious focus on encouraging doctors to learn, train and work in the regions. It is being coordinated by the Charles Sturt University in Bathurst and the University of Western Sydney. With WA struggling the hardest in the country to get enough GPs to rural areas, and with a rural clinical school that could do with some of that largesse, it seems like a lot of eggs in the east coast political basket.

Tackling endometriosis A revised draft of the National Action Plan for Endometriosis has just been released with a three-pronged approach to improve the health and quality of life of those women who suffer from it. It wants to raise awareness of the condition, improve clinical management and treatment, especially in the area of early diagnosis, and investment into research around treatment and cure. The establishment of new clinical guidelines are a stated aim.

Healthscope has had two takeover bids in the space of several days.

Brookfield Asset Management launched a $4.35 billion takeover ($2.50 a share) while private equity group BGH has put up a conditional $2.36 offer.

Brett Hayes, a Clinical Nurse Manager of Palliative Care in the Wheatbelt is WA Nurse of the Year. The 2018 Lifetime Achievement Honour was presented to Prof Phillip Della, Curtin University's Head of School Nursing, Midwifery and Paramedicine.

A research team led by OT Dr Kate Smith from UWA has been awarded $2.5 million NHMRC funding to research dementia in Aboriginal Australians.

Former Health Minister Jim McGinty is the new chair of Communicare.

Leading the way The Australasian College of Health Service Management (ACHSM) is holding its WA conference on June 19, which has a theme, Call to Leadership – 2018 Onwards, and it has gathered an interesting posse of speakers. During the day, a discussion will take place on Aboriginal health led by Aboriginal health leaders including Glenn Pearson from Telethon Kids Institute, Dr Kim Isaacs from Kimberley Aboriginal Medical Service Council, Vicki O’Donnell from the Derby service, Wendy Case from the Department of Health and Jackie Oakley and Jenny Bedford from Derbal Yerrigan. For more information www.achsm.org.au/events

Come West …?

It was interesting to note the Australian Government’s injection of more than $95 million to set up the Murray-Darling Medical Schools Network, which it says

Dr Jennifer Walsh will be involved in the sleep trial

WA cannabis trials begin UWA’s Centre for Sleep Science has begun a trial to examine the effect of medicinal cannabis on adults suffering from chronic insomnia using a cannabinoid extract provided

by WA company Zelda Therapeutics. Study lead Prof Peter Eastwood said current evidence suggested medicinal cannabis could be a less invasive alternative to current drugs, such as benzodiazepines, non-benzodiazepine hypnotics (such as Stilnox, Sonata, Imovane) and some antidepressants and antihistamines. The race is sure on – a week later we were told that WA firm Little Green Pharma had harvested Australia’s first crop of medicinal cannabis for commercial use at a secure growing facility south of Perth.

CURIOUS CONVERSATIONS Passion for Life Dr Lin Arias loves travelling to new destinations and writing about it in Medical Forum.

And there’s nothing wrong with her long-term memory.

I’m excited about… what today might bring and I’m hoping it will be my visa for Russia!

One of my best moments in medicine was… when I received a call from the wife of a man I’d cared for at Hollywood when it was a veterans’ hospital. She told me he’d passed away peacefully at home and went on to say that ‘your visits meant a lot to him and I know my husband really mattered to you.’ That was 30 years ago and she was right. They did.

MEDICAL FORUM

One thing I’d like to do before I turn 70 is… do a road trip through North and South Western USA. I haven’t been there, gulp, for more than 30 years. It’s magnificent country.

The election of Donald Trump as President… groan, as an American I guess you had to ask me that?

I’d describe myself as… short, enthusiastic, loquacious and passionate. And a bit of a fire cracker at times! I care deeply about people, well… not all people (see above). I love travelling and writing.

JUNE 2018 | 9

CLOSE-UP

‘Awesomely simple, safe and affordable’ Dr Tobias Strunk (centre) with fellow researchers (l to r) Dr Jennifer Wood, Dr Sanjay Patole, Dr Ashok Buchiboyina, Dr Mary Sharp

Of the roughly 2000 infants admitted to the often above-capacity Neonatal Intensive Care Unit (NICU) at KEMH each year, most qualify for coconut oil on their skin. It is used twice daily (everywhere but the scalp) as routine prophylactic care for infants under 30 weeks gestation as well as any infant with dry skin.

What’s special about coconut oil?

Apparently, it contains at least one fatty acid, monolaurin, that is active against bugs that cause septicaemia in premature infants, and an exciting recent study suggests this effect may come from that fatty acid entering the blood stream. More of that later. Tobias explains: “Around the NICU you will see infants with an immature epidermis and dry skin which becomes flaky and sometimes cracks.

Mineral oils were tested and we found that sepsis risk might increase. We then came across a study from Pakistan where they used coconut oil in premature infants and discovered a dramatic decrease in NICUacquired infections.”

“In many Asian countries, the massage of neonates with coconut oil is tradition.

Triggered by this knowledge and the Pakistan experience we set up a pilot trial where the primary outcome was an improvement in the skin integrity.”

They used the well-validated Neonatal Skin Condition Score to assess the skin – two independent people assess dryness, redness, and breakdown of the infant’s skin.

10 | JUNE 2018

Some lab testing completed the picture.

“Some of coconut oil’s components are very active against NICU bugs, particularly Staphlococci.” But this is old news. Tobias found that the FDA in the US had already approved isolated monolaurin in an antiStaph cream and for impregnation of tampons to prevent toxic shock syndrome.

They went ahead and sourced “squeaky clean” coconut oil from Fiji and applied it twice-daily to the skin for 36 infants born between 23 and 30 weeks gestation.

Another 36 infants, acting as controls, received routine care. They applied the coconut oil within 24 hours of birth and for a further three weeks.

“During the intervention period we observed the skin remained healthy. The nurses and parents saw the benefits – their hands improved and they saw how the skin of the baby was visibly improved. It also offered a great opportunity for the parents to get involved with their babies, which is a great thing.”

“We hope to get funding for a larger random controlled trial to show if we can reduce blood infections by applying coconut oil to the skin, which would be an awesomely simple, safe and affordable.”

The trial will be suitably powered and they are not sitting on their hands waiting.

“We are awaiting results of swabs on baby’s skin that we think will show less colonisation post-coconut oil. It is pretty exciting!”

Necrotising enterocolitis (NEC) With up to 8% of infants of >35 weeks gestation receiving empirical antibiotics for suspected early onset septicaemia, Tobias is more mindful of the use of antibiotics, even those of obvious benefit.

“About 50% of septicaemias in infants come from the gut.”

Reduce the incidence of NEC and you may decrease late onset septicaemias?

“KEMH was the first NICU to reduce the

incidence of necrotising enterocolitis (NEC), approximately halving the rate seen in Australia.” It has done this by feeding premature babies probiotics and by encouraging breast feeding and perhaps using the breast-milk bank.

Tobias is in step with the human biome and Mother Nature, and respectful of the clever work done by his colleagues at KEMH that has helped to make probiotic supplementation a routine intervention in many NICUs around the world.

“Like all organ systems, the gut is immature at 28 weeks and the mixture of bacteria that colonises the gut is very different to term breast-fed infants. We don’t know exactly what causes NEC, but bacteria are important.”

“Unpasteurised mothers milk is very beneficial, and next is pasteurised donor breast milk. From an evolutionary point of view breast milk was never meant to be sterile, For example, bacteria on the areola, which is transferred via breastmilk to colonise the infant’s gut.”

“With a few exceptions we do know that breast feeding establishes the most healthy microbiome. As well, it is easily disrupted by giving the mother or baby antibiotics. We are learning more and more how fragile this balance is and how easy it is to disrupt it.”

His views on the infant’s gut microbiome and interaction with mother’s birth canal are similar.

“It is important to be aware that caesarean sections are associated with risks such as a higher incidence of respiratory tract infections most likely related to a substantially different microbiome between infants delivered vaginally and by caesarean section. This is something that is only being appreciated recently.”

“By promoting breastfeeding and giving probiotics to the preterm infant we are looking after the gut.”

By Dr Rob McEvoy

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or nine months they’ve been putting coconut oil on the skin of premature infants at King Edward Memorial Hospital.

German-born neonatologist Dr Tobias Strunk is involved and he knows about 50% of late septicaemia in premature infants is likely to come from their skin. It is still early days but by mimicking what they do in some Asian countries, they may lessen this tendency dramatically.

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244616 (“BOQ Specialist”). Terms and conditions, fees and charges, lending and eligibility criteria apply. Any information is of a general nature only. We have not taken into account your objectives, financial situation, or needs when preparing it. Before acting on this information you should consider if it is appropriate for your situation. You should obtain and consider the relevant terms and conditions from boqspecialist.com.au/eofy18. BOQ Specialist is not offering financial, tax or legal advice. You should obtain independent financial, tax and legal advice as appropriate. We reserve the right to cease offering these products at any time without notice.

1 To earn 2 Qantas Points or Velocity Points per $1 of eligible spend, the equipment, fit-out, or motor vehicle acquired on the credit card must be financed with BOQ Specialist on a fixed term contract greater than 12 months and settled by 30 June 2018. For definition of eligible spend, refer to boqspecialist.com.au/cards. Available for lease, chattel mortgage, asset purchase or escrow (drawdowns must be in amounts of $10 000 or more). * A documentation fee of $445 and 1.5% credit card processing fee applies. For those applying for a BOQ Specialist Signature card, this must be done by 30 June 2018 and an annual credit card fee of $400 will apply.

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3 To earn and redeem Velocity Frequent Flyer Points you must be a Velocity Frequent Flyer member. Velocity membership and Points earn and redemption are subject to the Member Terms and Conditions, available at velocityfrequentflyer.com, as amended from time to time. Please allow 6-8 weeks after purchase for points to be credited to your Velocity Frequent Flyer account.

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SPOTLIGHT

Invest in Health, Not Illness Canberran health bureaucrats will be sitting a little higher in their chairs as Terry Slevin brings his strong arm advocacy to town.

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fter more than 20 years fighting the public health good fight in WA, Cancer Council WA stalwart Terry Slevin has moved to Canberra to continue the campaign on a national stage.

He became CEO of the Public Health Association of Australia (PHAA) on May 21 on a mission to grow the diverse member organisation and, in the process, expand its role in influencing public health policy.

Terry’s time at Cancer Council WA, where most lately he was Director of Education and Research, has seen his energies invested into campaigns urging people to stop smoking and avoid developing melanoma.

Areas of current concern are alcohol harm and obesity – the two spectres causing deep worry in health systems across the globe, and these issues are certain to follow him east in his new role.

Medical Forum caught up with Terry before he left, and asked him for his insights on the challenges ahead.

“The PHAA membership is enormously diverse. There are groups that are medically trained, geographers, teachers, psychologists and dieticians and others, all sharing their skills for the greater good and to contribute to public health policy,” he said.

Feeding the soul “Talking to people about public health and PHAA, it has been interesting to hear why people want to be involved. One academic who is now enmeshed in the machinery of the university she works for, said it gave her a chance to express what’s in her soul – and why she entered health in the first place. A chance to do stuff they really believe matters.”

“Public health work has a major impact the world over. Fewer people are dying with lung cancer today because public health campaigners worked with the evidence and took on the tobacco companies. We’re talking big numbers of lives that have been saved.”

If you are committed to public health work, you are in for a long haul because change is a very slow burn. Part of the challenge is engaging with the political process to help twiddle the dials and levers of public policy to keep the population healthier than its primal urges would have it so.

Politics and public health “I have always thought the political process is essential to health and wellbeing and a role like PHAA provides an opportunity to prosecute some of those ideas where decisions are made nationally and internationally. Sharing some of my experiences of the past 30 years with younger people committed to the field is my responsibility.”

“It is also vital that the next wave of public health researchers and campaigners are resourced. Idealism is not in short supply in 2018. Young people are every bit as idealistic and committed to help build a better, healthier world. To do something for the benefit of people they are never likely to meet!”

At the heart of the argument is research – the type of research that can convince individuals that some of their behaviours risk their health and life, and governments, that elements of politics and business run contrary to the health of people and ultimately negatively affect the national bottom line. That’s where the economists come in. How much does the state save if preventative initiatives are introduced?

It also opens up the fraught debate of freedom of choice and the creation of a nanny state.

The answer probably rests on ground somewhere in between where education resides but even then, knowing the numbers and witnessing the benefits doesn’t always result in positive action.

Well, not immediately at any rate.

Terry cites as an example a campaign close to his heart – reduction in skin cancer.

What can be achieved “I can show evidence of the reduction of melanoma in the under-40 age group in WA and Australia and a snapshot of the 40-59 age group which puts the efforts of our programs into context. The logic based on science that by reducing sun exposure, especially for those with pale skin, will reduce the incidence of melanoma has proven to be so,” he said.

“Stripping away the health considerations, using an economic-rationalist argument, it makes no sense to continue to pay more than $1 billion a year for the treatment of a preventable disease. With a modest investment we could cut that number again in half.”

“We do have to be responsible with how the finite resources of health are spent.

