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July 2011 $10.50 MAJOR SPONSORS

Perth Pathology

WA’s I n d e p e n d e n t M o n t hl y f o r H e al t h P r o f e s s io n al s

Men’s Health E-poll: Male Medicos Speak Out

Domestic Violence Empowering GPs to take action More Men’s Health:

Pioneer Dr Denis Cherry & Advocate Gary Bryant Sex Laws Threaten Clients’ Health Emerging Treatments for Myelodysplasia How to Choose the Right Smartphone Luxury BMW 730d Test Drive

Campaigner for Justice John Quigley MLA

Aust Australia’s Leading MDO

Major Sponsor:

Perth Pathology

Contents John Quigley: Man With a Mission


Dr Denis Cherry: Men’s special Business



Gary Bryant: Advocating for Blokes


The challenges of general practice in wa

25 Debunking Domestic Violence Myths.

44 Public Health and Medical Practice (Part 2).

2 Letters. Competency and Compassion.

28 Convergence of the Grey Nomads.

45 Laser Refractive Surgery – In a Nutshell.

Four Hour Rule.

29 Policing Domestic Violence in WA.

WorkCover’s World.

31 The Regional Men’s Health Initiative.


Angela Hartwig

Dr Abby Harwood

A/Prof Tim Leahy

Dr Revle Bangor-Jones

Carol Davenport

Mr Kim Snowball

Dr John Quintner

Dr Prasad Kumarasinghe


Julian Krieg

The Early Bird.

Dr Michael Morley

Support for Brain Tumour Patients

Mr John Crofts

10 E-Poll: Male Medicos Comment on Men’s Health 12 Eyes on the Screen: Telehealth 17 Have You Heard? 19 More Cosmetic Tourism. 21 Practice Tip: Single Issue Consultations. Dorothy (Dot) Melkus

23 The Toll of Workplace Injury. 33 A Glimpse Inside the Tackle Box. Beneath the Drapes. 37 Conference Corner.

Dr Ian Chan

46 Dermatology Update: Vitiligo.

32 Talking Men’s Tackle.

48 Wine Review: Rusden Wines.

34 Non-communicable Diseases: The Battle Ahead for GPs.

49 Recipe. The Funny Side. 50 How to Choose the Right Smartphone.

A/Prof Alan Wright

Adj A/Prof Trevor Shilton

Clinical Focus

Dr Martin Buck

Shane Cummings

5 Emerging Treatments for Myelodysplasia.

51 It’s All Done with Mirrors.

37 Triple Antithrombotic Therapy: Avoiding a ‘Little Aussie Bleeder’.

52 BMW 730d: A Luxury Limousine with Grunt.

39 Update: Sexually Transmitted Infections.

53 Competitions. Competition Winners – May edition.

Wendy Wardell

Dr Rebecca Howman

Dr Philip Cooke

Dr Lewis Marshall

Drs Daryl Sosa and Peter Bradley

tralia’s Leadin Opinion

Dr Michael Ledger

4 Looking For Ethics. Dr Rob McEvoy

21 Sex Laws Pose a Hidden Threat to Men’s Health. Meg Marshall

41 Technological Influences on Knee & Shoulder Surgery.


55 Clinical Services Directory. 78 Classifieds.

42 Anxiety in Pregnancy and the Postnatal Period. A/Prof Jonathan Rampono

43 History Repeats – Using the Family Health History.

Medical Forum Buyer’s Guide. (Supplement)

Dr Ian Walpole

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Advertising Mr Paul Morgan (0403 282 510)

EDITORIAL TEAM Managing Editor Mr Shane Cummings (9203 5222) Medical Editor Dr Rob McEvoy (0411 380 937) Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810)

Editorial Advisory Panel Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the 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. 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.

Graphic Design Pierre Designs Graphique

Medical Forum Magazine 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email

ISSN: 1837–2783


Letters to the Editor

Competency and Compassion Dear Editor,

I agree with Dr Rob McEvoy (Where to with Cultural Competency, June edition) that cultural competence is important in working with Aboriginal patients and that training can be helpful. I applaud any doctor who is interested in Aboriginal health and takes a bit of time to improve their care.

I use a combination of cultural knowledge and other types of knowledge and approaches in my management of Aboriginal patients. Much of what works for me is a strong commitment to courtesy and genuine warmth and care, with a strong interest in the life of the person I am dealing with. For example, with many of my patients, it’s important for me to know which footy team they are passionate about, where their country is, and what they are looking forward to when they next get back there (e.g. fishing or hunting bush turkey).

My experience tells me many patients are sick of “too many tablets”, and I often find myself giving permission to express this frustration, allowing for an honest and creative discussion about what tablets are most important, which can be made daily, and which can be ceased.

of cultural safety training modules for GPs, which are available through the Aboriginal Health Council of WA.

Il ne chantera plus mon merle, il ne chantera plus” ( Sob Sob ! )

The Early Bird

Four Hour Rule

Dear Editor,

As always, I enjoyed reading great wine buff Louis Papaelias’ article in your May edition on Irvine Wines – especially the 2004 Irvine Grand Merlot. However, no mention was made of why a wine is a Merlot! Of course, Shiraz originates from Shiraz in Iran, Muscat from Muscat etc. But there is nowhere called Merlot! So here is my explanation …

I was born in Mauritius at our family home called “Villa Louise”. As I was a bit slow at waking up (comme toujours!) my grandfather Louis gave me a sip of Veuve Cliquot Champagne (“Ancient Widow”), which did the trick! So I think this is why I retain an interest in French wine names. Merlot is named after the blackbird – le Merle – which is the first European bird to breed in the early spring. The Merlot vine is the first to flower, fruit, and be picked. After a few glasses of Merlot you might like to sing this ditty:

“Mon merle a perdu une plume (plume plume)

Dr Michael Morley, Crawley

Dear Editor,

With more than 830,000 presentations to our emergency departments last year, the benefit to the WA community of the success of the Four Hour Rule program cannot be understated.

All stage 1 hospitals – Royal Perth, Princess Margaret, Fremantle, and Sir Charles Gairdner – have made significant improvements and are in most cases exceeding their Four Hour Rule targets: 85% of patients transferred, discharged, or admitted within four hours (with three hospitals consistently above 90% and PMH hitting 100% several times in the past month). Recent figures show access block (where patients wait longer than eight hours for a bed) has dropped to 10.9% in March 2011, compared to 25.1% for the same time in 2010. This outcome is all the more remarkable in the face of increases of up to 9% in emergency presentations. This is an effort by the whole health system to deliver real results. Credit must go to the clinicians and other hospital staff who have

Add to all that an interest in making life a bit easier. This means enrolling patients in the Medicare Indigenous Practice Incentive Payment, including writing CTG with my initials on their scripts, to get PBS medications cheaper or free (if they have a health care concession card).

For another patient today, I asked about their housing situation – there are at least six people in the house including a sibling who drinks heavily. This situation will put my patient’s current sobriety and health at risk if it continues. I offered to help with any further efforts to get independent housing and this was much appreciated.

Quite a few patients lately have been very interested in referrals for dental care under the Medicare arrangement for those with chronic conditions, with GP management plans and team care arrangements. The referral covers dental treatments up to $4250 over two years. As C. S. Lewis said, “Knowledge combined with competence has the power to make human life better. However, (they) are not enough on their own.” He calls for a knowledge combined with passion for a just world. I agree, and I am interested in the views of others.

A/Prof Tim Leahy, Mt Lawley

Ed. Although Tim is an A/Prof of Indigenous Health in the School of Medicine, University of Notre Dame Australia, his letter reflects his personal opinion as a GP. Tim is a co-author 2

Doc of the Swan: Cheque Please! At the Royal Freshwater Bay Yacht Club cheque presentation last month, it was announced that the Doc of the Swan charity raised around $10,000 this year. Pictured left to right: Rear Commodore Ian Clarke (Royal Freshwater Bay Yacht Club),

Dr Gordon Baron-Hay Grant recipient Vicky Corkish (Nurse at PMH), Ian DeNazareth (PMH Foundation Board Member), Pat Baron-Hay (wife of the late Dr Gordon Baron-Hay, the event’s co-founder), and Chrissie Jordan (Doc of the Swan Organiser). l


shown a willingness and desire to make this program a success.

The Four Hour Rule program has delivered on safety and quality and means that our patients are not waiting inordinate amounts of time in emergency departments; they are receiving safe, timely, and appropriate care.

Indeed, WA is the envy of other states. WA Health has led the nation with the Four Hour Rule program. It is testament to the success of the program in this state that other jurisdictions across Australia are now moving towards introducing similar programs as part of national health reforms. During my recent visits to the stage 1 sites, it was evident that our hospitals are better places to work. The message from staff was very clear – nobody wants to return to the old approaches. Our work has not finished. WA Health will continue to strive to improve our hospital system.