The Sustainable Health Review determined that the 2.7% of health budget spent on prevention was way too low. A similar observation was made in the Reid review in 2004.”

“On the other hand, we in public health have to stop being the hungry dog crouched over the food bowl, growling when anyone comes near, and make rational and strong businesses cases for more resources and what can be achieved with the investment.”

“This new job gives me the chance to have those arguments on a national level; to encourage investment in people’s health not their illness.”

By Jan Hallam

“There’s a saying that goes around public health: ‘saving lives, millions at a time’ and that’s not to reduce the power of the important work going on with the patient in front of you, but it’s a perspective that societies have to adopt to improve the lives of the many.”

MEDICAL FORUM

JUNE 2018 | 13

FEATURE

Life-Changing in a Heart Beat When the thing that could never happen, happens, and a doctor faces a health crisis, who are you going to call?

On November 18, 2017, she had an emergency coronary artery angioplasty and stent inserted to treat the 80% stenosis of her mid-left anterior descending artery. The condition is also known as the widow-maker.

But Corinne’s story begins about 12 months beforehand in a sequence of events that still has her shaking her head in disbelief. Disbelief that while the warning signs were flashing like neon lights, her steadfast faith in her genes (or at least those of her maternal grandmother, who lived to 92, unlike her parents who both died of lung cancer at 69 and 70 years) and her medical training were telling her it couldn’t happen to non-smoking, occasional drinking Corinne Jones, 52 years, BMI 24, mother, wife, surgeon and someone too busy to get sick.

It was just before Christmas in 2016 when the random reflux Corinne had been experiencing during the year took a turn for the worse.

“It was a really hot day, I had taken some antibiotics but I had to go to the dressmaker who was up a set of stairs in the shopping centre. I started to get this feeling in the middle of my throat and my chest tightened and I had tingling down my left arm,” she told Medical Forum.

The Denial Zone “I told myself, I am not having a heart attack, this is not happening to me. I pointblank refused to accept it so I kept walking.

When I finally made it to the dressmaker, she told me I looked as dreadful as I felt but I sat down and it passed off.”

That’s when the internal wrangling began.

Was it heart? Was it reflux? Should I go to hospital?

“It just goes to show how blind you can be when you are a doctor. I told my husband about the turn and he said I should go to the hospital if I was worried, but I shrugged it off and said I was all right.”

In mid-January the little voice continued to nag away inside her head, so she relented and went to see her GP who told her in no

14 | JUNE 2018

uncertain terms that it could not be ignored and thrust a referral to cardiologist Dr Richard Clugston into her hands.

But then a busy year got busier and the juggling of clinics and theatre lists got all too hard, so the visit never happened.

Then in June 2017 there was the news that rocked the local medical world, particularly the close-knit world of obstetrics and gynaecology. The much-loved and highly respected O&G specialist Dr Glenn Lewis died of a heart attack while out jogging.

“Glenn was a year ahead of me at medical school and we and his wife Julie, with whom he worked, would always have a chat at the St John of God Subiaco tea room between operations. I attended his funeral service with hundreds of others at St Joseph’s church and I thought then that I must do something with myself. He was just 54, and I was 52,” she said.

Ill or unfit?

“Dr Brendan Adler is the star of the show here. I thought he was just being friendly, colleague to colleague, in for a chat. He was with another doctor and they looked serious. Then Brendan gave me the good news.

The awful truth “Well, Corinne, your muscle is good and the valves are okay, but you have calcium there.”

“Oh, well, a bit of calcium is not so bad, is it?”

“Well, you have quite a lot of calcium there.

You have a score of 524.”

“I had no clue what that meant because I am a surgeon so Brendan explained exactly what it meant.”

“About 75% of women your age have a score of 0.”

“I thought to myself this wasn’t going in a good direction.”

“Those months leading up to November, I was overwhelmingly tired. Walking up stairs, running for a train – I was exhausted, but I put that down to being unfit while the pressure in my throat when I was sitting was getting worse. Still nothing clicked. I complained to my husband and he quite rightly told me I needed to sort myself out!”

“But you know what, Corinne, the calcium score is not your main problem.”

“I had absolutely no symptoms while I was standing in theatre operating. The only trace of something wrong was the Mylanta bottles and tablets everywhere – at home, in my office, in my locker. I was drinking it like it was going out of fashion.”

“I could not believe this was happening to me. I was in shock, really. With that, Brendan said 33% of people never get to tell the tale and I was still here. My immediate thoughts went to my 15-year-old daughter, Katherine. I had to be around for her.”

“I was given a referral for a CT coronary angiogram that was booked to take place after a thyroid conference in Noosa. In the plane, I thought I was a goner. I felt terrible.

I went to the loo and my lips were blue and I sat there and thought, OK, I’m hypoxic, will I survive?”

“With that he magnified the artery and pointed at the layers of thrombus occluding the vessel.”

“That’s your main problem… you have a 70-80% blockage.”

Just one more day

“I did, but the penny still hadn’t dropped! At Noosa I was so exhausted after walking to the conference hotel I slept through most of the meetings. I’d paid all this money and I couldn’t keep awake.”

So, Brendon rang Richard Clugston, who advised Corinne to start aspirin immediately and to see him first thing the next morning. However, Brendon’s and Richard’s comprehension of the seriousness of her situation was far greater than Corinne’s. She tells Richard that she has a full theatre list the next day (a Friday), she is asymptomatic standing, can she possibly see him on Monday?

On her return to Perth, Corinne packed in a couple of busy clinics before heading over to Envision for the CT coronary angiogram.

Bells only started ringing when she was told one of the doctors would like to speak to her.

“My presentation was very unusual and while Richard hesitated, he finally agreed to see me on Monday. I did my list which didn’t finish until 9pm and I was totally shattered (though the patients all did very well).”

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his is a cautionary tale, and one that surgeon Dr Corinne Jones is pretty pleased to be able to tell.

FEATURE When Saturday morning dawned, Corinne was totally overwhelmed by everything that had happened. She needed to have her fasting lipids taken at Pathwest but she was feeling unwell and emotionally shattered.

“I decided to see my GP. I tell my patients how important it is to have a relationship with their GP, so I practised what I preach but not before I did an early ward round to see my patients.”

Corinne got the last appointment at her local clinic on Saturday morning and saw Dr Yvonne Mews, whose late husband was a cardiologist. Sensitive to the danger signs, she rang the cardiologist and Richard ordered Corinne to head down to Hollywood hospital. Pronto!

“I still had no chest pain and it really wasn’t registering with me, but I picked up a few things from home, certain that I would be there only a couple of hours. My husband and I dropped Katherine at a friend’s place, I hadn’t said much to her, and I’m dropped off at the hospital.”

Going with the gut “When I get into coronary care, I was retelling the story to everyone. My Pathwest results came back and the fasting lipids and troponin were normal and the ECG standing and sitting were fine. Richard was standing at the bottom of the bed shaking his head – the symptoms were unusual but the CT angiogram is so accurate that at the back of his mind, he knew something was wrong.”

“I was wheeled into the angiogram suite and asked if I wanted to watch, which I told them in no uncertain terms I did not.

The next thing I knew I was in the ward with a newly acquired stent after the 80% blockage was cleared.”

Six months on, Corinne still pinches herself. How lucky she was; how closed off she was to her own health and mortality; how it had all come to this.

for the first time in her life her future has parameters; it is tangible. Retirement is something she would like to experience along with the obvious desires to see her daughter finish school and make her way in the world. It has also made her a better doctor, she thinks.

“I understand better now how my patients feel when they are told they have breast cancer. I understand what it’s like contemplating your own death and the utterly overwhelming feeling that engulfs you. I feel well, but mostly I feel grateful and very fortunate”.

“My message would be DON’T IGNORE your own health and be aware that it can happen to you. I can’t stress enough the importance of getting any new symptoms checked by your GP and getting the tests done as soon as possible”.

By Jan Hallam

The experience has also introduced her to some newfound concepts. While work and life continue to be busy, Corinne says

Dr Corinne Jones and daughter Katherine enjoying a holiday in Albany in April.

MEDICAL FORUM

JUNE 2018 | 15

LIFESTYLE

New T1 Diabetes Centre – Food for Thought Telethon’s investment in a new clinical and support centre for people with Type 1 diabetes is offering hope and some new solutions.

“New technology is utilising Continuous Glucose Monitoring [CGM] with smartphones and wearable fitness devices becoming fully integrated with CGM so you’re able to see the immediate impact of exercise on your glucose levels,” Bec said.

“There are many platforms that integrate food intake, exercise and diabetes data. It will make the management of Type 1 a lot easier for me and many others.”

Dealing with Type 1 is a complex, 24/7 undertaking and, as Bec knows only too well, some people manage it better than others.

Emotional toll “The complications of Type 1 Diabetes hang over our heads every day and they can be long-term and devastating. If a person lives with high glucose levels it will eventually damage every tissue and organ in the body, particularly the eyes, kidneys and bodily extremities.”

“The possibility of lower-leg amputations is certainly a motivator for good control.”

“And it’s not just an actual blood glucose level that’s important but also any fluctuations because you don’t want to

be on a roller-coaster ride. The microvascular systems are highly vulnerable and the aim is to spend as much time as possible within a ‘safe’ range.”

“A low blood glucose level [BGL] is an acute situation and a large hyperglycaemic event can also be very scary. You’re walking a tightrope. It’s a juggling act between insulin levels, carbohydrates, protein, fats, exercise levels and sleep patterns.”

“There’s an interesting website called Diatribe that lists 42 factors that impact on BGL and every day I’d be thinking about 30 of them. You’re always making dose decisions, and that’s not always easy.”

Success stories “But there are a lot of people out there who are not just managing diabetes well but living extraordinary lives at the same time.”

Bec Johnson is clearly one of them after her life was utterly transformed by a Type 1 diagnosis at the age of 17.

“It’s shaped my personality and the way I look at the world. Without doubt it’s been the single-most powerful force in my life and given me a great sense of purpose in my work within the community health sector. I fully accept living with Type 1, in fact I embrace it. It probably sounds crazy but it’s given me so much and I’m not sure, if I could go back and flick a switch, that I’d change the situation.”

“I once thought I’d be walking down the corporate lawyer path and here I am in the Type 1 Hub and Family Centre working with more than 600 families on their own diabetes journey.”

As CEO, what’s Bec’s vision for the centre?

Focus for families “I’d like it to become the one-stop shop in WA, a wrap-around clinical and social support for people living with diabetes and those who support them. I think we’re breaking new ground, we’ve got a dedicate team most of whom are personally affected by Type 1 Diabetes, and a highly collaborative and hardworking Board.”

“We’re always striving to be creative, flexible and think outside the square.”

Bec would like to encourage GPs and specialists involved in area to consider ‘food is medicine’ because she believes it profoundly affects the health of the person with diabetes. We have the capacity to manage chronic disease with medication but if we focus more closely on food we can truly change people’s lives.”

“Perceptions need to change regarding the people who have Type 1. I think doctors need to do two things. First, become more engaged in the ‘food’ conversation and second, have a closer look at the people who are living great lives despite having Type 1.”

“The question needs to be asked, ‘what’s different about us?’”

A Bumpy Ride Neil McLagan freely admits he’s had some ups and down since being diagnosed with Type 1 at the age of 14.

Neil recently completed a 20-day, 411km ride from Perth to Sydney raising funds for the Type 1 Hub and Family Centre and is a passionate advocate for a lowcarbohydrate dietary approach.

“The bike ride was pretty tough. It was solo, totally unsupported and designed

The new T1 diabetes centre in Stirling

16 | JUNE 2018

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here’s no disputing that a diagnosis of Type 1 Diabetes reshapes virtually every aspect of a person’s life. The CEO of the Telethon Type 1 Diabetes Family Centre, Bec Johnson, knows firsthand that there are no limits to making that life extraordinary – and that includes swimming to Rottnest!

LIFESTYLE to demonstrate that a low-carb diet can control Type 1 really well.”

“There were several aches and pains along the way from extreme saddle sores to bursitis in both knees and damage to the ulnar nerve in my hand. But it was worth it to raise funds for the Centre, which is such a great support to young people living with Type 1.”

“I’d have to give a lot of credit to my low carbohydrate dietary regime. The ride was an extended period of intense, sustained exercise and I maintained low levels of both serum insulin and glucose variability that would have been pretty similar to any other normal day.”

Neil’s diet is simplicity itself.

Good days, bad days One of the Centre’s first patients, 19-yearold Tori Brown, considers herself ‘quite lucky’ to have been diagnosed at five years-of-age.

“It’s a different way of looking at it but I think I was fortunate to be diagnosed at such a young age because I can’t really remember life without Type 1. But it’s been a struggle to maintain balance and normality, particularly with all the social activities when I was at school. ” “There are good hours and bad hours, good days and bad days.”

A lot of discipline is required to manage Type 1 well, says Tori.

Keeping tabs

Fuel for the road “I follow a traditional low-carb approach, less than 30g of carbohydrates per day with lots of leafy green vegetables, plenty of protein and high quality dietary fats.