Mr Kim Snowball,

WA Director General of Health

WorkCover’s World Dear Editor,

I had to smile when I read the request by Ms Michelle Reynolds, WorkCover’s CEO, for suggestions from your readership as to how to make the WA workers’ compensation scheme more efficient (Workers’ Comp Matters advertisement, June edition). Of course, this would be extremely difficult given that on the face of it the current system appears to be well nigh perfect. Through its Guides for the Evaluation of Permanent Impairment, Third Edition, WorkCover has reinforced biomedical reductionism, a bastion of medical

fundamentalism whereby each and every injury must be assessable in terms of its underlying demonstrable pathology. To this end, psychiatric conditions have been rebadged as measurable (but only by WorkCover trained psychiatrists) impairments. Here, as evidenced by the Psychiatric Impairment Rating Scale (PIRS), WorkCover has used “impairment” as a surrogate for “disability”.

Unfortunately “pain” has not been rated as a similar “impairment”, although in most industrialised countries it is a significant barrier to many injured workers who wish to return to work. I accept that there are no validated instruments for its assessment, but as far as I can ascertain, the PIRS, which is based on self-report, has not been properly evaluated for its reliability and validity. So much for the Guides’ purported accuracy and objectivity. To ensure that its system continues to work so well, WorkCover has convinced sufficient medical practitioners to go along with this charade, although it must be said that the financial rewards made available to them are not inconsiderable.

Support for Brain Tumour Patients Dear Editor,

Local registered charity, the James Crofts Hope Foundation, has recently commenced facilitated brain tumour support group meetings. They are held at 6pm on the last Tuesday of each month (including public holidays) at “The Niche”, corner of Hospital Ave and Aberdare Road (next to Sir Charles Gairdner Hospital). The meetings’ facilitator is from the Neurological Council of WA. The support group has 38 members, and each meeting can attract up to fifteen people. Anyone with a brain tumour and their family and carers are welcome to attend. More information on the Foundation and its support group can be found at www.

In the immortal words of Marcus Tullius Cicero, Cui bono?

John Crofts, Innaloo

Dr John Quintner, Mount Claremont

Ed. WorkCover’s CEO Michelle Reynolds was asked to reply to John’s letter, but she declined the offer.

@ LETTERS INVITED Letters over 300 words may be subject to editing. Deadline: July 10th for the next edition. Send to All letters must be accompanied by a high-resolution image of the author, and those over 300 words may be subject to editing, Go to to send us a lead for your story.

Blast From the Past Renal physician Dr Mark Thomas dredged this old beauty from the archives, circa the 90s. Mark said, “I think it was at the Premier’s award for our inaugural remote area dialysis service and first aboriginal self-care home HD patient.” From left to right: Sr Chay Lim, the administrator who issued the award [name lost to history], Sr Jenny Whishaw, Dr Mark Thomas, Sr Sandie Porter, social worker Rosemary Offer, and Sr Margaret Matthews. (Stalwart HD technicians not pictured but a crucial part of the team: Mr Fred Ordynski and Cheryl Ducat).



Editorial By Dr Rob McEvoy

Looking For Ethics Life at a fast pace, with competition all around, is not conducive to careful introspection amongst medical leaders. As followers, should we give a toss or simply go with the flow? Given recent events, I’m not the only one wondering where the profession’s moral or ethical compass is pointing and who is cradling it, doctors or lawyers. Are we to see altruism and concern for others overshadowed by legalese? Has society just headed that way and the profession is along for the ride, or are we leading the charge? You might think society has become less forgiving of doctors’ mistakes but the alternative is hard to swallow – we are now a spineless lot. Rarely do you hear a doctor speak out loudly on principle – this is wrong, ignore the politicians, or, the profession will not tolerate it! Instead, we see spokespeople ducking and weaving and whistleblowers given a hard time. Our medical defence organisations tell us to empathise but not admit liability. Why? It’s to minimise risk (read cost). Responsibility for actions, transparency and accountability amongst peers are trumpeted as ideals but often poorly adhered to. Professional shame is outdated; everyone for themselves is the new doctrine. The adversarial world of the legal profession, which is way behind in the reform

stakes, now dictates professional behaviour in ways that often do not sit well with a caring profession.

During the interview for our Pioneer spot, Dr Denis Cherry (page 8) said the tone of his internal dispute over patient care soured badly when lawyers got involved. In another interview (page 6), John Quigley MLA outlines how he rejected the money-buys-justice system to enter politics and free Mallard. In conversations of late, someone often ends up lamenting that altruism and the I’m-smallerthan-the-profession outlook appears to be fading, as a generational thing. So, am I just a sad old fart or are my concerns important? The coming squeeze will tell. As tax dollars decline and retiree numbers increase, health priorities will be hammered out in the media (or behind closed doors amongst who-youknows). A look at just one June edition of The West is a good example. In it, we read Avocare is under-resourced to care for the 4.6% of WA elders being abused. The Carson Street School doesn’t want Education Minister Liz Constable to pull the $220,000 pa grant

to help 15 severely disabled children. The State is spending $8m on a body to oversee publicly funded health and medical research. The WA Sports Federation chairman resigns from Healthway, unhappy that sporting bodies that accept junk food or alcohol sponsorship could suffer a $30m shortfall. Health Minister Kim Hames says delays in getting a specialist appointment at public hospitals were unacceptable but funding was needed for school health services and child health nurses. A Fremantle Hospital doctor is attacked at night in the car park, prompting a revamp of CCTV and lighting. They are all competing legitimate interests with enough voice to be noticed. In this clamouring for attention, the ethical foundations of the profession will need to be unequivocal and strong. Will we shine as advocates for our patients and craft, or just ourselves? In this regard, I’m not convinced that some people who say they represent the profession, really do.

I live in hope that a group of health professionals, preferably not confined by religious dogma or politics, will bubble to the surface and put professional ethics on top. l

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Dr Rebecca Howman FRACP, FRCPA, MClinRes. Haematologist. 0417 935 873

Perth Pathology

Rebecca is a local graduate who trained at Perth teaching hospitals and at the Peter MacCallum Cancer Centre, Melbourne. Her special interests include myelodysplasia, the diagnosis and management of haematological malignancies, and obstetric haematology. She works at Perth Pathology, Sir Charles Gairdner Hospital and Hollywood Medical Centre.

(Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 Ph 9433 5696 Fax 9433 5472 Collection centres throughout the Perth metropolitan area including: Fremantle (Main Lab); Perth CBD, Atwell, Bedford, Belmont, Bentley, East Perth, Ellenbrook, Hilton, Joondalup, Kardinya, Kinross, Maddington, Malaga, Palmyra, South Lake, South Perth, Southern River, Subiaco, West Leederville

Emerging treatments for myelodysplasia By Dr Rebecca Howman


yelodysplasia (MDS) is a condition predominantly affecting the elderly population that traditionally is managed with transfusion of packed red blood cells and platelets, and antibiotics for bacterial infection. Whilst supportive care remains a central component of the management of all patients with MDS, it is not without risk, such as iron overload from repeated red cell transfusion. Further, it does not treat the underlying malignant condition affecting the bone marrow and the risk of progression to acute myeloid leukaemia. Patients with intermediate-2 or high-risk scores on the international prognosis scoring system (see Table) have a median survival of 1.2 or 0.4 years respectively and are at high risk of progression to acute myeloid leukaemia. Until recently there have been no treatment strategies, apart from allogeneic stem-cell transplantation in younger patients, that could meaningfully alter the natural history of this disease.

DNA hypomethylating agents (azacitidine)

Aberrant DNA hypermethylation has been implicated in the progression of MDS. DNA-methyltransferase inhibitors reverse hypermethylation and restore normal transcription of suppressor genes. One of these agents, azacitidine was shown to improve overall survival (median 24 months compared to 15 months with standard care). Importantly, a significant proportion of patients in this study became transfusion-independent. Azacitidine is administered by subcutaneous injection given 7 days every 28 days. The median time to first response is 2 months with a median time to best response of 4 months. The main adverse effects are initial worsening of cytopenias prior to haematological response and local skin reactions. In February 2011 azacitidine became available on the PBS under Section 100 for patients intermediate-2 or high risk MDS. A similar agent, decitabine, is approved for the same indication in the US and Europe.

Table: International prognosis scoring system (IPSS) in myelodysplastic syndrome Variable Bone marrow blasts Karyotype* Cytopenias**

0 <5% Good 0/1

0.5 5-10% Intermediate 2/3

Risk group Low Intermediate-1 Intermediate-2 High


1.5 11-20% -

2.0 21-30% -

IPSS score 0 0.5-1.0 1.5-2.0 2.5-3.5

* Karytope definitions:

Good: Normal;-Y; del (5q); del (20q)

Perth Pathology

Poor: Complex (≥3 abnormalities); abnormal chromosome 7

Intermediate: All others

** Cytopenia definitions:

Red blood cells: Haemoglobin <100 g/L

White blood cells: Absolute neutrophil count <1800/µL

Platelets: Platelet count <100,000/µL


Lenalidomide, related to thalidomide, is an immunomodulatory drug that has approval in Australia for the treatment of relapsed and refractory multiple myeloma. It has multiple mechanisms of action and has been shown to benefit patients with MDS, most potently patients with low and intermediate-1 risk 5q- MDS. 5q- is a specific subtype of MDS in which an interstitial deletion on chromosome 5 results in macrocytic anaemia, thrombocytosis and megakaryocytic dysplasia. In clinical trials of this subgroup, lenalidomide has led transfusion independence in up to two-thirds of patients. There is also improvement in transfusion requirements in patients with non5q- MDS. The combination of lenalidomide with azacitdine is currently being studied in

Score 1.0 Poor -

patients at Sir Charles Gairdner Hospital with intermediate-2 and high risk MDS.