A typical breakfast for me is a couple of eggs with bacon and avocado plus kale or spinach with some macadamia nuts.”

“Two books that I’d recommend are, The Art and Science of Low Carbohydrate Living and Dr Bernstein’s Diabetes Solution. The latter was written by an endocrinologist who was diagnosed with Type 1 at the age of 12 and it really was a ground-breaking study. There have been several reports in the media of people with Type 2 going into a ‘pseudo-remission’ so I think there’s huge potential there.”

“You develop a different perspective on the world with this disease, there’s no doubt about that. Even something as simple as sitting down and having lunch you need to think about. In my case, I’ll need two needles and then have to calculate in my brain the possible effects of what I’m eating.”

Tori, a nursing student, describes a typical ‘Type 1’ day for her.

“I wear an insulin pump 24/7 and I’ve had that since I was seven, which is a long time to have a machine attached to you. I wake up in the morning, take my BSLs using my ‘pricker’, eat breakfast and adjust the dose on my pump.”

“Whenever I eat anything I also have to take into account the amount of exercise I’m doing because my adrenalin level affects my numbers. I’ve got a CGM and that gives me a broader understanding of my BSLs which is important when you have to consider almost everything that’s going on around you, even the weather!”

“Even a trip down south takes a bit of planning. I need two suitcases, one for my diabetes paraphernalia and another for my clothes. A holiday overseas is even more complex because sometimes you don’t have easy access to the usual medicines and that’s a bit scarier.”

Each day as it comes “I certainly don’t take anything for granted anymore.”

Tori has seen more than her fair share of doctors during her Type 1 journey.

“When I go to see a GP I’m often asked a lot of questions regarding my diet and weight. I’ve even had the occasional doctor who seems to be a little confused regarding the essential differences between Type 1 and 2, which is a little surprising.”

“The other thing I’d say is that the mental side of Type 1 is often under-emphasised.

It’s well known that anxiety and depression are important issues during adolescence.”

By Peter McClelland

And for any person recently diagnosed with Type 1, Neil hopes a doctor-patient conversation can be flexible.

“I understand that doctors have to stay within certain guidelines but I would encourage them to be open-minded. I’ve been to GPs where my ideas have been quite abruptly rejected but a ‘one-size-fitsall’ approach is not the answer.”

“Anyone with Type 1 needs to be fully informed and there’s no shortage of information out there.”

Prime Minister Malcolm Turnbull at the centre's opening

Tori Brown receiving a centre scholarship

CEO Bec Johnson and some young recipients of the centre's facilities

MEDICAL FORUM

Neil McLagan on the road during his cycling trip to Sydney

JUNE 2018 | 17

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18 | JUNE 2018

MEDICAL FORUM

FINANCE

Single Touch Payroll – How it Works We’ve had the budgets, now we have tax time. We’ve asked the ATO and a financial planner for the news that will help come July 1

I

f your medical practice employs more than 20 people the ATO Assistant Commissioner, John Shepherd has got news for you!

“There are some significant changes to payroll reporting that will commence on 1 July 2018 that may well affect some medical and healthcare practices,” says John.

“One of the most important is Single Touch Payroll (STP), which will change the way employers report tax and super information to the ATO. Under STP, you’ll need to report payments such as salaries, wages, PAYG withholding and super information from your payroll software each payday.”

“Your pay cycle doesn’t need to change and you can continue to pay your employees weekly, fortnightly or monthly.”

Medical Forum has broken down some of the salient points: • Employers with 20 employees or more will need to report through STP using STP-enabled payroll software.

• Complete a headcount of employees on your payroll on 1 April. If the total was 20 or more you need to prepare for STP. You don’t need to report this information to the ATO, but you should keep a copy of the calculation for your own records.

• Speak with your payroll software provider to find out if your payroll solution will be ready for STP reporting.

• If it won’t be ready, ask your provider if you have received a deferral from the ATO. • If your current payroll software product

will not be updated to offer STP you will need to choose an STP-ready solution.

• You can also ask your registered tax or BAS agent (or other payroll provider) if they can report through STP on your behalf. If they need more time to get ready they can apply to the ATO for a later start date.

• If your software will be ready but you won’t, you’ll need to apply to the ATO for a deferral.

“We’re ready for the STP transition here at the ATO and the best way to make the transition is to check in with your payroll software provider, download the STP Checklist and Fact Sheet from our website.

Alternatively, you can speak with your registered Tax or BAS agent and go from there.” ato.gov.au/stp

By Peter McClelland

smithcoffey

MEDICAL FORUM

JUNE 2018 | 19

FINANCE

Tax Tips To Ease the Pain The end of the 2018 financial year is a time we need all the help we can get.

Independent planner, Brad Dudumas explains.

I

s it that time of year already?

Yes it is! Some of the key areas to consider pre and post 30 June 2018 are: Concessional Contributions (Pre-Tax) A significant change is the reduction in the concessional cap to $25,000.

Despite this, making use of your concessional contribution cap is one of the most effective ways to boost superannuation savings and reduce your assessable income. Importantly, as many medical professionals have a GESB West State account, you may be able to increase your contributions above the annual cap that will deliver a substantial tax benefit compared with your marginal rate. But be aware, lump sum concessional contributions are no longer allowed into GESB West State.

Non-Concessional Contributions (After Tax) The current cap stands at $100,000, provided your total superannuation balance is under $1.6m. If you have surplus funds

available you may want to consider contributing some to superannuation (yours or your partner’s). You may save thousands of dollars, both now and in retirement, due to the inherent tax advantages. Those eligible may also want to take advantage of the ‘bring-forward’ rule, which currently totals $300,000 for those aged under-65 at any time during the 2018 financial year.

immediately deduct the cost of each and every depreciating asset purchased for less than $20,000. In order to access the deduction, the asset must be purchased, installed and ready for use before 30 June 2018. There is no limit on the number of eligible assets costing less than $20,000 that you can deduct.

Superannuation Equalisation

One of the benefits of geared investments is that you are generally entitled to claim a tax deduction on the interest cost. Given the current low interest rates, it may be worth considering pre-paying up to 12 months interest on relevant loans. Doing so will allow you to lock in the interest rate you pay for next financial year and will bring forward your tax deduction to this financial year.

With the introduction of the $1.6m pension cap (effective 1 July 2017), you should think about splitting your superannuation with your spouse. There are two main ways of optimising this: • Contribution Splitting – putting a portion of your concessional contributions to your spouse each year.

• Recontribution Strategy –commuting a portion of your superannuation to your spouse’s fund.

Key benefits include earlier access to your superannuation; more effective use of joint pension caps – $3.2m vs $1.6m tax free savings; and a boost to your spouse’s retirement savings. $20,000 Asset ‘Write-off’ Small businesses with an aggregate annual turnover of less than $10m are able to

Pre-Pay Investment Interest

Other Deductions Another effective way to reduce your assessable income is to consider prepaying relevant expenses such as Income Protection and professional memberships and fees.

Disclaimer: This information is of a general nature only and has been provided without taking account of individual objectives, financial situation or needs.

ED: Brad Dudumas is a director of Profusion Planning.

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20 | JUNE 2018

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MEDICAL FORUM

GUEST COLUMN

Healthy Finances When You’re Not Financial adviser Nada Maticevic outlines a five-step program to keep money worries out of the equation when tackling illness.

BACK TO CONTENTS

“Health,” wrote Ralph Waldo Emerson, “is the first wealth.” He’s right, of course. All of us would choose health above wealth, but we don’t get the choice when it comes to life threatening illness. Disease has no regard for financial status.

Unfortunately, though, finance also has no regard for disease.

While patients, quite rightly, want to focus on their treatment rather than their superannuation contribution strategies, the money worries don’t disappear with the diagnosis. In fact, serious health issues tend to compound financial stress, which in turn can make recovery even more difficult.

It’s vitally important, then, for anyone fighting serious illness to have a clear map for managing their money through what may be a long road ahead.

Everybody should have a budget – a brutallyhonest picture of their bottom-line.

Today there are many online budgeting tools to guide people through what can be a confronting number-crunching exercise.

However, if you don’t know where you’re starting from it’s hard to know where to go next, although for many the next step will be in the direction of Centrelink.

Centrelink provides a number of support mechanisms for people suffering severe illnesses – most notably, the Sickness Allowance. However, the offer comes with

Individual circumstances vary widely, but many people facing serious illness are hit with the double whammy of increased costs (for example, travel and accommodation expenses associated with treatment) and lower income as employment either is paused or scaled back.

Generally, those common, seeminglycomplex financial symptoms can be treated via a simple five-step process that attacks the root causes of any money disorder – budget; Centrelink; debt; Superannuation; and estate.

a byzantine set of rules that limit access based on income and assets, which is why Centrelink applications should be considered in the context of a person’s total financial situation covering debt and superannuation.

For example, it may make sense to pay down any non-mortgage debt prior to applying for government assistance: Centrelink will not deduct such debt from the asset test when weighing up an application.

Likewise, within super, there are many strategies covering factors such as insurance, Transition to Retirement (TTR) and accessing super early, which can help with cash-flow. However, the rules can be tricky to negotiate without professional financial advice.

Estate planning looms naturally as the final step. While we always recommend clients – whatever their stage of life – to have up-to-date estate plans, the question is undoubtedly more pressing for those dealing with life-threatening illness.

The good news is that medical knowledge and technology has greatly advanced our ‘first wealth’ and while it may be of a secondary order, financial knowledge can play a similar role in keeping our money healthy when we need it most.

ED: Nada Maticevic is a qualified financial adviser with Perth-based Integro Private Wealth.

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MEDICAL FORUM

10/01/2018 11:20:53 AM

JUNE 2018 | 21

FEATURE

End-of-life Inquiry Digs Deep

T

he issue of euthanasia is never far from the surface of the public’s consciousness, but it has rarely been so much exposed as in recent times.

BACK TO CONTENTS

The WA Parliament’s inquiry into end-of-life choices is currently being conducted on a backdrop of passed Victorian legislation to allow doctor-assisted death for terminally ill patients and the more socially provocative narrative generated by two West Australians: Long-time euthanasia advocate and terminally ill Clive Deverall’s suicide in May last year (on the day of the state election) and the non-terminal 104-year-old E/Prof David Goodall’s planned death in a clinic in Switzerland in May this year.

The inquiry has heard many thousands of pages of evidence and personal testament. From transcripts Medical Forum has seen, the eight committee members of various personal views are genuinely seeking a path through the labyrinth of opposing opinions passionately felt.

A number of individual doctors and organisations representing health professionals and consumers from all facets of the care industry have prepared submissions and many have appeared in person before the committee.

Here we pick out the major talking points from the AMA WA’s personal appearance and opposite is the case from Doctors for Assisted Dying Choice (WA) prepared by Dr Peter Beahan.

The committee’s final report is expected to be tabled in Parliament on August 23 this year.

AMA WA President Dr Omar Khorshid and Dr Katharine Noonan fronted the inquiry on February 28. The federal organisation has made it clear that it is opposed to voluntary assisted dying. When quizzed how it came to that position, Dr Khorshid said a survey of members (where 5000 responded) and discussion within the ethics committee help form policy. He said, “50% of doctors are effectively opposed but that ranges from a little bit opposed to very opposed, and less than that number are for, and there are some that do not know.” But when it came to the question of “would I be involved?” it was a lower number, he said.

The committee chair Ms Amber-Jade Sanderson cited a 2015 survey in which it was identified that 1-2% of patients had experienced unmanageable symptoms around end-of-life.

Dr Khorshid did not have data but said end-of-life could be a “fantastic experience for a family. It can be awful. That is the reality.

We do our best with the tools that we have to alleviate suffering.” He added there could be better teaching and integration of palliative care principles into all the medical specialties.

The doctrine of ‘Double Effect’ – where pain-relieving medication hastened death – was a common occurrence he said and fitted into the Medical Board’s code of conduct. He said the doctor was protected in these circumstances.

However, Dr Khorsid offered in his introduction his belief that “there is a need, both within the medical profession and in the community, for an open and frank discussion around death and dying, including palliative care, end-of-life choices, approaches to futile treatment and bereavement.”

“Whilst this has been a topic of contention in the past, we are not aware of any doctors who have been prosecuted in WA for that in good faith. So we do not believe there is a problem with the laws as they stand, and we believe that doctors are able to provide adequate pain relief and symptom relief to patients at that phase of life under current rules.”

He was adamant, though, that medical ethics and the law have created a clear line between ethical and unethical conduct, between legal and illegal conduct. In this light, the “medical profession’s general reluctance to be involved in the deliberate ending of a patient’s life, even when it seems to be the right thing to do and in the interest of the patient, and when there is significant public support for that sort of change” was understandable.

“In our view, a discussion around voluntary assisted dying or assisted suicide…is not really about that group of patients who are dying in their last day or couple of days of life…in our view terminal sedation is completely different to somebody who is not in imminent danger of dying who requests assistance with dying…We would not consider terminal sedation to be voluntary assisted dying; it is relieving symptoms at the very, very end of life.”

He acknowledged that many doctors agreed there were “circumstances where voluntary euthanasia or assisted suicide is both ethical and in the interest of the patient. However, many other doctors were concerned about the implications of crossing that line.”

There is still a long road to travel. Dr Khorshid told the committee that the AMA’s policies are reviewed regularly as will this position statement as the situation becomes clearer here and nationally.

The committee quizzed Dr Khorshid on the quality and access to palliative care. He conceded access was affected by geography and to some extent a public/private divide, “which sometimes makes it complicated as to how patients can access care and how care is communicated between the different sectors.”

22 | JUNE 2018

“But I hope we can make it a positive discussion rather than have members sniping at each other…If we handle it poorly it can be an extremely divisive discussion… if everybody acts in food faith and we are able to come together as a community, properly informed, and make good decisions, what is there for anybody to complain about?”

By Jan Hallam

MEDICAL FORUM

FEATURE

The Case for Voluntary Assisted Dying

By Dr Peter G. Beahan, in collaboration with Doctors for Assisted Dying Choice (WA) – Dr Alida Lancée, Prof Max Kamien, Dr Richard Lugg, Dr Roger Paterson and Dr Ian Catto

BACK TO CONTENTS

Throughout history, many have suffered a slow, painful and undignified death. Some have taken their own lives in lonely, often violent circumstances. Sadly, this is still all too common. It is only in the past 50 years that medical attention has been focused on this last stage of life.

Despite much progress, some patients still suffer a ‘bad death’. Figures from the University of Wollongong’s Palliative Care Outcomes Survey suggest that over 5% of palliative care patients fall into this category.1 Strategies for such patients have included avoiding futile intervention and the withdrawal of life-supporting treatment.

In addition, the ‘doctrine of double effect’ allows for medication that, while relieving suffering, may hasten death.

Terminal sedation (TS) stems from this.

While it may be defensible in the courts, TS is a form of assisted dying not exempt from a charge of murder under the Criminal Code.

Another type of assisted dying is Voluntary Assisted Dying (VAD), where the physician provides the necessary means, as specifically requested by the patient. This previously taboo subject has undergone reappraisal, driven by: 1. Diagnostic and prognostic certainty of a high degree.

2. Management options able to prolong life without necessarily including its enjoyment.

3. Medications that can provide a painless dying process.

4. Community demand that has reached a critical point.

5. Attitudes that have moved in a more kindly, less judgmental and less patronising direction.

The case for VAD is based on the right of individuals to autonomy and dignity with respect to their personal lives. The World Medical Association’s Declaration of Geneva was recently updated to include: I WILL RESPECT the autonomy and dignity of my patient.

The difference between TS and VAD is contrived rather than real.

The fine line between intention to relieve suffering and intention to end life is so fine as to be apparent only in the mind of the physician. It is not measurable, transparent or accountable.

MEDICAL FORUM

In application, there are differences: 1. With TS, timing is prolonged and uncertain. The patient may linger in a semi-comatose state, dehydrated and deteriorating.

With VAD, the process is quick and certain.

The patient makes a personal decision while dignity and purpose are intact. This is both a rational and a mentally healthy choice.

2. With TS, documentation is cryptic and statistical information difficult to collect.

There is no regulatory framework.

With VAD, documentation is clear, frank and open to scrutiny.

3. With TS, death can be a trial for all concerned, and remembered with guilt and horror.

With VAD, death is remembered with reverence and thankfulness – a fitting end that rounds off a special life.

3. Retaining consciousness up to the point of death allows for communication that can have an easing effect on the process of ‘letting go’.

Among points of opposition to VAD are: 1. That better funding for palliative care is the answer.

But funding cannot be expected to reduce the residual proportion of ‘bad deaths’ that occur even in the best-run centres.

Funding can help access problems, and should be suppported.3 We see VAD not as an alternative to palliative care; rather, it is a natural, fitting and complementary part of the spectrum of service that should be available to the dying patient.

2. That pressure may be applied to the patient by family members, or other interests.

4. With TS, the decision is made by the physician.

In his study of overseas jurisdictions, Andrew Denton came to the conclusion that this was a near impossibility.

Nevertheless, we recommend monitoring, and case review, as occurs overseas.

With VAD, the decision is made by the patient.

3. That of a ‘slippery slope’ and of ‘normalisation’.

Most opposition to VAD stems from faith-based beliefs. Such beliefs are often subliminal, undisclosed and unacknowledged. Even the double effect doctrine (itself a religious concept) rests uncomfortably with some, and is not always applied.

These are largely unsubstantiated fears.

Increasing uptake may just reflect the unmet need.

The bulk of the population prefers government to follow a path based not on dogma, but on reason, evidence, science and fairness. Over 70% of those who identify as Catholics and of those who identify as Anglicans, support VAD.2 The word “suffering” suffices to cover the whole gamut of what motivates a patient to seek VAD, including existential considerations. Pain is not at the top of the list of motivating factors.3 More common concerns are those of losing independence and autonomy, of losing dignity, of being unable to carry out usual activity and of being a burden on others.

There are other benefits of VAD: 1. Giving a patient the option of VAD can greatly relieve anxiety. Over a third of patients granted access to Nembutal never actually use it.4 2. Giving patients control over the timing of death can make parting with loved ones easier to organise and to cope with.

4. That VAD will ruin the doctor-patient relationship.

On the contrary, the empathy and consideration given is much appreciated by the patient and loved ones.

Support for VAD in the WA community runs at 88%.5 Support among doctors is also strong, estimated at over 60%.

Once VAD is legalised, it is likely that a greater number of doctors would be willing to support it publicly. There is every reason to believe that VAD would be seamlessly embraced. Those who do not wish to participate would be fully respected.

References: 1. Connolly A. et al. (2017) Patients Outcomes in Palliative Care: Results for Western Australia, July-December 2016 Palliative Care Outcomes Collaboration, University of Wollongong 2. 2007 Newspoll Survey 3. ABC News 3 Dec, 2017 Euthanasia: it’s not just about unbearable pain, it’s about selfdetermination, expert says 4. K. Callinan The Hill 25 Dec 2017 Allow Modern Medicine to Relieve Agonizing End-of-Life Experiences 5. Roy Morgan Survey 10 Nov 2017, Finding No 7373

JUNE 2018 | 23

Doctor Owned • Doctor Managed • Doctor Focused Standards

Celebrating

Years

PERTH RADIOLOGICAL CLINIC

Perth Radiological Clinic is pleased to welcome Drs Phil Misur, Matt Prentice and Peter Counsel as new Partners of the Practice. The reassurance of independent doctor ownership allows us to continue to provide an uncompromising commitment to excellence. www.perthradclinic.com.au 24 | JUNE 2018

MEDICAL FORUM

MARKET FORCES

Watch the Pennies, or Lash Out? Medical Editor Dr Rob McEvoy draws inferences, mainly for those in private practice, from an in-depth look at one financial report.

A

flurry of media releases follow any federal budget.

You can perhaps work out where these came from: “20,000 Reasons To Invest In Dental Equipment Thanks To The Budget” and “Budget – Great Preventive Health Initiatives”. But it was a slightly earlier media release from BankWest (1.5.18) that caught our eye, entitled Strong growth predicted for the medical services industry.

A recent study by the WA Department of Health found that by 2025, there will be a 1450 shortfall in medical practitioners in the state (including a 974 shortage of GPs and severe shortages in O&G, Ophthalmology, and Psychiatry).

While some might see this as a beat-up by the bank to drum up business, the report looks at what financial opportunities will present themselves in the medical marketplace over the next few years sourced from data from IBIS World, Australian Bureau of Statistics, APRA, WA Department of Health, and the Australian Trade and Investment Commission, mainly from the 2016-17 financial year.

• If you are happy to see the ageing and have one eye on their costs.

Firstly, the consumption of medical services is increasing.

Consumer visits to GPs and specialists are rising, up 1.5% and 2.1%, respectively, nationwide. In WA things are booming with the corresponding increase in figures for doctor attendances at 5.8% and 7.3%. Will this continue?

The trial of Health Care Homes is focused on those with chronic diseases – to keep them well and out of expensive hospitals. This opens the door to anyone who has a method or product that fulfils that aim. Cost savings will come to Medicare, such as reducing the urgent after-hours doctor’s services (grown 154.7% in the five years to June 2016, the report says).

What will drive your success in the next five years* • If you are a personable specialist or GP who works in the chronic disease area.

• If your patient group are not among the 3% decline in private health cover (mainly young Australians, with 50,000 fewer extras cover policies amongst 20-29 year olds).

• If you can integrate technology that increases productivity (and reduces costs), both your own and those you work with.

• If you can collaborate more with other health professionals in getting the job done for patients.

• If you have a bright idea for an App or the export of healthcare. *Predicted growth 15.7%

The report goes on to say “technology and innovation within the industry [has opportunities] to drive down industry costs”. Anything that will “facilitate services and adopt a more preventative approach to healthcare and chronic disease” will have the ear of policy-makers.

In the 2016-17 financial year, medical services from GP services totalled $11.8 billion (50.4% of industry revenue) with specialist services accounting for $11.6 billion.

Government commitment to Medicare and Australia’s ageing population will make this cost juggernaut hard to slow down – revenue is predicted to grow 15.7% in the five years to June 2022.

What about relative incomes. Compared to GPs (wage decline of 0.6% predicted over the same period) specialist incomes will increase by 11.4%.

Employment of workers in the health sector full time is the greatest it has been for 20 years (up by 3% for 2016-17 compared to a 3.7% decline in part-time workers). Great if you are looking for a job!

Feminisation of GP workforce continues with a 36% increase in women entering general practice compared to 19% increase in men in the five years to June 2017.

Private health insurance is a mixed bag. Private hospitals are ‘doing it tough’ we hear. “About half of Australians have private health insurance extras cover but extras cover is on the rise (by 10.2% in the five years to June 2017).”

Western Australians have taken out private health ‘extras’ at above the national average (67.5% of the population during 2016-17).

“Bulk billing rates increased across specialist and GP attendances, however average patient fees also increased, highlighting greater use of public services and modest price rises in the private sector.”

MEDICAL FORUM

Pages from Medical Future Of Business

JUNE 2018 | 25

Wherever your workplace, whatever your role, donâ&#x20AC;&#x2122;t put yourself or patients at risk.

Get your free flu vaccination today.

Join the growing number of health workers who get the flu vaccine each year.

It is safe, effective and reduces your risk of catching flu and passing it to patients and colleagues.

health.wa.gov.au 26 | JUNE 2018

MEDICAL FORUM

CLINICAL OPINION

Testing Blood Sugars in DM2

Looking for a new challenge?

By Dr Timothy Welborn, Endocrinologist

BACK TO CONTENTS

The Author believes it is ‘horses for courses’ when testing blood sugars in DM2 but testing should not cease because things seem stable. The array of new meters and apps add enjoyment to this mind-numbing task.

Devices available to measure blood glucose levels are tailor-made for patients to take control of their diabetes.

Knowledge of their results empowers them to learn the effects of diet, activity, and medications. The National Diabetes Supplies Scheme (NDSS) provides test strips on the authority of doctors or diabetes educators. How to test?

The frequency of testing and the targets selected, depend on the patient’s age and motivation. Initially, type 2 diabetics should test before each meal and before bed with blood glucose targets, say, fasting 6–8 mmol/L and before meals/ bed 6-10 mmol/L. Eventually many patients reduce testing to perhaps twice daily or twice weekly – say, fasting (before breakfast) or 3 to 5 hours after the main meal (indirectly monitoring dietary compliance). Note: not two hours after meals – impaired insulin release inevitably gives dispiritingly high values that subside 4-5 hours after eating.

Expressions of interest are invited from General Practitioners with current skills in Emergency Medicine, Obstetrics or Anaesthetics to work in various locations across rural and remote Western Australia.

GP Emergency Medicine Fellowship of ACRRM or RACGP extensive generalist experience

Home blood glucose monitoring (HBGM) helps check efficacy when oral hypoglycaemics are commenced. Patients may be nonresponders. Also, sulphonylureas are very potent at lowering blood sugars so HBGM helps reduce the risks of hypoglycaemia.

significant emergency department skills primary health care knowledge and skills

For patients commencing insulin, HBGM is essential. Those adding long acting insulin at night (Lantus or Protaphane/NPH) should check fasting glucose levels and “titrate” the insulin dosage every 4-7 days to achieve targets.

GP Obstetrics or GP Anaesthetics

Many with DM2 will progress to require twice-daily combinations of short and long acting insulin (e.g. Humalog Mix25 or NovoMix30 insulin), a regime well suited when breakfast and dinner are the main (carbohydrate containing) meals. Blood sugars tested before each meal and before bed assess each component of the mixed insulin preparation and allow adjustments of dosage every 4-7 days.

Once control is satisfactory, testing can be reduced, perhaps to bi-weekly.

ability to practice without clinical supervision in procedural area

Patients who can, should visualise their patterns of response, rather than relegate the data to the meter’s memory.

They and their doctors will find this useful for adjusting treatment and it is a great catalyst for working together on the problem.