The future

This is an exciting time in MDS as we are beginning to understand the pathogenesis and molecular biology of this condition. For the first time, we can offer patients with poor prognosis disease, who are ineligible for allogeneic stem cell transplantation, the possibility of haematologic improvement and transfusion-independence. However, it is clear that even with current best treatments, the prognosis of patients with high-risk MDS is guarded and further research is required to meaningfully improve long-term outcomes for patients.

General Pathologist / Managing Partner: Dr Wayne Smit


Histology / Cytology: Dr Dr Dr Dr

Michael Armstrong Tony Barham Bruce Latham Ai Rene Kee

0417-094799 0416-577619 0407-080608 0402-101318

Infectious Diseases (Microbiology): Dr Laurens Manning


Haematology: Dr Rebecca Howman 0417-935873

Laboratory Director: Paul Schneider


Providing phone advice to clinicians and a comprehensive range of medical pathology investigations, including: • • • • •

Histology (Skin, GI, etc) Cytology (incl. Paps and FNAs) Haematology (yes, we do lab controlled INRs) Biochemistry (including hormones and markers) Microbiology and Serology

Professional personalised service from a non-corporate, pathologist owned and operated laboratory practice



John Quigley – Man With a Mission Prominent lawyer and politician John Quigley MLA has fought many battles: for justice, to represent the downtrodden, and more personally, to survive T-cell lymphoma. John Quigley MLA turned himself from truck driver into lawyer before successfully entering politics in 2001. Then came his freeing of Andrew Mallard, a bitter split with the Police Union, and a serious brush with T-cell lymphoma. Now in remission, John told Medical Forum his ups and downs have followed a reawakening of his ethical boundaries and his innate passion for justice, something that was imparted to him by his upbringing. “What gets me steamed up is where people not been blessed with some of the skills I have are disadvantaged by the system and do not know how to speak up for themselves or for their rights. At this stage of my life, I feel compelled to use what God-given gifts I’ve got to set them right.” He remembers that his parents imparted a strong moral compass under the mantle of a religious upbringing. His mother was WA’s first female pharmacist and his father worked as a salesman.

“He suffered the Depression, went to war, but never had a cross word to say about anyone, and he was always fair to everyone. All these different influences played their part in fashioning my desire to see equal justice for all, no matter what their station in life.” Unfortunately, John’s mother died of asthma when he was just 16. “I don’t know whether I became depressed but I shot through up north and worked as a jackaroo on sheep stations before returning to Perth to work in various odd jobs around town – salesman, accounts clerk, and then truck driver. “I was taken in by the story of Abraham Lincoln and his early struggles to get into law school by parttime study. He then founded his own law firm and got into Congress after 13 attempts.

Of course, he went on to become President and an advocate for the most downtrodden people in America, the slaves.” John followed suit and eventually became the high profile barrister for the WA Police Union, a position he held for 20 years. But things did not sit right for him in the legal system. “In the medical profession, outcomes are not determined by the wealth of the patient, by and large, because of our public health system. Whereas in the legal profession and before the courts, access to justice is determined by how much money you’ve got.”

“At the height of my success, I was acting for people who could afford me and charging between $2500-3000 a day, and I observed a lot of people who just couldn’t access justice. I felt I’d lost my way in the sense that I’d started off with these Lincoln and Christian ideals but had drifted into the lure of the filthy lucre.” It was during a prolonged case in South Australia over the killing of a police officer that he decided he had to change.

I’d started off with these Lincoln and Christian ideals but had drifted into the lure of the filthy lucre. “I entered a period of serious introspection. I just remembered that passage in the Bible where He told them all not to wait until tomorrow, throw away your worldly goods and do the right thing today. I thought the best way was to put my skills to work for the public.”

He chose a foray into politics with the Labor Party, despite being brought up in a Liberal household and taking a $300,000 drop in income. He won Innaloo from the Liberals in 2001 before the seat was abolished in a redistribution, then he won Mindarie, and during Labor’s most recent election defeat, managed to attract a 4.5% swing. Clearly, he has a public following.

It was an astute Colleen Egan who then approached him to look over the Andrew Mallard case. He took six weeks


reviewing it and concluded he was innocent and he had to do the right thing. He was now headto-head with the Police Union. “A lot of police thought I’d turned my back on my mates, but I don’t see it that way at all. I say the corrupt police had turned their back on truth and justice. So it wasn’t a difficult decision, but it was hard work.”

This hard work saw Mallard walk free after 12 years’ wrongful imprisonment and a case that had to get to Australia’s High Court before justice saw the light of day. John must now answer a complaint before WA’s Legal Practitioners Complaints Committee that his parliamentary naming of an allegedly corrupt former undercover policeman, with its consequences, was something that would bring the legal profession into disrepute. “It doesn’t make me angry; you can’t get angry at ignorance. What is important is that I’m doing it for the right reasons. I’m the only person to be prosecuted out of Mallard. Does that say much about me, or does it say more about the legal profession?”

In an earlier interview, he had implied the Police Union had lost its way in the justice system by defending corrupt police. After Mr Mallard’s release in 2006, the disciplinary action recommended by the CCC against two WA Police Assistant Commissioners and the senior Director of Public Prosecutions lawyer did not eventuate because their resignations meant they avoided public service disciplinary action. But John had another challenge to face. In 2005, he was diagnosed with an aggressive form of T-cell lymphoma. His treatment and opinion of the profession will make a story for another edition, but John is now in full remission and his experience gave him fresh insights.

He said whereas doctors seem committed to patient care, a lot of people enter law for the money and because it looks a bit sexy. Those that want to really fight for human rights are in the minority. Then, the adversarial nature of legal practice takes its toll.

“A high number of lawyers get to 45 and they’re just burned out and depressed. I’m trying to spread the message that instead of leaving the profession, take some pro bono work for the disadvantaged and it’ll light the fire within.” As examples, he points to the great pro bono work done by Malcolm McCusker, Jamie Edelman, and law firm Clayton Utz on the Mallard case, as well as Steven Penglis on the Pratt case. l



Medical Pioneer

Dr Denis Cherry – Men’s Special Business A GP who applied his skills to reproductive health and learnt some valuable lessons. Denis Cherry’s knowledge from 22 years working in men’s sexual health will be passed to other doctors at his clinic when he retires soon. While his attention now turns to his four grandchildren, the promised restoration of his 1945 jeep, doing the Canning Stock Route by 4WD, and learning to play the harmonica – “I’ve got as far as a pretty good rendition of Three Blind Mice” – we take a look at his professional journey as a pioneer who came from left field in this area. After graduation at UWA and residency up north, he spent 10 years in the hospital system, which included stints in the ED, as dermatology registrar and a five-year term in clinical biochemistry at RPH. After an unsuccessful crack at the fellowship, he undertook some generalist training and headed off to Donnybrook to start up in general practice. The year was 1981, and the country air must have agreed with him because he met and married his current wife and practice manager Kit (the person who helps him with his affliction organising time and money, amongst other things!). At Donnybrook, Alistair Tulloch was doing the occasional urology clinic, and he suggested Denis do some sessions with Dr Ted Keogh at Perth’s then Reproductive Medicine Research Institute. They

needed more manpower and Dr Anne Jequier was in favour because of her knowledge of GPs in the UK NHS hospital clinics – their ‘can do’ attitude and broad knowledge were a big success. “They found out I was a real money spinner – three or four consulting rooms and I would rotate with snap-fire consultations, seeing up to 30 patients in a session. Little did I know they were billing Medicare and then paying me a pittance, but I never regretted it because I was gaining experience you couldn’t get any other way. I dealt with just erectile dysfunction.”

After some politicking between the specialists over money and clinical control, the Perth Human Sexuality Centre was born and ended up at Hollywood Private Hospital in 1989, thanks to an enlightened medical director John Stokes. Denis evolved into full time sexual health medicine there over the next five years.

“While at the Keogh Institute, I kept seeing patients with ejaculatory disorders, hormone difficulties, libido and relationship problems, and it was difficult because I was employed just to do a quick check on their erectile dysfunction. So I was happy to start the Human Sexuality Centre and develop it to cover both males and females.” He made a rule that males saw males, and vice versa, and employed female practitioners. Taking a history from and performing pelvic examinations on women who may have been abused – when he couldn’t afford a chaperone nurse – was too great a risk. His worst fears were realised after he took on a male associate who asked to see women and do relationship counselling, and then got into problems with the Medical Board. Denis was forced to end their seven-year working relationship.

In sexual medicine particularly, guys should see guys. It was a very difficult experience for me, trying to judge a colleague, trying to get advice, trying to deal with the emotional turmoil, and run a clinic. You always learn a lot from these one-offs.”

How had working in sexual health affected his relationship with patients?

“You became more aware of what erections mean to men. It was quite stunning to see men break down because they were no longer able to get involved in sexual intimacy with their partner. The psychological impact was extreme – getting the story out of them, not using the ‘m’ word (masturbation), learning that gay guys have exactly the same 8

problems, and dealing with true transsexuals who were genuinely a female brain in a male body.”

“The best days were just where guys would march in and share their most private details, and you could reassure them that something could be done and you could change their relationship. Sex is such a high priority for people; after food and a roof over your head.” When we asked him for the big ticket career items he offered first the Massachusetts Male Ageing Study in 1995.

“That defined that men with erectile dysfunction were vasculopaths. Following that, in 2005, was the realisation that erectile dysfunction can be a forewarning of impending cardiac problems. If you had ED and no prior history of a cardiovascular event, on average, you had a two to three-year window to get him organised or he had a 30% probability of either his first heart attack or the onset of angina.” Vascular causes made up 75% of his ED cases. “The next big step was the realisation that testosterone had an effect on the cavernosal tissue, on the expression of enzymes, such as PDE5 and others. Cases where there were failed PDE5 inhibitors, if they were hormone deficient, would often be resurrected by adding in testosterone.”

The PBS authority guidelines for testosterone prescribing were “quite clearly an ass”, but he stuck to them. Men with metabolic syndrome or diabetes were the biggest losers. Only a handful of patients paid for their own testosterone, out of maybe a hundred who needed it.

He said testosterone has known effects on brain (Alzheimer’s), bone and heart, through both its “genomic effects via protein production” and also its “direct effects on cellular cytoplasm that is vascular dilatation”, adding that some overseas EDs use IV testosterone as an acute treatment. Another big ticket item was Viagra.

“Intracavernosal injections, while effective, were not every man’s fancy. These PDE5 inhibitors worked well. They needed astute management to get the best out of them. The hysteria around Viagra’s release in 1998 was over the top, and to this day, Viagra remains one of the best recalled brands, alongside Muhammad Ali and JC himself.” Now, he points to nanotechnology to deliver slow-release drugs directly into cavernosal tissue. And stem cells may have some use in regenerating carvernosal endothelial cells, the “master cell” of erectile function that supplies nitric oxide for maintaining erections.

He will continue to oversee new doctors at the clinic and help young spinal cord injured men with their sexual rehabilitation until the end of this year. After that? “I’ve come to appreciate that retirement is a pretty good gig. The freedom to do things when and how I want is just terrific!” l


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Male Medicos Comment on Men’s Health Support services, violence, chaperones, and DV from the male perspective. Men’s Health is a broad subject, so to narrow the perspective, we surveyed WA’s male Specialists and GPs on the hot issues of what underlies male violence, men’s health support services, HPV vaccination for males, and the use of chaperones when doctors examine female patients. (Because of the high response rate, interesting answers and comments on work/life balance and retirement plans have been held over until August edition). Just over 600 doctors answered our call and checked out the survey, while 197 took the 5 minutes or so to complete it. We say ‘thanks’ to those who did and amongst those who provided their details for our wine prize draw (optional), the winner was Dr Husain Nazir.


Male Violence Serious violent behaviour in young men on the streets has increased. From this list, please choose those FOUR things you consider most likely lead to such violent behaviour: Family breakdown������������������������������������ 67% A violent upbringing�������������������������������� 67%

Exposure to violent media����������������������� 54%

Relationship problems������������������������������ 43% Permissive parenting���������������������������������41% Mental illness�������������������������������������������40%

Bullying���������������������������������������������������� 27%

Lack of other physical outlet������������������� 25%


Absent fathers������������������������������������������� 23%

No-one to confide in�������������������������������� 13%

For any violent act by a young man, please tick the single item you feel is the strongest catalyst for violence at the time: Alcohol consumption������������������������������� 69%

Illicit drug use������������������������������������������ 17% Perceived lack of consequences����������������� 9% Trying to impress mates����������������������������� 1% Ethnic differences�������������������������������������� 1% Other*��������������������������������������������������������� 3%

*Most suggested a cocktail of alcohol and drugs, one suggested “carefree attitude amongst peers”, and another “crime”.

Any comments on violence in young men? Our survey respondents were concerned enough for all to offer comment (n=197), mostly around the root of violence in young blokes. Several agreed that there were many contributing factors (including “all of the above!”). We have subcategorised to assist you. Alcohol and Drug Abuse

>40% of comments involved alcohol and illicit 10

drug use. Here’s a sample:

“It appears often to be the result of repressed anger (related to deprivation, abuse, feelings of inferiority etc) unmasked by alcohol or stimulant use.”

“Methamphetamine abuse in young males is massively underestimated. It allows users to consume vast quantities of alcohol, lose their faculties, but remain on their feet and engage in physical violence. Organised criminals (read: bikies) are huge in WA and law enforcement seems powerless to stop them.” Influence of Violent Media

This was the second most common theme. Here’s a representative sample:

“The link between watching violence in the media and real life violence is put aside and ignored by many. However, the evidence is now overwhelming, with a statistical link of the same magnitude as that of smoking and lung cancer.”

“The media is definitely partly to blame. You can’t hit a guy in the temple and not expect risk of haemorrhage. It is nonsense to suggest that the head hitting the bitumen is to blame for the injury.” Parenting Concerns

A third blamed parenting. Are you listening to this, baby boomers?!:

“I think that an excessive belief in their right to tread on others comes from childhood, as spoilt brats who are never criticised during their adolescence, may be a factor.” One empathetic doc said, “Trying to impress females (either negatively or positively, that is, just to be noticed) could be important, as well as underlying fears of inadequacy, either personally or sexually.” While a philosopher in the profession (presumably of a more mature vintage) said, “Their Great War is with themselves, their Great Depression is their lives.”


Using Men’s Health Services What do you think is the single strongest barrier to you referring male patients to men’s health support services in WA? Patient most likely will decline��������������� 35%

Often no service available����������������������� 32% Patient embarrassment������������������������������� 9%

Lacks time or timing inconvenient������������ 7%

Cost prohibitive������������������������������������������ 1% Other*������������������������������������������������������� 16%

*Responses were split down the middle between those who didn’t refer patients because it was outside the scope of their job (such as radiologists) and those medicos who did not refer because they were unaware of services available (often due to low demand).


As one quipped, “What men’s health service?”

Should more support services be provided to men who are on the RECEIVING end of domestic/partner abuse? Yes������������������������������������������������������������ 74% No��������������������������������������������������������������� 4%

Unsure������������������������������������������������������� 22%

Which men’s health support service or group do you refer patients to most? List here*�������������������������������������������������� 10%

Rarely/Don’t refer������������������������������������� 46% Doesn’t apply�������������������������������������������� 44%

*The most common (in order) were: psychologists/counselling; drug & alcohol services (including Next Step), Relationships Australia, mental health services, Police Domestic Violence Support Service, Men’s Sheds, and Kinway (anger management).


Any comments on men’s health support services? Only 21 doctors felt the need to comment. Most common related to promotion, such as “not well publicised”, “terrible”, and that “more information needs to be provided to GPs”. There is also a “ridiculous emphasis on the prostate”, one doctor said. Another said, “We live in a misogynistic state where men are either rednecks themselves or feminist apologists who don’t recognise the systemic barriers to allowing men the support they need to receive better/more equitable access to health services.” Another wanted services set up in mining regions.


Men’s Health Priorities Of these health issues involving men today, which THREE do you think should take priority in the allocation of community resources? Mental health���������������������������������������������71%

Diet/Overweight��������������������������������������� 60% Domestic violence�������������������������������������41% Smoking���������������������������������������������������� 34%

Parenting����������������������������������������������������31% Accident/Injury prevention���������������������� 23%

Prostate problems������������������������������������� 13% Sexually transmitted infections����������������� 8% Sexuality (e.g. erections, libido)����������������� 7%

Other*������������������������������������������������������� 12%


* >75% (or ~9% of those surveyed) rated alcohol and drugs as the priority issue. Suicide, bowel cancer, and relationships/ parenting were also mentioned.

The PBAC has recently rejected HPV vaccination for boys, saying it is not cost effective. HPV infection has been medicalforum

Held Over Questions If you have children, do you have regrets that your work commitments have not allowed YOU to parent them enough? Comment?

implicated in cervical, throat, and anal cancers. Do you agree with the PBAC decision?