As above, plus formal qualification in obstetrics or anaesthetics

If you have the qualifications and experience we have the opportunities View our current vacancies at www.wacountry.health.wa.gov.au/index.php?id=552 To express your interest Email: WACHSDoctors@health.wa.gov.au

Most type 1 diabetic patients and some type 2 diabetic patients require “intensive” insulin, that is, a 3+1 regime (three injections of short-acting before meals and one injection of long acting insulin at night). Testing four times a day is essential here to achieve targets and adjust doses. Patients can access convenient meters with attached lancets and cassettes, and some meters avoid the “fiddle” and inconvenience of extracting and then disposing of strips.

All new DM2 patients should be taught blood glucose monitoring.

Achieving good control does mean that testing can cease. DM2 is progressive and subtle diabetic complications can emerge.

Self-recording is a powerful behaviour modifier and a way for patients to be in control of their DM2. Whether patients use a written Diabetes Diary or spreadsheet or an electronic record, it is still important for them to visualise their results.

MEDICAL FORUM

JUNE 2018 | 27

28 | JUNE 2018

MEDICAL FORUM

CLINICAL UPDATE

Hiatus hernia surgery

By Dr Krishna Epari, Upper GI Surgeon, Murdoch

Hiatus hernia is common, increasing with age and BMI. Whilst medical management predominates, there remains a role for surgery.

BACK TO CONTENTS

Hiatus hernia is the protrusion of abdominal contents through a widened diaphragmatic hiatus, typically involving stomach but may include omentum, colon, small bowel, pancreas and spleen.

Large and or recurrent hiatus hernias are more technically difficult to repair but can usually be done laparoscopically.

Presentation & investigation Small sliding hiatus hernias are most commonly associated with gastrooesophageal reflux including both acid and volume reflux symptoms.

View at laparoscopy showing enlarged oesophageal hiatus, through which abdominal contents can herniate.

Large hernias are more likely to present with other symptoms including epigastric or chest pain, dyspnoea, dysphagia, early satiety, nausea, vomiting and aspiration. They can commonly cause iron deficiency anaemia. Rarely, gastric volvulus can occur resulting in obstruction (a surgical emergency requiring urgent decompression).

Gastroscopy is the most useful investigation. Large hiatus hernias may be seen on chest x-ray. CT scanning, barium study, pH and manometry and gastric emptying studies can help define the anatomy, confirm reflux and exclude other conditions (e.g. oesophageal motility disorders, gastroparesis).

The surgical approach Asymptomatic small sliding hernias do not require surgery. In those with ongoing acid reflux symptoms not controlled with conservative measures and medical management hiatus hernia repair and fundoplication is an effective option and should be considered or as an alternative to longer term medication.

Surgery can almost always be performed laparoscopically with low morbidity in most patients. Complications of fundoplication include dysphagia, inability to belch, gas bloat and increased flatulence. These can be reduced by performing a partial fundoplication without compromising reflux control. Patients may need to follow a modified diet slowly transitioning to solid diet over two months. They should avoid heavy lifting, straining and strenuous exercise during this time whilst the tissues are regaining strength.

The natural history of large hernias is to progress in size with increasing symptoms.

Surgical repair is usually recommended and even in the elderly, provided there are no severe cardio respiratory co-morbidities.

Fundoplication is often not necessary in those without reflux symptoms.

MEDICAL FORUM

Obesity is a major contributing factor in hiatus hernia initially and with recurrence post surgery. Achieving and maintaining significant weight loss is highly desirable.

Combining hiatus hernia surgery with a bariatric procedure is another alternative.

KEY MESSAGES Medical management predominates for small hiatus hernias.

Consider surgery for failed medical management, or as an alternative to long-term medication.

Hiatus repair with mesh.

Recurrence rates for traditional suture repair are high. Absorbable biological mesh has not been shown to be more effective.

Permanent mesh reinforcement does decrease the risk of recurrence as with other forms of abdominal wall and inguinal hernias.

Surgical repair is mostly laparoscopic.

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

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JUNE 2018 | 29

CLINICAL UPDATE

Hepatitis C infection update

By Dr Wendy Cheng, Head Liver Service, RPH, Adjunct Prof, ECU

Challenges still exist in the management of HCV including: Assessment of fibrosis

to 12 week regimes. All DAA regimes are approved only for compensated cirrhosis.

MaviretTM is also approved for specific DAA failures.

Special populations Sofosbvir-based regimes are contraindicated in patients with renal impairment with eGFR < 30min/min. Until the introduction of MaviretTM, treatment of HCV patients were restricted to – genotype 1 (ZepatierTM and Viekira-PakTM) and genotype 4 (ZepatierTM – elbasvir 50mg + grazeprevir 100mg).

Patients with significant co-morbidities e.g. renal failure, coinfections with HBV or HIV and cirrhosis should be referred. Patients with decompensated liver disease may be transplanted before treatment of HCV, to reduce the risk of further decompensation.

Establishing cirrhosis is critical prior to treatment as surveillance for hepatocellular carcinoma (HCC) is required for cirrhotic patients even after SVR. As liver biopsy is not mandatory for treatment of HCV, non-invasive methods of fibrosis are currently being used. Accessibility to Hepascore, Fibroscan or Elastography may be limited in the community. APRI (AST platelet ratio index), a relatively simple test may be helpful to establish the presence of cirrhosis (i.e. APRI > 1). See www. hepatitisc.uw.edu/page/clinical-calculators/ apri for more information.

Drug-drug interactions

Choice of DAA regimes

• Antiarrhythmic drugs – e.g. amiodarone

With the approval of pangenotypic drugs – EpclusaTM (sofosbuvir 400mg + velpatasvir 100mg) and MaviretTM (glecaprevir 100mg + pibrentasvir 40mg) in 2018, treatment of HCV is no longer restricted to genotype 1, 3 and 4. Patients with genotype 1 who do not have cirrhosis are eligible for 8 weeks’ of treatment with MaviretTM and those with viral load of < 6 X 10^6 IU/ml also for 8 weeks’ of HarvoniTM with SVR comparable

• Antiretroviral drugs

Direct acting antiviral drugs have potentially serious drug-drug interactions with several commonly prescribed and over-thecounter medications. It is essential that prescribers refer to Liverpool DDI website prior to initiation of therapy (see www.hepdruginteractions.org).

Drugs include: • Proton pump inhibitors (PPI) • Statins • Antiepileptic medications – e.g.

Phenytoin

• Oral contraceptive pills - coadministration of MaviretTM with ethinyloestradiol-containing products is contraindicated due to the risk of ALT elevations Consider stopping PPI as these may interfere with absorption of DAA with reduced SVR. If essential, low dose PPI

Table: Recommended treatment protocols for treatment-naïve people with HCV and compensated liver disease, including people with HCV–HIV coinfection Regimes

Genotypes

No cirrhosis

Cirrhosis

Harvoni

1

8 or 12 weeks

12 weeks

Epclusa

1,2,3,4,5,6

12 weeks

12 weeks

Maviret

1,2,3,4,5,6

8 weeks

12 weeks

Zepatier

1,4

12 weeks

12 weeks

SOF + DAC +/- RBV

1a/b, 3

12 weeks

Gt1 – 12 weeks Gt3 – 24 weeks or 12 weeks + RBV

Genotype specific antivirals act directly against the Hep C virus.

Community prescribing improves accessibility. Of those infected (mainly baby boomers) about 80% have chronic infection. Challenges remain. once daily may be given at the same time as DAAs, and with EpclusaTM 4 hours before or after PPI. Statins have variable interactions with DAA, some with absolute contraindications.

Phenytoin is contraindicated in all DAA regimes and alternative antiepileptic drugs found. Amiodarone has been associated with severe bradycardia with DAA. Patients should be advised to check with the prescriber with all medications whilst on treatment.

Hepatitis B (HBV) reactivation and hepatocellular carcinoma (HCC) risk with DAA treatment Patients with HBV-HCV coinfection should have HBV treated at the same time. Those with past HBV infection should have ALT monitored and if it rises HBV DNA should be performed to check for HBV reactivation (uncommon and treatable). There is little evidence to indicate increased risk of HCC with DAA treatment, however, those with HCC should have it treated before DAA treatment is commenced.

Treatment of HCV in primary care Online learning modules are available for GPs to get involved in the treatment of HCV – as independent accredited prescribers, referral to tertiary centres, or screening of high-risk patients – depending on training and expertise.

• GESA website: www.gesa.org.au • Edith Cowan University/ DOH WA: http://hepatitis.ecu.edu.au • NPS MedicineWise modules: http:// learn.nps.org.au/mod/page/view. php?id=7278 • Australian Society of HIV, Viral Hepatitis and Sexual Health Medicine (ASHM): https://www.ashm.org.au/training/ Resources available at www.gesa.org. au include references e.g. Australian recommendations for hepatitis C infection, treatment algorithms, and remote consultation referral forms.

Author competing interests: nil relevant.

Questions? Contact the editor.

Legend: SOF= Sofosbuvir; DAC= Daclatasvir: RBV = ribavirin

30 | JUNE 2018

MEDICAL FORUM

BACK TO CONTENTS

Since the May 2015 approval of HarnoviTM (sofosbuvir 400mg & ledipasvir 90mg), the first genotypespecific direct-acting antiviral (DAA) in chronic hepatitis C (HCV), there has been a rapid evolution of new DAAs to pangenotypic regimes, with high efficacy of sustained virological response (SVR) of >95 %. Nonresponders to previous treatment, including DAA failures, can be successfully treated. Strategies to encourage community prescribing have made it possible to achieve total HCV elimination in Australia by 2026.

CLINICAL UPDATE

Preventing deterioration in chronic kidney disease

By Dr Wai Lim, Nephrologist, Nedlands

BACK TO CONTENTS

Chronic kidney disease (CKD) affects one in ten adult Australians (AIHW figures; a probable underestimate of prevalence). Strategies have been used to help identify CKD in the community.

These include automatic serum creatininebased estimated glomerular filtration rate (eGFR) reporting by laboratories, promotion of kidney health checks (blood pressure, eGFR, albuminuria), CKD management guidelines for GPs, apps providing guidance to primary healthcare providers and patients and web-based clinical risk prediction tools for CKD. There are pitfalls in relying solely on eGFR to detect CKD. These include biological variations in serum creatinine, potential laboratory analytical error and external factors that can influence accurate serum creatinine. In fact, the widespread use of eGFR to identify CKD has led to the misclassification and over-diagnosis of people without true CKD, resulting in anxiety and unnecessary investigations.

• In CKD patients with diabetes, target glycated haemoglobin to 7.0% (unless risk of hypoglycaemia).

• Maintain serum bicarbonate within normal range with oral bicarbonate supplementation.

• Dietary information and advice regarding the restriction of salt and intake of protein, potassium and phosphate according to CKD severity.

• Appropriate dose reduction of medications excreted by the kidneys.

• Sustained reduction in eGFR (<60ml/ min/1.73m2) • >25% reduction in eGFR over 6 months

• History / examination • Vascular risk factors • “Nephrotoxic agents” • Urine microscopy • Urine proteinuria / albuminuria • Full blood count, urea / creatinine and electrolytes • Renal tract ultrasound

Early stage chronic kidney disease is often asymptomatic and unrecognised. Community doctors are key to slowing progression.

• Ensure patients seek appropriate advice about prescribed nephrotoxic agents, over the counter medications or protein supplements.

• CKD patients should be considered high risk for developing CVD. Manage using general population treatment guidelines.

• Timely referral to specialist renal services (as per flowchart).

References available on request.

• Family history of hereditary kidney disease • Diabetes • Hypertension: recent onset, long-standing or resistant (requiring 3 or more drugs) • Antibiotics, over-the-counter drugs (NSAID), proton-pump inhibitors) • Sustained proteinuria over 0.5g/day (or equivalent) and/or evidence red cell casts • Recurrent/extensive renal calculi • Unilateral or bilateral small echogenic kidneys • Unexplained normocytic anaemia • Unexplained electrolyte abnormalities (e.g. sodium and potassium) Consider referral to renal services

Even though physiological reduction (i.e. age-related sclerosis) in eGFR occurs with increasing age, it is important to distinguish from other kidney pathology i.e. that needing referral and targeted investigations.

Irrespective of the aetiology, reduced eGFR below 60ml/min/1.73m2 is associated with a heightened risk of mortality and many other diseases, including cardiovascular disease (CVD) and cancer.

A major challenge is differentiating a “benign” process from the more serious. The flow diagram shows a simple diagnostic pathway to assist in decision-making.

In patients with established moderate to severe CKD (i.e. eGFR <60ml/min /1.73m2), a shared-care model between GP's, nephrologists and other specialists is essential. Target CVD risk factors and proteinuria, to (hopefully) delay the progression of CKD and reduce future CVD events.

Evidence-based management tips: • Diabetic and non-diabetic CKD with urine albumin excretion of <30 mg/mmol, target blood pressure to ≤140/90mmHg. • Diabetic or non-diabetic CKD with urine albumin excretion >300 mg/mmol: use angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB). Aim to reduce urine albumin excretion of <100 mg/mmol and target blood pressure to ≤130/80mmHg. Monitor eGFR and serum potassium.