Arising from the global financial crisis (GFC), about 24% of the value has been wiped from self-managed super funds since 2008. How has the GFC impacted on your retirement plans? Comment?

Yes������������������������������������������������������������ 25% No��������������������������������������������������������������51% Unsure������������������������������������������������������� 24%

Ed. A few doctors commented later that HPV vaccination should be subsidised for selfidentified gay males.


Use of Chaperones by Male Doctors How often do you use a chaperone during intimate examination of female patients (e.g. vaginal examination, breast examination)? Never�����������������������������������������������������������10%

Occasional, if concerned��������������������������� 21% Most of the time�����������������������������������������15%



Doesn’t apply����������������������������������������������28%

Any comments on the use of a chaperone? With the indecent assault case against Dr Durani hitting local headlines, the use of chaperones is again hotly debated. There are strong arguments for and against and judging by comments from our respondents, experience varies widely. About one third (31%) felt competent and safe enough to never or occasionally use a chaperone during intimate examinations. A similar proportion however (26%) used chaperones all the time.

Cost is a factor. One doctor said “chaperones should be mandatory, and the patient should have to pay extra for it – or Medicare” and “It is a bit sad I have to, and it uses resources (staff)”.

Legal protection was the crux of many comments. “As a gynaecologist, I always have a chaperone for my own protection.” Others said, “I always ask the female patient if she would like a female chaperone and document this, in the event she declines the offer”. One medico challenged the concept of chaperones altogether: “it has been shown to offer no protection – assaults and accusations of improper behaviour are just as likely in other settings.”

Risk management, linked to circumstances, was raised by around 25% of respondents. “Most of my patients are long-term, and the question of boundaries is less evident,” and “Resources militate against the use of chaperones – clear explanations of what is going to be done, and why, are an adequate replacement in my experience,” and “Always for vaginal, rarely for breast unless concerned.”

Hard line responses were few, for and against. Example: “I resent the implication that (all) men require a chaperone for (only) female patients, and that (no) women require chaperones for (any) male patients. This level of generalisation/ stereotyping maintains the erroneous myth that women are victims of men according to gender stereotypes.” Patient comfort and embarrassment came into play. “Many women don’t want one – a chaperone needs to be with you and not the other side of the curtain and this extra person


See coming August edition. can make some women feel uncomfortable, and the chaperone as well.” “I often ask the husband/partner to be present – they appreciate this respect for them.” “I am guided by patient preference – most decline a chaperone, so I

usually proceed without one – very occasionally I am more proactive in including a chaperone (e.g. with adolescents with no experience of intimate examinations or with patients with maladaptive personality traits).” l

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Eyes on the Screen – Telehealth Is bringing specialist and patient together over a video link the best medical option or simply good politics? The new telehealth initiative starts July 1. The Federal Government is providing Medicare rebates for online video consultations across a range of medical specialties. This is meant to assist rural communities because specialists are light on the ground and flying them to regional centres (or patients to the city) is expensive. The $620m telehealth initiative, as it is called, offers the carrot of a 50% additional Medicare rebate for the specialist and a 35% additional rebate for the GP at the patient end, and there will be fees payable to nurse practitioners, midwives, practice nurses and Aboriginal health workers because of “the time, complexity and administration involved in telehealth services”. Only patients living in defined geographical areas outside inner metropolis are eligible (with aged care facilities and Aboriginal Medical Services the exception). Any registered doctor can take part. Incentives include a $6000 bonus payment for health practitioners when they start using the new technology, and $20 every time a telehealth service is bulk-billed in the first year. The GP (or other health professional) bills according to the time spent assisting the whole consultation.

The RACGP has been asked to put together new telehealth standards by October this year. RACGP president Prof Claire Jackson says nation-wide standards are needed to “ensure the identification of potential risks and risk mitigation strategies, including protocols for establishing patient identification, protecting patient privacy, and determining the level of clinical appropriateness of video consulting,” she said.

Until now, telehealth has been aimed at consults where the transfer of images is critical – tympanic membranes for the ENT specialist, slit lamp images for the ophthalmologist, hand trauma for the plastic surgeon, x-rays for the orthopod or skin shots for the dermatologist. Conversely, the transfer of thoughts alone, has been the domain of psychiatrists who have been telepsychiatring for some time. This new initiative says an audio and visual link between specialist and patient is required for the medically necessary consultation. Anyone who has used Skype, you will know this sort of link-up is demanding on bandwidth and imagery in particular can be poor. How will this new initiative fit current needs? At the recent dermatologist conference in Perth, software vendors were promoting

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web-based systems that would allow a dermatologist to give advice case-by-case from batches of images from GPs, with each image accompanied by a brief history entered by the GP via the web. No doubt, IT savvy GPs would crop and enhance images for the dermatologist while preparing each batch. The dermatologist would sit and respond to the images with histories, working efficiently within a time segment set aside for telehealth, perhaps after hours. The GP would do as much work as the dermatologist, including arranging review of the patient after the dermatologist has responded in his/her good time. Under the new telehealth initiative, the GP would not get any remuneration for initial time spent on case preparation and neither would the dermatologist for assessing images without the patients’ presence.

In the UK, NHS dermatologists (nearly all working out of hospitals) have patients triaged using telehealth, before consultation goes ahead. Some docs have commented that a similar triage system in Australia, coupled with low level advice, might mean fewer patients actually make it to the dermatologist. In other words, teledermatology could be very effective. The concept of a GP or another health care professional, together with patient, in consultation with a specialist via audiovisual link seems very hard to organise and time inefficient in many instances, mainly at the patient end where much of the organisation goes on and the benefits are meant to accrue. Telehealth proponents from the Royal College of Physicians would have specialists telehealthing their way into sexual health clinics, rehabilitation clinics, aged care facilities, patients’ homes (to assist the visiting neonatal nurse), EDs, and secure facilities in the community.

There will be some watch-this-space questions: where are the really useful demands for these services outside rural settings; is there potential misuse of consultations to attract incentive and other payments (e.g. practice nurses consulting on behalf of GPs); are we simply weighing up the cost of service providers going out vs information coming to them when maybe neither is the best option; will incentives to bulk bill cap private fees, especially amongst specialists; will the inevitable subspecialty telehealth services across Australia (thanks to national registration) impact positively on specialist access; and the big one – will the system return health savings by reducing doctor/patient travel and making more efficient use of the specialists’ time? The scheme kicks off July 1, so time will tell. Everyone is hoping for positive responses on all questions. l


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Men’s Health Resources for doctors

A Man to Man Talk with Gary Bryant Men’s Advisory Network Director Gary Bryant discusses the state of men’s health services in WA, noting the gaps in the system and how they can be filled. hosting at Perth’s Pan Pacific Hotel (formerly the Sheraton) in September this year.

Gary Bryant has been directing the Men’s Advisory Network (MAN) since 2002, the year WA Health contributed to the organisation’s funding, and some five years after, a group of 25 blokes met and decided WA’s men needed a peak organisation. “Our interests are really any issues that impact on men and boys and we aim at both consumers and professionals. Our extensive database of services can be used by professionals who are unsure where they should be referring somebody, and it is also accessible to the public,” he explained before stressing that MAN is not a service provider but instead represents various organisations and individuals that do so. Gary said they have put together extensive helpful resources over time – most displayed on their website, – with links to other useful websites, DVDs, books, and other resources. He regards the website as the single most valuable resource they have for professionals and the public.

“We need to link more with the medical profession. Raising awareness of the needs of men and encouraging practices to overcome the barriers there to make men less likely to come through the door.



“Lotterywest has been very good with this national conference. They’ve allocated $62,000 for scholarships for WA people from nongovernment organisations to pay registration feeds and to country people for accommodation. They did the same for the Healthy Men, Health Profits conference last year and the 2006 and 2008 Babies for Blokes conferences.”

n Gary Bryant is about giving males a voice in the allocation of health resources in WA

“If a GP came across a man who has just separated, can’t see his children, and doesn’t know what to do about it, if they’re not sure, they can go to the MAN website and find Dads@ Lifeline might meet those specialised needs. “A big part of our work is advocacy. We produce posters and fridge magnets, we have an email newsletter and we run conferences and seminars,” he said and added a plug for the National Men’s Health Gathering 2011 they are

While he laments that State Health never came to the party with a state-based men’s health strategy, he is pleased we now have a National Male Health Policy (see malehealthpolicy). He now wants to see it properly funded beyond the programs mainly for Aboriginal men and Men’s Shed.

“There is no central focus on the development of men’s health or for policies on men and boys in general. Many years ago, the House of Representatives ran an enquiry into boys education, but I’m not sure whether that has gone anywhere since then. There has been funding for men and family relationship programs but that’s about to be amalgamated into just a general family relationships program. “The national policy made it very clear. Men


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MAN: Supporting Men’s Health Men’s Advisory Network WA (MAN) is the peak body for service providers, organisations and individuals concerned with men’s health, wellbeing, and other issues affecting males of all ages in WA. MAN primarily supports service providers, organisations, and professionals from various disciplines who work with males of all ages. In addition, MAN provides general community education and raises awareness of the issues affecting males. The MAN website – – has an exhaustive list of referral, support, and emergency services for men including:

have particular needs, and we’re not just talking things like prostate cancer, but the whole way in which they access services, whether health or other services. They do it differently to women. One of the big things in the men’s health policy is the importance of the social determinants of health. That’s an even bigger area for Aboriginal men’s health.