MEDICAL FORUM

JUNE 2018 | 31

CLINICAL UPDATE

Disappointment over new Dengue vaccine?

By Dr Astrid Arellano, Infectious Diseases Physician young children, developing more severe disease when infected with Dengue post Dengvaxia® vaccination. This led to revised product labelling (December 2017) and the recommendation that Dengvaxia® be restricted to those >9 years who live in a Dengue-endemic area or those who have serologic evidence of prior Dengue infection.

Over 400 million people worldwide acquire Dengue with an estimated 500,000 developing severe Dengue-shock-syndrome that causes 25,000 deaths each year.

Australia reports >2000 cases of Dengue every year with most being acquired overseas. Outbreaks occur in Queensland with 385 cases reported in 2016.

• Most Australians travelling to Dengue endemic areas are seronegative and the vaccine is contraindicated for them.

Overall, Dengue remains a risk for Australians who travel overseas and mosquito avoidance is the mainstay for the prevention (see Table).

Appraisal of the vaccine.

Dengvaxia® is a live attenuated recombinant tetravalent Dengue vaccine.

It has been approved in 19 countries but only extensively used in the Philippines and Brazil. The vaccine is administered as 3 doses of 0.5mL, given every 6-months. This induces neutralising antibodies against all 4 serotypes but titres are highest in individuals previously infected with Dengue. Pooled vaccine efficacy in seropositive individuals is reported at 78.2%, whereas only 38% of seronegative people respond to the vaccine.

The youngest age group aged 2-5 years reported only 33% vaccine efficacy.

There has been significant concern regarding vaccine safety with high numbers of seronegative individuals, especially

The Dengue Fever vaccine appears to have limited and specific indications. What about Australians travelling overseas?

BACK TO CONTENTS

Dengue is a Flavivirus infection transmitted by the Aedes aegypti and Aedes albopictus species of mosquito - four serotypes (DEN-1, DEN-2, DEN-3 and DEN-4) circulate globally.

Although most do not, a person who contracts Dengue can develop symptoms. Infected individuals become immune to that serotype but are susceptible to others and at higher risk of severe disease if they contract a different serotype.

Opinion Why is it unlikely Dengvaxia® will take off in Australia (TGA registered in 2017 but currently not available for prescribing.)

• Vaccination schedule (3 injections over 12 months) is impractical for one-off Bali holiday makers.

• Children below 5 years, at highest risk of severe Dengue disease, are not able to be vaccinated with Dengvaxia® due to poor efficacy in this age group and a higher risk of severe Dengue post vaccination.

• There is no data on vaccination in immunocompromised individuals. As a live-attenuated vaccine, the usual contraindications apply.

References: Dengue vaccine: WHO position paper July 2016 Vaccines and Global Health: The Week in Review, 2 December 2017, Centre for Vaccine Ethics and Policy WHO Updated Q&A related to information presented in the Sanofi Pasteur press release on dengue vaccine Dengvaxia® (30 Nov 2017) Author competing interests: nil relevant.

Questions? Contact the editor.

Table: Dengue Fever Profile Incubation period

3-14 days

Symptoms

Fever, headache, retro-orbital pain, myalgia and arthralgia, rash Positive Dengue virus and NS1 antigen by RT-PCR within 1-3 days of onset

Laboratory confirmation

Positive IgM (ELISA) Leucopaenia and thrombocytopaenia common

Management

Supportive

Prevention

Vector control, mosquito avoidance (long sleeved clothing/DEET mosquito repellent/mosquito nets and coils)

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32 | JUNE 2018

MEDICAL FORUM

CLINICAL UPDATE

Claremont Pain Clinic

Heart failure in 2018

By Dr Andrew Klimaitis, Physician, Duncraig Modern heart failure treatment is improving quality of life and survival time. Each intervention should usually be personalised.

Dr David Holthouse Neurosurgeon/Pain Specialist FRACS FRACGP FPMFANZCA

BACK TO CONTENTS

Much has changed since 1982 (my graduation) when heart failure had a 40% 5-year survival, worse than most cancers.

In the early 1980s ACE inhibitors were shown to improve heart failure survival. Likewise, beta blockers in the 1990s and spironolactone in 1999.

Ideally any patient with CCF should be on this heart failure threesome.

Potassium should be monitored, particularly once spironolactone is prescribed, and be very cautious if the baseline K is >4.8.

Heart failure patients can be divided into two groups echocardiographically: two thirds have reduced ejection fraction (systolic dysfunction) and ejection fraction (EF) is normal in the rest (diastolic dysfunction).

Dr Pat Coleman Anaesthetist/Pain Specialist

FANZCA FPMFANZCA FRACGP DRCOG

Providing a Comprehensive Service for Chronic Pain Patients Dr David Holthouse has a neurosurgical background and is a qualified GP. He remains open to seeing neurosurgical cases although the major focus of the clinic is procedural pain management. He also has a keen interest in neurostimulation.

Nothing prolongs survival in diastolic failure. Diastolic dysfunction is often associated with LV hypertrophy, so hypertension should be aggressively treated and sleep apnoea looked for (and considered in systolic heart failure patients).

Dr Pat Coleman is an anaesthetist as well as qualified GP, who has a FPMANZCA and is experienced in pain interventions such as spinal injections, rhizotomies and stimulators. He is also able to see cases with pain issues such as CRPS and post-surgical pain in any region of the body or other pain states.

The data below concerns systolic failure.

About Claremont Pain Clinic

Loop diuretics provide symptomatic relief without improving survival.

In symptomatic low blood pressure stop their nitrate (especially if no angina), calcium channel blocker and thiazide, and try cutting back the frusemide (assuming they are euvolaemic) before reducing their ACE inhibitor or beta-blocker.

• On-site clinical educator and a registered nurse experienced in pain • Focus on neurostimulation as a potential treatment and a comprehensive education program for stimulator candidates to attend • An affiliation with Pain Options – Specialist Physiotherapy • On-site pain/spinal physiotherapist who assists in the rehabilitation of pain patients and workers compensation patients • Close working relationship with a number of other spinal surgeons who are sub-specialists in fusion surgery and often assist in the workup and selection of patients for this surgery • Work closely with a clinical psychologist and psychiatrists with experience in pain management and pain conditions • We do not see patients with active MVIT claims, public liability cases or non-insured patients • We are unable to cater for drug addicted patients who should be referred to a public pain clinic

Natriuretic peptides (NPs) promote vasodilation and natriuresis.

B(brain)NP is released by ventricular wall stress, A(atrial)NP by atrial wall stretch. The enzyme neprilysin breaks them and angiotensin II (AT-2) down; inhibition of this enzyme increases NP levels (good) but also AT-2 (bad); increased AT-2 causes vasoconstriction and fluid retention, counteracting any benefit from increased NP levels.

EntrestoTM combines an neprolysin inhibitor (sacubitril) with an angiotensin II blocker (valsartan) to counteract the increase in AT-2.

The 2016 PARADIGM study compared EntrestoTM to the ACE inhibitor enalapril in NYHC stage 2-4 patients with ejection fractions under 40%. CV death and heart failure hospitalisation were reduced by 20%, and all cause mortality by 16% for those switched to EntrestoTM. When changing from an ACE inhibitor to EntrestoTM, ensure a 36 hour washout period and do not use in anyone with a history of angioedema.

Serum BNP (not covered by Medicare) can be a useful test in dyspnoeic patients. If normal (<100) they probably don’t have heart failure. If 400 they probably do. Between these values you need to rely on clinical acumen.

Implantable defibrillators are indicated in ejection fraction below 35%.

Cardiac resynchronisation therapy (biventricular pacing) can be used in patients with wide QRS complexes (at least 120 ms) and significant symptoms (NYHC 3). Studies show atrial fibrillation patients with LVEF under 35% have reduced combined mortality and heart failure admission rates with AF ablation.

Digoxin does not reduce mortality but can result in less heart failure hospitalisation and improved symptoms.

Workers Compensation • David is part of the Workspine group and both practitioners have a keen interest in workers compensation cases • Workers compensation cases can be referred directly and will be dealt with quickly • Workers compensation consult and procedure slots set aside for cases to be seen urgently

Claremont Pain Clinic Phone: 9385 1323 Fax: 9463 6333 Email: glsfax@jazi.net Address: 12/237 Stirling Highway, Claremont WA 6010 PO Box (please send all mail here): PO Box 563, Claremont WA 6910

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

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JUNE 2018 | 33

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CLINICAL UPDATE

Top ten diverticulitis misconceptions

By Dr Nigel Barwood, Colorectal Surgeon, Murdoch Pressure on hospital beds and an ageing population means the revisiting of ‘diverticulitis’ as a clinical entity is worthwhile.

BACK TO CONTENTS

All attacks of diverticulitis require antibiotics?

Current evidence suggests uncomplicated diverticulitis is more inflammation than infection. Mild episodes get better as quickly without antibiotics. Antibiotics are only needed for severe attacks (e.g. fever), complications (e.g. abscess) or in compromised patients.

Acute diverticulitis requires hospital admission?

Traditionally diverticulitis is admitted under general surgery with IV antibiotics and bowel rest. Current evidence suggests this is only needed in unwell patients (with severe attacks as outlined above).

Perforated diverticulitis requires surgery?

There is a huge difference between localised micro perforation (very common, localised tenderness blebs of free gas around the sigmoid diverticulitis on CT) versus free perforation (generalised peritonitis free gas/fluid on CT). Both are usually reported as ‘perforation’ on CT. Only free perforation requires urgent surgery.

Recurrent diverticulitis attacks make perforation more likely?

Current evidence suggests diverticulitis

is not a progressive condition. The first episode is usually the worst attack. Most will continue to have similar attacks with complications of diverticulitis being relatively rare.

Avoid nuts and seeds?

Current evidence is strongly against this – both are fibre rich and hence probably beneficial.

Diverticulitis is one clinical entity?

There are two variants of mild uncomplicated diverticulitis SCAD (segmental colitis associated with diverticulitis) and SUDD (symptomatic uncomplicated diverticular disease) which has overlap with irritable bowel syndrome.

Changing diet and drugs are useful to prevent attacks?

Surprisingly, these are generally disappointing. While evidence suggests a high fibre, diet leads to a lower incidence of diverticulitis, there is no evidence that instituting a high fibre diet reduces recurrent attacks.

All diverticulitis requires a follow up colonoscopy?

This remains controversial. The incidence of colon cancer masquerading as diverticulitis is much less than originally reported.

Patients with colonic wall thickening on CT should have a colonoscopy to exclude cancer or colitis. My practice is to individualise for each patient but with a

There remains a surprising high level of mythology about management of diverticulitis.

Old habits die hard, until now! general recommendation for colonoscopy unless performed recently.

Asymptomatic diverticulosis is of concern?

Diverticulosis is a very common finding on CT or colonoscopy with prevalence approaching the patient’s age (e.g. 35% at age 45, and 70% over 85 years). Very few patients experience symptoms in their lifetime – a high fibre diet probably reduces this risk.

Two or more attacks means resection?

Diverticulitis surgery is often technically demanding and best left to colorectal surgeons. Despite lap surgery reducing inpatient stays to a few days, the indications for elective surgery have tightened significantly. Complicated diverticulitis (i.e. abscesses over 4 cm, fistulae and strictures) generally require surgery in good risk patients. Micro perforations, phlegmons and small abscesses indicate more significant disease, but don’t necessarily need surgery.

The current approach is individualised patient risk versus benefit.

Author competing interests: nil relevant.

Questions? Contact the editor.

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ASSOC PROFESSOR GARETH PROSSER

MR BORIS BRANKOV

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MEDICAL FORUM

CLINICAL UPDATE

Ketoacidosis in Type II Diabetics on SGLT2 inhibitors

By Dr Paul Grolman, Physician, Joondalup

BACK TO CONTENTS

Large amounts of glucose are filtered by the kidneys daily, all reabsorbed with sodium via Sodium Glucose Co-Transporter (SGLT) on the luminal border of the proximal convoluted tubule. No glucose is excreted in the urine of non-diabetics. Suppressing glucose reabsorption through blockade of SGLT increases overall urinary glucose excretion, reducing plasma glucose levels, independent of insulin and with a low hypoglycaemia risk. SGLT2 inhibitor trials showed reductions in HBA1c levels.

Other benefits include weight reduction likely due to loss of calories in the form of glucose in the urine and a diuretic effect with fluid loss resulting in subtle blood pressure lowering. Uric acid levels are also reduced.

Recent experience at our institution confirms the potentially serious risk of diabetic ketoacidosis (DKA) with these agents. In randomised clinical trials of SGLT2 inhibitors DKA incidence was very low but real world data (FDA adverse event reporting) shows a much higher risk.

Sodium glucose Co-transporter 2 (SGLT2) inhibitors are second line dual therapy. They can cause diabetic ketoacidosis. A high index of suspicion is needed for diagnosis.

Management is similar to DKA management in general, with intravenous fluid and insulin. Cease the SGLT2 inhibitor until the patient’s condition has stabilised. Consider withholding these agents in those acutely unwell or undergoing elective surgery.

Other potential negative effects include increased risk of genital mycosis and UTI’s. Slight increases in serum potassium, magnesium and phosphate levels may occur. Osmotic diuresis induced hypovolaemia can cause a reversible reduction in GFR resulting in acute kidney injury (or potential increased falls risk in the elderly, although this diuretic effect would likely benefits heart failure patients).

Avoid concomitant use of loop diuretics and NSAIDs. Author competing interests: nil relevant Questions or references?

Please contact the editor.

Investigation of use of SGLT2 inhibitors includes ‘off label’ use in type I diabetics and DKA might occur more commonly in this group. In the literature, some type I patients previously diagnosed as type II were unmasked.

Pathophysiological mechanisms for DKA Urinary glucose losses cause lower blood glucose levels which in turn decreases insulin secretion. The lower insulin levels, and increased glucagon secretion (by direct effect of SGLT2 inhibitors on pancreatic α-cells) leads to an increased glucagon/ insulin ratio, which favours a metabolic shift to fatty acid use and ketogenesis. As well, SGLT2 inhibitors increase renal ketone reabsorption.

KEY POINTS VT/VF therapy (shocks) affects quantity not quality of life and can be simply electronically turned on and off.

Mild ketosis is not necessarily a problem and may even have beneficial effects. However, under stressful situations (e.g. surgery, infections or alcohol use), DKA may be precipitated.

Moreover, this diagnosis may be delayed or missed as urinary glucose losses may preclude markedly elevated serum glucose levels. Serum glucose levels may be normal (euglycaemic DKA).

Renal ketone reabsorption means urinary ketone levels may not be elevated, with the ketosis diagnosis missed if only urinary ketones are checked.

Clinical matters Maintain a high index of suspicion if a patient taking SGLT2 inhibitors has clinical features consistent with DKA (nausea, vomiting and abdominal pain), even with a normal blood glucose level. Assess serum acid-base parameters and ketone levels.

There are not extensive robust survival data set of older patients with ICD. ICD patients more commonly die of non-cardiovascular death.

Discussing timing of turning off shock therapy is best done prospectively during reasonable and of mentation.

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KEY MESSAGES SGLT2 inhibitors are not side effect free but their positive effect on blood sugar, weight and CVS risk make them useful.

Use is likely to increase in the future.

DKA risk is low but important. It must be considered in appropriate clinical settings.

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JUNE 2018 | 37

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CLINICAL UPDATE

Hidden allergens in natural supplements

By Dr Meilyn Hew, Immunologist and Allergist, Murdoch

BACK TO CONTENTS

An older woman, with known allergic rhinitis, started daily morning smoothies containing powdered hemp protein, fermented goats milk, maca, kiwifruit, cashews and bee pollen.

A few minutes after the first smoothie she developed itching hands, facial swelling, nasal congestion, breathlessness, and generalised hives.

fungi, bacteria and bee faecal material.

It is held together in granules with honey.

Its use as a protein nutritional supplement has increased.

Skin testing was negative to all components of the smoothie except bee pollen. Further testing showed significant reactions to grasses and tree pollens. Her diagnosis was acute anaphylaxis in an aeroallergic patient following ingestion of aeroallergen in bee pollen.

Skin test reactivity to common aeroallergens especially mug wort, olive tree and grasses correlates with reactivity to bee pollen granules.

Pollen, the male germ from a flower, is the major source of protein for honeybees.

Called â&#x20AC;&#x153;bee pollenâ&#x20AC;?, it is high in plant pollen, dependent on the available plants and may be contaminated with insect body parts,

There is also potential risk for allergy with honey given it can have pollen contamination, and royal jelly. It is unclear whether all patients with aeroallergen sensitivity need to avoid all bee products.

This patient was significantly sensitised to pollen aeroallergens though with little aeroallergy symptoms. One gram of bee pollen (approximately half a teaspoon) is estimated to contain between 0.4-6.4 x 10^6 plant pollen. Two to three tablespoons used in the smoothie would represent high oral pollen intake.

Fertility Specialists congratulates Dr Tamara Hunter on achieving Certification as a Subspecialist in Reproductive Endocrinology and Infertility (CREI).

CREI is an advanced qualification, available to clinicians who are Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Fertility Specialists WA is the only Fertility Unit in Western Australia that is an accredited RANZCOG training facility.

Under the leadership of Medical Director Professor Roger Hart, the unit has trained a number of local and intestate clinicians. Dr Hunter is the first clinician to complete the CREI through the training program at Fertility Specialists.

Dr Hunter consults at both Fertility Specialists WA (Claremont) and Fertility Specialists South (Applecross) Fertility Specialists of WA Bethesda Hospital Claremont Tel: (08) 9284 2333 www.fertilitywa.com.au

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Fertility Specialists South 764 Canning Hwy Applecross Tel: (08) 6217 3800 www.fss.net.au

Bee pollen is one ingredient those with hay fever should watch out for, as this Case History illustrates.

Increasing use of dietary supplements in Australia increases the incidence of allergic reactions to them. Numerous herbal medicines are derived from plants particularly of the Asteraceae family, (common flowering plants) which often

KEY MESSAGES Allergies to natural products are increasing with increased consumption.

Labelling may not always be helpful.

Patient advice needs to be individualized.

continued on Page 40

Dr Tamara Hunter MBBS, BSc, FRANCOG, CREI

Prof Roger Hart MD, FRCOG, FRANZCOG, CREI

JUNE 2018 | 39

GUEST COLUMN

Balint Groups – what are they?

Psychoanalytic Psychotherapist Judy Griffiths is currently the only accredited Balint group leader for health professionals in WA – read on to find out more.

The group shares in a respectful and supportive way what has got in the way of having a meaningful, productive consultation. We meet to hear, reflect and speculate on what may be happening in the meeting between the doctor and the patient for it to stick troublingly in the doctor’s mind. This may be anything from feeling uncomfortable, dissatisfied, worried or disabled, to the sinking feeling of being left humiliated or angry, or with the anxious, niggling thoughts that don’t go away after some challenging consultations.

What happened and what is the doctor left with? A the doctor sits out of the circle and listens, the group reflects on how this scenario affects them as either the doctor or the patient in that consultation.

As the group shares their differing ways of resonating with the issues, there is often a lessening of tension and a deepening of understanding about the human behaviours triggering the situation. The presenting doctor returns to the discussion in the last 10 minutes of the case to face things again with less intensity and a feeling of thinking more reflectively again.

S/he is able to recognise more about what s/he had become caught up in and brought to the group.

Over time in a Balint Group, as the trust of group members deepens, there is greater depth to what can be shared without the fear of people undermining or labelling each other, and the resulting discussions become enriched, diverse and generative in what is brought up for speculation, reflection and exploration. It can be both a companionable and liberating experience for group members.

Balint group members can claim the higher CPD points for attendance when they participate in setting and reviewing the annual outcomes.

Ed: To learn more about Balint Groups see http:// www.balintaustralianewzealand.org/ and for more about Perth groups contact judygriffiths@gmail.com

How does it work? In each meeting members bring two confronting consultations – each lasts for ¾ hour. First we’ll hear the situation that is on a doctor’s mind.

And it will be told to us just as it tumbles out, without preparation or notes so we get the feel of how it was to be in the consulting room.

continued from Page 39

Hidden allergens in natural supplements cause allergic rhinitis and asthma.

Patients with sensitization to Asteraceae pollens may present with allergic reactions to plant-derived complementary and alternative medicines (CAM). These can vary between minor oral allergy symptoms due to plant cross-reactivity, or more severe anaphylaxis (see Table).

When using subcutaneous or sublingual allergen-specific immunotherapy, concentrated allergen induces tolerance. Doses are gradually increased to reduce acute allergic reactions including anaphylaxis. There are reports of some patients having anaphylaxis from taking unconventional treatment containing bee pollen to treat allergic rhinitis, especially when commencing at high levels.

Some authors suggest patients with pollen allergy be advised of the potential risk when consuming pollen products. This patient did not realise the significance of the general allergy warning on the label until her assessment. She now avoids bee pollen, but continues to tolerate honey.

40 | JUNE 2018

Table: Examples of Asteraceae flowering plants and possible cross-reactivities EDIBLE PLANTS FLOWERING PLANTS WEEDS

Lettuce Safflower Artichoke Chicory

Echinacea

Daisies Chrysanthemums

Ambrosia spp (e.g. Ragweed)

Marigolds

Artemisia spp (e.g. mug wort, wormwood)

Sunflowers

Parthenium (feverfew)

Dahlias

CAM

Dandelion Chamomile Feverfew Wormwood Milk thistle

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

BACK TO CONTENTS

In 2009, eight GPs met with me to share and reflect on their difficult experiences with patients. Nine years later, five of the original doctors still meet monthly to bring their painful and difficult consultations. What is it that the Balint Group does that keeps the doctors coming back?

House of Cards – A Sure Bet

By Dr Craig Drummond Master of Wine

WINE REVIEW

A wonderful old Aussie farmer, a relative of mine who is sadly no longer with us, used to tell me, "One could never say I am not a gambler, as being a farmer I bet with at least $100,000 each season". Travis and Elizabeth Wray, the owners and operators of House of Cards, agree with John's statement. They believe "each vintage is a gamble" and "you have to play the hand that you are dealt".

Their 12ha vineyard is located in the Yallingup sub-region of Margaret River. Varieties include Cabernet Sauvignon, Shiraz, Merlot, Malbec, Petit Verdot, Chardonnay, Sauvignon Blanc and Viognier. Original vines were planted in 1997, giving wonderful age; deep rooted to allow them to be dry grown; and subsequently with lowcropping levels giving fruit great concentration. Organic and biodynamic principals are followed as best they can be, with east-west trellising in place to reduce the vagaries of the coastal elements.

The Wrays do the whole process, from viticulture, to vinification, to the promotion and marketing of the final product. For this, as like many we feature in Medical Forum, I take my hat off to them as I know the difficulties of that workload.

Things that particularly impressed me about their operation were, firstly, their website, which is full of up-to-date information when so many others are not, and, in particular, is the amazingly original and eclectic packaging. It portrays various aspects of the pack of cards, and of various card games. Added to this is the detailed information on production methods on the labels. As a previous producer, I am well aware of the importance of what the consumer sees 'on the shelf'. However, most important of all is what’s in the bottle and, as my tasting notes indicate, it did not disappoint. Their gamble is certainly paying off.

House of Cards 2016 Blackjack Malbec (RRP $48) It would be easy to name the Ace of Space "wine of the tasting" and, yes, it is impeccable. However, I’ve chosen this Malbec for its expression of a great variety that I am keen to see promoted here in our state. This Southern French variety, I believe, has a superb second home in the South West/Great Southern regions of WA. I am always excited to taste them as varietals from our state and this example doesn’t disappoint. Still so youthful with a vibrant lively deep purple colour, the aromas briary and brambly, with a touch of aniseed and fennel, and sandalwood characters from oak. It is full-bodied, warm on the palate, with earth and pepper, fine, focused, dusty tannins, firm linear acid, and lingering sweet fruit on the finish. I give this wine another 10 years to mature.

1. House of Cards Three Card Monte 2017 Sauvignon Blanc (RRP $25)

3. House of Cards 2015 The Royals Cabernet Sauvignon (RRP $40)

The striking feature of this 100% SB is the aromatics, lifted, rich gooseberry and green herbs, with a flinty underlying character.

Reminiscent of the great wines of Graves (Bordeaux), 0ak-ageing for 12 months (20% new) and seven days’ skin contact resulting in powerful and complex flavours. Fruity characters abound – gooseberry, green bean and nettles. Oak gives weight structure and complexity. This is not your short-term fruity SB style.

Crunchy acidity holds it all together. Despite strong winemaking influences, the varietal character shines through.

A medium-to-full-bodied Cabernet that is very enjoyable now but will benefit from 4-6 years in your cellar. It shows a slightly developed garnet colour; on the nose there’s redcurrant, cinnamon, dried herbs and cedary oak. Flavours include black plum and black olive, the tannins fine and focused, medium acidity, oak is well integrated considering its 18 months’ (35% new).

2. House of Cards The Royals 2017 Chardonnay (RRP $40) Here’s an enjoyable Chardonnay in the ever-reliable Margaret River style. The nose shows opulent ripe pear and peach skin.

The oak is integral and the palate textured, complex, with nectarine and white peach. Clean acid finish. Medium length.

For mid-term consumption.

MEDICAL FORUM

4. House of Cards 2015 Ace of Spades (RRP $65) In the producers words "the highest of the deck" and I’d agree.

Composed of CS 50%, Malbec 25%, Petit Verdot 25%, it is a variation on the classic Medoc (Bordeaux) blend and it works beautifully. A blend from the best six barrels in the winery.

A wonderful wine. Subtle yet powerful. Smooth, mellow, sliding across the palate. So easy to consume now, but if you have the will power, it will go on for many years. Classic cassis; sound structure from non-evident acid and fine tannins. Everything in beautiful balance.