“In terms of doctors, men are reluctant to take time off work to see a doctor. They believe they’ll be alright and will get over whatever is wrong with them. If they have an appointment at 4.30pm, they want to get in, get fixed, and get out. They don’t want to wait maybe thirty or forty five minutes for their appointment. Having services open in the evening allows men to attend without having to take time off work, which they’re reluctant to do.”

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He agreed that more direct interaction with men gets the job done but preventive health is a hard sell. Some support groups have found their niche. The Regional Men’s Health Initiative in the wheatbelt has raised community awareness around men as an important rural asset, suggesting it is okay for them to seek help. Men’s Sheds are there to overcome the social isolation.

• Help lines.

• Health services and counselling. • Rural services. • Fathering.

• Aboriginal men’s services. • Men’s sheds.

• Gay and bisexual services.

• Advocacy and support groups.

information about coaxing men into your practice.

• Drug and alcohol services.

• Legal and financial counselling.

MAN also provides free resources for general practice such as DVDs, brochures, fridge magnets and posters, as well as plenty of online If men feel that attending a doctor is a sign of weakness, what are the alternatives?

“With a men’s health strategy, you’d have targeted messages going out, as well as services. Taking programs into the workplace has proven to be very useful, whether they be health promotion or actual screening or treatment programs.”

Medical Forum has covered Pit Stop, the innovative program that visits rural shows etc. and likens health checks by rural men to vehicle servicing, something they identify strongly with. (See page 31 for more details.)

“Programs will go to country shows, agricultural field days, and places like that. The object is to uncover a certain issue and say ‘go and see your doctor’. A follow on from that is something like the Water Corporation did in Narrogin – paid for their staff to have a long consultation with their doctor, so it was costing the worker nothing.” He said this sort of approach to men’s health came out in their recent Healthy Men, Healthy Profits seminar, which featured high profile corporate speakers. It is all part of changing attitudes.

MAN is hosting the National Men’s Health Gathering, September 19–22 at the Pan Pacific Hotel (formerly the Sheraton) in Perth. See: www.

“It’s fair to say in the 1950s, it was very clear that the man’s major role was to be the family provider. That has changed substantially now with most families having two incomes. In terms of the gender revolution, women have mapped out what they’ve wanted and they have largely achieved it. Whereas men are probably saying, what does this mean for me? Where do I fit into this new order? A lot of men are confused about that. “Younger men want to spend more time raising their children but they still have the pressure of being the primary provider. If someone said ‘I can’t get in until 9.30am and I have to leave at 3pm because I have to look after my children’, for a woman, that would be quite acceptable and the employer would work around it. For a man, he would probably be seen as not committed to the job.”

The MAN office, mainly Gary and committed volunteers, is now focused on short term projects. One is to work with an Aboriginal men’s health coordinator to put together a health strategy plan for that group, with input from Health Department regional representatives. l

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Have You Heard? Durani to appeal

Dr Suhail Ahmad Khan Durani is to appeal against his conviction for indecently assaulting a female patient at RPH early last year. As reported, the trial judge believed the patient’s statements ahead of the doctor and rejected his defense that her intent was malicious or she was mistaken. We shudder at the after effects. Medical Forum has already been contacted by other doctors at RPH who feel sullied by the publicity around the episode. Could it mean chaperones galore for examinations at RPH from now on? Your views on chaperones are in our latest e-poll (page 10).

Less sleep, more labs

‘Another sleep laboratory?!’ we thought after news of John Day’s ribbon cutting on the three-bed Centre for Sleep Science at UWA for a princely sum of $1m. However, enquiries to the boss, Prof Peter Eastwood, a sleep scientist, reveals the unit is a training ground at UWA to augment the sleep clinic at SCGH under Dr David Hillman, mainly directed at training ancillary staff such as sleep technicians who do most of the sleep study reporting. Currently, if you hand a study to 10 different sleep technicians, you can get very different interpretations, so standardisation is badly needed in the industry. Peter told us the centre will do research and provide training in all the sleep disorders and associated problems, not just sleep apnoea, which is needed in a well-rounded tertiary service attached to any sleep lab.

Bad Behaviour

Every hospital worker will be allocated a personal security guard after it was revealed there were 2272 reported ‘assaults’ on doctors, nurses, orderlies, and other hospital staff in two years. This covered all levels of assault, including swearing such as, “Get your finger out of my arse, you wanker,” which was overheard in a urology department, and “How would you like it if I stuck that needle in your eyeball?” overheard in an ED. An Opposition health spokesperson said a dozen WA health workers were being assaulted daily like this, with assaulters fuelled by drugs and alcohol. Health Minister Kim Hames said staff were excellent at de-escalating assaults by talking them down, but with extra security staff in EDs, people behaving badly are in for it. For a more serious look at workplace injury and assault stats see page 23.

Paget’s genetic breakthrough

Another day, another gene discovery. This time around, Paget’s disease of bone by UWA’s Clin A/Prof John Walsh and his team at Charlies. He told Medical Forum their study identified 7 genetic loci associated with Paget’s. Each alone only offered odds ratios ranging from 1.4 to 1.7, but when combined in an allele risk score, individuals in the top decile had a 10-fold increase in the risk of Paget’s disease, which is clinically relevant. How? Future genetic profiling to assess risk. He said non-genetic


factors are also at play because the incidence of Paget’s and the severity of newly diagnosed cases have fallen substantially (incidence by 50%) over 30 years. Improved calcium nutrition and reduced viral infections are the leading candidates to explain this fall.

Heart care for South West

SJOG Bunbury is to contribute towards the building of a coronary care unit, a first for regional WA under a $5m Royalties for Regions investment. In about a year, around 3,000 south west residents, public and private, will be able to get their cardiac angiography and suchlike at the six-bed CCU instead of travelling to Perth. The public-private mix at the South West Health Campus seems to be working well to bring specialist services to the region, and jobs for nursing, allied health, and support staff.

some havoc across the northern hemisphere. In the land of Oz, 2,200 flu-related hospital admissions are the target.

OTC flu vacs

Speaking of the flu, West Australians can get a flu vaccination for $30 in Priceline pharmacies (six in WA). No script required. While doctor groups have criticised the service, state-run vaccination clinics have been doing similar things for kids for years. It’s all about convenience, and if out-of-pocket expenses with the local doctor remove the “free” incentive, consumers will shop accordingly, even more so for those not subsidised. And we have the new web-based WA Vaccine Safety Surveillance system that consumers can report to if they get into trouble.

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Cost of Caesareans

Following our write-up on WA’s >30% caesarean rate, Monash midwives say everyone is deluded about ‘cost neutral’ caesareans, compared with a normal vaginal birth. This contributes to overuse. The Australian Health Review article says important data omitted from the risk-benefit analysis involves the 85% of women with no serious morbidity when they undergo caesarean. CS increases maternal mortality x2.8 compared with vaginal delivery (UK study) and in the second pregnancy doubles the risk for unexplained stillbirths, spontaneous abortion, ectopic pregnancy, infertility, uterine scar rupture and caesarean hysterectomies. Morbidity costs for women and the system associated with unexplained caesareans should inform policy and choices, including affects on future health and fertility.

Flu herd immunity failing?

Pre ‘flu season’ stats on vaccination attitudes are interesting. When 1,120 people were surveyed, 82% said even healthy people benefit from vaccination, but 72% were unsure if they would get vaccinated, 42% said they have never had a flu jab and 35% said vaccination was not for them this year. While 95% realised being vaccinated in the past didn’t protect them from future influenza outbreaks, 28% said it wasn’t important to be vaccinated every year. Many see vaccination as ‘too much hassle’ (40%), or unnecessary because they ‘never get the flu - so there’s no point’ (18%). GPs were being asked to educate patients – the H1N1 influenza is still circulating and causing

The Australian Genome Research Facility (AGRF) has opened at WAIMR. Academia and industry are the expected clients. AGRF CEO Dr Sue Forrest is thrilled. Genomics experiments that were previously not thought to be possible are being done. It’s federally funded. Genomics is transforming the landscape, and creating opportunities that we have yet to dream of. AGRF provides services including sanger sequencing, next-generation sequencing, SNP genotyping, gene expression, epigenomics and structural genomics, nucleic acid extraction, plant growth and stress services. Website:

Traumatic stats

Quiet campers may not recoil from State Director of Trauma Services Dr Sudhakar Rao’s announcement that since 1995 there have been >1500 people admitted to RPH because of an off-road accident (with 280 on a quad bike), 23% with major trauma. We have 29% involving farm use and the rest recreational use (with 81% male, and 16% admitting to drug or alcohol use). A third weren’t wearing any safety gear. Most bang into trees or other vehicles.