JUNE 2018 | 41

Home: The place doctors hope to go when they die. Considered mythical.

SCIENCE OF PUNS I left my Adderall in my Ford Fiesta.

Now it’s a Ford Focus.

What do you call a Mexican bodybuilder who’s run out of protein?

No whey Jose.

Heisenberg is out for a country drive in his new Lamborghini.

A police officer stops him and asks: “Do you know how fast you were going?”

Heisenberg responds; “No, but I know exactly where I am.”

Two chemists walk into a bar. The first one says “I’ll have H2O”. The second one says “I’ll have H2O too”. The second one dies.

Q: What did Gregor Mendel say when he founded genetics?

A: Woopea!

Never trust an atom… they make up everything!

An unemployed biologist was having considerable difficulty in finding a new job. He finally saw an add in a local newspaper for a position at a zoo.

In the interview, the manager told him that their only gorilla, which had been a star attraction, had recently died, and it would be sometime before they could replace it. Meanwhile, they needed someone to dress up as a gorilla and pretend to be the animal. The biologist was quite embarrassed, but, being desperate for money, he accepted the job.

The next day, the biologist put on a gorilla skin and headgear and entered a cage from a rear entrance. Visitors smiled at him and threw bread. After a while, the biologist really got into the act.

He jumped up and down, beat his chest and roared as people cheered.

The following day, the biologist entered the wrong cage by accident and found himself staring at a lion. The lion roared and rushed toward him. The scared biologist turned and ran, while screaming, “Help! Help!”

The lion leaped onto the gorilla, knocked him to the ground and whispered in his ear, “Hey, it’s me Leonard, your former co-worker.

Shut up or we’ll both lose our jobs!”

One mouse to another: “look at that fellow with white coat on. whenever I push the paddle, he starts writing something!!!”

"Some cause happiness wherever they go; others, whenever they go."

- Oscar Wilde Old chemistry teachers never die, they just fail to react.

Student: I… have a confession to Make Prof Professor: Uh Oh Student: I had an accident in the Lab Professor: Did anyone die?

Student: No Professor: Is anyone going to sue us?

Student: No Professor: Was any equipment permanently damaged?

Student: No Professor: Did you clean it up?

Student: Of course Professor: Did you get data out of it?

Student: Actually yes…

Professor: CAN YOU DO IT AGAIN I was on a flight the other day when the air hostess came up to me and said, "Excuse me sir, would you like to have dinner?"

I said, "What are the options?"

She said, "Yes and No."

Wine winner

42 | JUNE 2018

The winner of the Lambert Estate Doctor’s Dozen, Dr Theresa John, says she doesn’t know much about wine but she’s more than happy to drink it! Theresa leans towards the safety of sparkling and happily confesses to being overwhelmed by all the available choices. With 12 bottles of Lambert’s in the cupboard and a 50th Birthday coming up, Theresa’s task just got a little tougher.

MEDICAL FORUM

OPERA

Sizzling in Seville It’s 7.30 in the evening in Washington DC when Medical Forum sits the everbusy ex-pat Australian conductor Antony Walker down for a discussion about his upcoming turn at WA Opera for its 2018 production of Carmen in July.

Music lovers will instantly know the phenomenal output of this apparently tireless musician. In Australia he established the baroque opera company, Pinchgut Opera, the early music ensemble, Orchestra of the Antipodes, the choral group Cantilation and he’s been at the helm of productions in just about every opera company and state orchestra in the land.

Making his home now in the US with his partner Lauren and five-year-old daughter Genevieve, based in Minneapolis, Antony leads the Washington Concert Opera and the Pittsburgh Opera companies, and the buzz is they love him as much there as we do here Down Under.

The night before our chat he was leading a group of his singers at a gala at the Italian embassy. Rossini was on the menu. Such is the ease in which Antony Walker moves between cultures and musical styles. He thanks Australia a little for that.

“I am grateful for my Australian upbringing – its freedom and giving me the knowledge that I am no better and no worse than anyone I meet throughout my day. Everyone is accorded with the same respect and I think that is noted and appreciated everywhere,” he said.

And that’s a handy attitude to have

because Antony covers an awful lot of ground in his musical life. The list of opera companies and orchestras with whom he has performed is long, but each has their own way of doing things, so flexibility is an essential quality. What is not negotiable is the primacy of the music.

However, back in Australia and Perth this month, Antony will return to his happy sotto voce self, joining director (and onetime Perth festival director) Lindy Hume in leading the WA Opera’s long-awaited Carmen, Bizet’s gloriously sumptuous drama set in Seville.

In Italy, he said, order at rehearsals is restored only with a little shouting.

Queensland mezzo soprano Milijana Nikolic smoulders in the title role with tenor Paul O’Neill as the hopelessly-in-love Don Jose, James Clayton as the swaggering toreador Escamillo, and Emma Pearson as Carmen’s friend Micaela.

“The Italians expect a firm conductor. Now I’m not a shouter but I had to learn to do a bit of it when I took over from an ailing Bruno Campanella for a season of Rossini’s Semiramide at the Maggio Musicale in Florence back in September 2016.”

“The title role was being played by Australian soprano Jessica Pratt and it was such a thrill. The last time that opera was staged in Florence, Joan Sutherland was singing and Richard Bonynge was conducting – two great Australians.”

While the opera is set in Spain, Bizet is, of course, French and Antony thinks this cross cultural marriage brings forth a synthesis of elegance and passion. He felt moved by this idea when he and his partner toured Spain in December last year for his 50th birthday.

“I have always wanted to explore Andalusia – Seville, Cordoba, Granada – and feel what composers for centuries have been inspired by. It was a transformative experience. There is a distinct cultural aesthetic.”

“Hearing Carmen now – I can feel and understand that Spanish passion of the second and third acts; the drama and the dread of what’s to come. I can also understand the French lightness of act 1.”

“Bizet premiered this work at the Opéra-Comique in Paris on March 3, 1875 and people were expecting it to be much lighter than it was.”

As it turned out, Carmen’s sensuality (rather than her cigarette habit) was almost too much for the Parisians to bear but the accumulative controversy has only served to make this opera one of the most treasured in the repertoire.

It’s got the lot.

By Jan Hallam

JUNE 2018 | 43

COMPETITIONS

Entering Medical Forum's competitions is easy!

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

Scandanavian Film Festival Celebrating the best in Nordic cinema, the Volvo Scandinavian Film Festival next month offers some great cinema from Denmark, Norway, Sweden, Iceland and Finland. Highlights include the Danish dark comedy A Horrible Woman, and people’s choice winner What Will People Say from Norway.

Cinema Paradiso, July 19 July to 1 August

Dance: Sydney Dance Company ab[intra] The world premiere of Sydney Dance Company’s latest creation, ab [intra], heads to Perth as part of the company’s 2018 season. ab [intra] is an electrifying journey to the extremes of human nature – a dynamic work of powerful athleticism and sublime aesthetics.

In 2019, Sydney Dance Company celebrates its 50th anniversary. Once synonymous with the creative output of dancers/choreographers Graeme Murphey and Janet Vernon, SDC has been under the inspired guiding hand of Rafael Bonachela since 2008.

In ab [intra], Bonachela again teams up with composer Nick Wales. Known for his challenging and abstract dance scores, Wales’ work has included collaborations with Sean Parker and Company, Ballet de l’Opéra de Lyon, performance artist Justin Shoulder and singersongstress Sarah Blasco.

Discover what drives our relationships and ignites our ambitions in this visceral new piece showcasing Australia’s best contemporary dancers.

Movie: Equalizer 2 Denzel Washington reprises his role as vigilante Robert McCall in the sequel to the 2014 box office hit The Equalizer, which is based on the TV series about a retired CIA black op’s agent who’s a hired gun for vengeance. How far will he go when it's someone he loves?

In cinemas, July 19

Movie: Brothers’ Nest The Jacobson brothers Shane and Clayton, who brought Kenny into our world, join forces precariously again in this family comedy that sees them attempt to change their dying mother’s will so their stepfather does not benefit. But they have to get along to see that one through.

In cinemas, June 21

His Majesty’s Theatre, June 28-30, 7.30pm

Opera: Carmen

Winners from April Comedy - Craig Hill: Dr Jenny Vance Movie - Spanish Film Festival: Dr Cathy Irvin, Dr Mireille Hardie, Dr Mariet Job, Dr Danii Paterson, Dr Greg Hogan

One of the most thrilling opera’s in the repertoire – proud, fiery and defiant, Carmen is a femme fatale who lives by her own rules. She draws Don José into her wild world and he falls under her spell, leaving his sweetheart, Micaëla, and his honour behind.

Hearts in our Hands GPs on Lifestyle & Drugs CVD & Rural Dilemmas; HT; Endometriosis Research Focus & Results

MAJOR PARTNER

Movie - Tully: Dr Neda Namdar, Dr Tuck Chin, Dr Rob Hendry, Dr Tanya Subramaniam, Dr Joanne Keaney Musical - Mamma Mia!: Dr Clare Matthews. Dr Kate Hammond Theatre - Summer of the Seventeenth Doll: Dr Ravinder Dhillon

His Majesty’s Theatre, July 21-28, 7.30pm

New Rules for Data Breaches

April 2018

www.mforum.com.au

Music: David Helfgott & Rachmaninoff David Helfgott returns to Perth with an astounding two-piano version of the famous Rachmaninoff Piano Concerto No.3 in D minor, which features prominently in the biopic of his life, Shine. Welsh pianist, soon-to-be Australian Rhodri Clarke will play orchestra to Helfgott’s solo. Also enjoy some Liszt solo works.

Perth Concert Hall, July 20, 7.30pm

44 | JUNE 2018

MEDICAL FORUM

MUSIC

‘Rach 3’ Shines On Rachmaninoff’s mighty Piano Concerto No. 3 has defined David Helfgott’s life and career since he was a young man. Some in WA will remember a capsule of time when he was one of the main reasons for pulling up a stool at Riccardo’s bar in Northbridge. Not before or since could you hear a musical maestro for the price of a glass of wine.

Since the release of his biopic Shine in 1996, David is most often found in the best concert halls in the world, but he never forgets WA – returning to play concerts in all manner of venues. In July he will be in the Perth Concert Hall where he and fellow pianist Rhodri Clarke debut in WA the twopiano version of ‘Rach 3’.

David will play the piano role while Rhodri does a stupendous job of playing the orchestral accompaniment transposed for the piano.

Medical Forum caught up with the Welshborn, soon to be newly minted Australian Rhodri Clarke at his Melbourne home. He has been thrilled to be on this magic carpet ride with David Helfgott for the past three years.

the year the movie came out. It was his first world tour and my parents had the amazing insight to take me to the concert.

He was the first solo concert pianist I had seen and we were all blown away by his performance. Several years later I studied at the Royal College of Music just as David had done.”

“It feels like I’ve been following him around!”

The pair now tours the world with this piece, most memorably last year in the famous Golden Room in the Musickverein in Vienna.

“Every performance we give, it feels electrifying to play and to witness the audience reactions. I had to pinch myself in the Golden Room, You couldn’t ask for a more sumptuous, beautiful concert stage and knowing that we were walking in the footsteps of all the great performers, it was daunting and exhilarating.”

Rhodri and his Australian-born wife are now settled in Melbourne after meeting more than eight years ago. The “Hollywood

story”, as he likes to describe it, began on an early morning flight out of London’s Stansted Airport and they have been together ever since.

Rhodri’s musical life as collaborator and accompanist sees him agilely moving between chamber work as part of the Melbourne Piano Trio to accompanying singers and solo instrumentalists.

“Many musicians like to specialise in an area but I see myself as a jack of all trades for piano accompaniment and collaborative work, and I have always wanted to work like that since the age of 12 back in school.

Then I was asked to be repetiteur for school productions and I got to know a lot of musical theatre repertoire. In some way I have always done diverse work,” he said.

“I’ve been fortunate to continue to do that at a high level working with wonderful experienced musicians and students at Melbourne and Monash universities. It’s very rewarding.”

By Jan Hallam

The pair first performed the ‘Rach 3’ twopiano version at the Sydney Opera House, which Rhodri admits was a fairly auspicious venue for the piece’s first airing.

“David has been touring the world now for the past 30 years playing that piece with an orchestra so, for him, it was a completely new challenge to present that work with another pianist. In the rehearsal process, which was a fairly slim two sessions before the concert, it was so important for us to get to know each other’s musical ideas,” he said.

“I feel strongly that when you play collaboratively, it’s essential to have a connection with the other musician. You need to like the person you’re performing with. As soon as David and I met, we had this special connection.”

“It was also important in the context of that piece of music. David’s life has been lived through the prism of that work. He knows it intimately but he made sharing it with me pretty easy. He’s always listening to my ideas on interpretation. I think that’s another reason it works so well.”

While West Australians have their David Helfgott stories to share, Rhodri has one of his own.

“The first time I saw David play, I was about 15 when he came to Cardiff for a concert,

MEDICAL FORUM

Rhodri Clarke and David Helfgott

JUNE 2018 | 45