What have you heard Share the news or ring the editor on 9203 5222


Sexual Health By Meg Marshall, Scarlet Alliance

Sex Laws Threaten Men’s Health Sex workers are in the best position to educate their middle-aged male clients about STIs, but will WA’s proposed new sex industry laws derail this clandestine sex ed? This month, the WA Liberal Government’s proposed sex industry legislation will be debated in Parliament. This ‘new’ legislation is almost identical to Labor’s 2003 Prostitution Control Bill, which the Liberals, then in Opposition, actively opposed as a risk to sex worker health and safety. Like the 2003 model, Attorney-General Christian Porter’s framework has been created to ‘protect the public from the prostitutes’ rather than improve conditions for sex workers. Unlike Labor in 2003, Mr Porter has made no secret of this fact, publicly stating that “[his] ... fundamental concern is not, and has never been, to fulfil the wishes of those who operate commercial prostitution. They are not the key driver for this legislation”. The new legislation primarily seeks to force sex workers into brothels and force brothels into industrial areas. As you would expect from legislation created with no industry input, it mostly addresses problems that do not exist and includes numerous provisions that will prove completely unworkable.

I had intended to talk about the potential health risks for sex workers, but in light of this month’s Men’s Health focus, I’d like to touch on an issue often neglected in these discussions – the clients of sex workers. Any risk to the health and safety of sex workers will obviously present a risk to the health and safety of their clients. Like sex workers, clients will face prosecution for

engaging in illegal sex work. Like sex workers, this will leave clients less able to talk openly to their healthcare providers, resulting in the provision of inappropriate or inadequate testing and advice. Unlike sex workers, however, their clients will be less likely to visit a healthcare provider in the first place. It’s widely acknowledged

that the ‘average’ sex work client belongs to a notoriously hard-to-reach demographic: white, middle-aged, heterosexual males, often married or divorced, many of whom became sexually active pre-HIV and do not have a history of condom use. Sex workers have unique and exclusive access to these men. This is particularly true of male sex workers with clients who do not identify as gay and would be highly unlikely to disclose those desires outside of a sex work setting.

Without the sexual health education that occurs during a sex work interaction – from talking through an STI inspection to defending enforcement of condom use – some clients may never actively seek advice about STIs or HIV. And without the support of the law behind them, sex workers may not be empowered to acquire or disseminate that information. Mr Porter has made it clear he’s concerned about the safety of the community, not the sex industry, but he appears to have forgotten that sex workers and their clients are members of the community. They do not exist in isolation, just as any increase in STI/HIV infection within the sex industry will not exist in isolation. The Liberal Government needs to see past their personal distaste for sex work and ensure that any new legislation prioritises the health and safety of sex workers and their clients. l

tralia’s Leadin Who is this Mystery Man? This bust statue was recently found in a cupboard at the Claremont Community Health Centre. The subject is wearing an academic gown and appears to be a man of substance. However, none of the older GPs who have worked in the building since it was built in 1979 can identify him. Can you name this mystery man?

The RACGP’s Dr Max Kamien is keen to get to the bottom of this conundrum. If you can put a name to this dignified face, drop us a line at l



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Domestic Violence By Angela Hartwig, Women’s Council for Domestic and Family Violence Services (WA)

Debunking Domestic Violence Myths When a suspected victim of domestic and family violence enters your consulting room, it is often a harrowing experience for both parties. Angela Hartwig debunks the myths. General Practitioners are the major professional group to whom women experiencing domestic and family violence (DFV) turn. A full-time GP is likely to be seeing one to two female patients each week who have experienced family violence. Responding effectively to domestic and family violence in a medical setting requires the ability to effectively screen and assess a victim’s level of risk. It is therefore vital for GPs to have good understanding of what constitutes DFV, a non-judgemental attitude, and a good network of local DFV service providers.

Will I have to attend Court?

There have been issues with some GPs who have refused to see victims of DFV due to concerns about being asked to attend court to give evidence, and the subsequent loss financial implications of loss of time to their practice. The reality is that this is not going to be the case. On occasions, professionals such as police, lawyers, psychologists, social workers, and GPs may be asked to provide a report to the court on matters as Violence Restraining Orders or Domestic Violence assault charges. This evidence may be given via a report or affidavit. GPs have a vital role in ensuring that the wellbeing and lives of women and children are paramount, and ultimately, saving lives.

Asking a women about violence

Women are often reluctant to disclose abuse because of fear or shame, or because they think they won’t be believed. More commonly, victims of DFV present with a broad range of symptoms such as physical injuries, anxiety, and panic attacks, stress related illness, drug and alcohol or tranquillisers dependency, a mental health diagnosis, and suicide attempts.

Barriers to leaving a violent relationship

Myth: it is easy for a woman to leave.

Reality: Many women who experience domestic and family violence are in fear of their lives and the lives of their children.

Fear is the biggest barrier to women exiting violent relationships. Other barriers include feelings of powerlessness and helplessness, being financially dependent upon their partner, lack of support, and limited crisis services for women and children to escape to.

Screening and risk assessment

Screening is a systemic process that enables identification of people who are affected by DFV, often before the situation has escalated and before they (and/or their children) have


Where immediate safety concerns are identified, a GP should take necessary steps to ensure the immediate safety of the victim and any accompanying children. suffered serious physical or psychological harm. It provides an opportunity for further action to be taken to assist them to be safe. Professionals conducting risk assessments require a solid understanding of DFV, its common pattern and dynamics, factors that affect risk and issues, or factors that may make some population groups more vulnerable to DFV and severe harm than others. Where immediate safety concerns are identified, a GP should take necessary steps to ensure the immediate safety of the victim and any accompanying children. Screening questions should not be asked in front of a partner. A major outcome from both screening and risk assessment will be safety planning. Practitioners who conduct screening or risk assessment should be familiar with the development of safety planning procedures.

New Common Risk Assessment and Risk Management Framework

Until now, a barrier to early intervention and response to DFV has been no common or coordinated tools and practises to agencies to conduct a simple screening of women who have sought their services for reasons other than DFV. The WA State Government has recently developed a Domestic and Family Violence Common Risk Assessment and Risk Management Framework that will promote a uniform approach to screening, risk assessment, and referral across the state. The Framework sets a minimum standard of screening, assessment, and response for all services in WA, both specialist and mainstream. The common risk assessment is a vital tool to ensure that DFV is quickly identified, regardless of what pathway victims may have entered; and they are responded to appropriately and linked into specialist services. References available on request.

Ed. If you are interested in receiving an information a package on DFV and referral options, contact the Women’s Council for DFV on 9420 7264 or l


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General Practice

The Challenges of General Practice in WA He may be out of town but he is not out of touch. Mandurah GP Dr Frank Jones talks about RACGP business in WA under his chairmanship health system and the diversity of practice it offers rural GPs (in particular), Frank’s experience in Mandurah speaks for itself. His four-doctor practice servicing 15,000 people in 1983 has grown to a purpose built 16-doctor practice (10 FTEs) offering a multitude of ancillary services next door to the Peel Health Campus with its ED and other facilities. The area’s population has ballooned as well. His practice has one GP obstetrician, one GP anaesthetist, and all doctors have inpatients they care for at the local hospital. A dietitian, audiologist, psychologist, and pharmacist are part of their service mix (and until seven years ago, they provided Casualty cover).

It is potentially two full time jobs ­­– Chairman of the RACGP WA and principal in a 16-doctor practice in Mandurah – but Dr Frank Jones has general practice at heart and soul. This means, for him, a college Faculty meeting every two months, a trip to Perth once a week with his laptop as train companion, an Executive teleconference each month, e-mails for his four committee appointments, and time spent responding to various queries. All up, Frank spends 20% of his professional time on college business, and you have to wonder what motivates him. “I have two main aims for the WA College. The first is to engage rural members and push out education activities to them. The second is to help the college be more of an advocate for, and be proactive about, general practice, particularly GP representation on WA Health committees.” “Simon Towler is pretty GP friendly and he talks about prevention a lot. I’m keen to coordinate GP representation when WA Health is establishing guidelines,” he said, pointing to his recent experiences with the WA Health’s renal prevention meeting, which seemed unaware of the college’s guidelines for GPs in this regard.

Collaborative care arrangements with nurse practitioners and the recent 40% decrease in mental health rebates are two current examples of advocacy priorities in Frank’s mind. He said that the money that had been allocated to early psychosis intervention and Headspace services, although meritorious, had a political inference.

“There is good evidence that GPs are efficient in the management of mental health and no-one else has the experience to deal with the oftenassociated physical issues,” he said. Frank also outlined how Queensland Health was considering “hospitalists”, a sort of recycled general physician, when GPs could readily do the job.

Regarding educational meetings for GPs, his rural experience has attuned him to the realisation that GPs are often the best teachers for other GPs. Case-based broader health issues are the best topics, something that has been pursued in his district. And the college has developed some fantastic online modules through its GPLearning website. Frank said that training in general practice was an altruistic undertaking often, given that GPs were usually losing money by taking on students. With 21 Faculty Board members, Frank is not working on his own by any stretch of the imagination, but he grapples with the centralised model the college has assumed since it ran into trouble 10 years ago. Western Australians are geographically and socially isolated so dictates from Victoria may not be well received here. The RACGP has new


His practice now offers patient appointments on line, which is gaining in popularity. He views the college’s role in promoting e-Health as a positive step.

facilities at Harrogate St in West Perth, and Frank is happy to represent WA GPs where immediacy in response is paramount, but he refers more contentious issues to RACGP Council as the need arises.

A Welshman who has warmed to the Aussie


Dr Roger Perkins MBBS, BSc, DA (UK), MRCOG, FRANZCOG

Dr Lincoln Br ett BMedsC, BSc (Hon), MBBS, FRANZCOG

Dr Julia Barton MBBS, FRANZCOG


Frank Jones has enough experience in WA to advise the national college people wisely. He sees that younger GPs have different lifestyle priorities to him but pins high hopes on the altruistic younger members on the current Faculty Board.

With 18 months left in his tenure and a lot on his plate, time will be his judge. l

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General Practice By Dr Abby Harwood, Kununurra GP

Convergence of the Grey Nomads The seasonal influx of tourists transforms general practice in the Kimberley. Every year, it comes. Sometimes, it starts with a trickle that gradually becomes a flood. Most years, it’s almost instantaneous, like somebody suddenly opened the floodgates. No, I’m not talking about the wet season but the influx of tourists that comes with the dry season. Each year, the population of the East Kimberley doubles from April to September, with both tourists and seasonal workers. Suddenly, all free appointments are booked up by 9am. The number of walk-ins increases from non-existent to about twenty a day. And of course, most people want to be seen by yesterday because they’re “only in town this afternoon. We’ve booked to go to the Bungle Bungles first thing tomorrow morning”.

Grey nomads usually come with more complex medical problems, but they are much more relaxed with their time. They’re willing to change their itinerary to allow time for further tests or recuperation. Backpackers also tend to be more relaxed. It’s the in-between ones, those on tighter schedules but usually with

lots of money, who can be a bigger logistical challenge as they don’t want to miss out on their luxury eco-tour. They don’t have time for chest pain! Even on holidays, there doesn’t seem to be any contingency built in.

annexe. He had to be sent by RFDS to Perth, but his wife was forced to drive the caravan the 3,000+ kms to Perth on her own.

Occasionally, something nasty rears its head. For example, the woman who was experiencing shortness of breath. It turned out she had ascites from ovarian cancer. Unfortunately, the Patient Assisted Travel Scheme in WA only covers permanent country residents. And most grey nomads don’t think about getting travel insurance, so they end up having to finance their own way back home to specialist care. I vividly remember the older gentleman who had a heart attack putting up the caravan

The best bit is learning about other people’s experiences … the places they’ve been, what they’ve seen, where’s the best fishing spot near Timber Creek. It’s all in a day’s work. l

Most of the time, it’s coughs and colds and repeat prescriptions for hypertension or hyperlipidaemia. As the first port of call for many people travelling to the West from the East, I often educate patients about the sparse facilities in WA or smooth the waters with the WA health system, as was the case with a lady on palliative chemotherapy on her final hurrah around Australia.

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My approach to medicine changes, too. Every consultation has the questions “so how long are you in town?” and “which direction are you heading in?” prior to decisions being made about treatment. The next pharmacy outside Kununurra is Katherine, 500km to the East, or Broome, 1,000km the other way, so it’s no good giving someone a script for 5 days’ worth of treatment with a repeat if they’re going to be somewhere between Halls Creek and Fitzroy Crossing when they need to get their repeat filled. Consequently, a bit more time is spent on the phone to Medicare for authority scripts, but the gratitude is worth it. And it may prevent an admission at Fitzroy Crossing Hospital.

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Men’s Health By Mr Julian Krieg

The Regional Men’s Health Initiative By shaping their educational approach to the needs of rural men, Julian Krieg and the health team are making a difference Ten years ago, when I took a job with Central Wheatbelt Division of General Practice (now Wheatbelt GP Network) to do something about rural suicides, our program attracted all the worried women instead of the men we needed to reach! The program was quickly altered to make it more attractive to men and we took it to places where men meet. Now, we see what we do as a bridge between men and the health services. They gain confidence through knowledge of issues they were often ignorant about and recognise they can “… talk to a mate – before it all gets too much…”, which is the message we want to give in everything we do. Although I and the team at RMH have always worked closely with health professionals to ensure we have up-to-date and relevant information, neither I nor any member of our frontline team has professional health qualifications. What we do have is loads of life experience in the types of workplaces and industries most men frequent to make a living.

Why is this important? Our role (as we see it) is to take the good research and information men need to know and translate it so it suits a man’s needs. We then have people deliver those messages while connected closely with the men’s work environment and lifestyle. Presentations focus on three fundamental topics:

• Male health and wellbeing – physical, mental and spiritual health issues covered with facts and jokes;

• Communication styles for men and women and reasons why they can clash.


• “Are You OK Mate” – a 90 minute session on destigmatising suicide and developing skills to ask another person, particularly another man, if he is OK.

We refuse to organise any programs. Instead, we deliver our presentations at events that local communities, clubs, and organisations develop and promote. This approach provides information to a particular group or community on what they identify they need rather than presume we know what that is. This approach also leads us to customise presentations constantly, to match community needs, but we never compromise the key messages.

One feature of our program is the “Fast Track Pit Stop” health awareness program that we take to local shows and field days. This again takes health awareness to a venue that is man friendly and non confrontational. We are usually assisted by local health professionals, which helps any future interaction with local health services. Our service also has access to a “resilience” support person who is a qualified psychologist/counsellor. Men resist counselling but accept support to build resilience. This may seem weird but changing the name has made a huge difference in men talking about issues! Most of the men using this service don’t need counselling, they need to be heard and confirmed in their lives and supported to make decisions. Funding over the years has come from different sources, importantly from outside “health” budgets. The current funder is Regional Development and Lands (RDL). l



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Men’s Health By A/Prof Alan Wright

Talking Men’s Tackle Andrology Australia Advisory Board Member and WA GP A/Prof Alan Wright is 100% behind the latest public campaign to get men to focus attention below their belts. If you see a lot of male patients in your clinic, you are hopefully noticing that more and more of them are speaking up about problems below the belt. In April this year, Andrology Australia launched the ‘Talk about your tackle’ campaign to get men to open up about their reproductive health. The reasons for this campaign are simple. Among Australian men, about half will experience prostate problems, one in five over the age of 40 has erectile problems, an estimated one in 20 is infertile, and one in 200 will suffer from testosterone deficiency. Each year about 680 men are diagnosed with testicular cancer, and this number is rising. These issues are real and yet very few of them are discussed by men when they visit their local GP.

The aim of ‘Talk about your tackle’, fronted by former AFL players Matthew and Alan Richardson, is to get men talking, preferably to their doctor but even to a mate or their partner or family member. As we know, the longer these issues go unspoken, the more damage they can do.



Some of the more common concerns I see in my practice relate to erectile problems and it’s important to remember that these can be the most difficult topics for men to discuss with their GP.

A survey of almost 6000 Australian men over 40 in 2003 showed that as they aged, significant numbers of men were affected by prostate disease, erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) 1. Yet, given the prevalence of reproductive health disorders in middle-aged and older men, treatment rates were strikingly low. For example, there was a wide gap between the estimated prevalence of ED and the number of men actively seeking or undergoing treatment.

The number of men leaving issues like erectile problems unspoken is very concerning, particularly as ED can be a sign of chronic illnesses such as diabetes and heart disease. Another issue is men buying unproven medicines for ED over the internet so that they can avoid the embarrassment of speaking to health professionals about sexual problems.

to inappropriate, inactive or potentially harmful medicines.

Given that we celebrated International Men’s Health Week last month, I hope that a lot more men are thinking about visiting their GP to talk over those issues they’ve tried to ignore for a few years. If you want more information about diagnosis and management of male reproductive health conditions, order a copy of Andrology Australia’s Clinical Summary Guides – a useful resource for every GP to have in their practice. Or visit

NB. Alan is a WA GP with extensive experience in men’s health management and is currently attached to the School of Medicine at Notre Dame University.

Ref: 1. Holden CA, McLachlan RI, Pitts M, et al. Men in Australia Telephone Survey (MATeS): a national survey of the reproductive health and concerns of middle-aged and older Australian men. Lancet 2005; 366: 218-224. l

These practices expose men to two issues – inadequate medical assessment, and exposure

3/03/11 1:46 PM medicalforum

Beneaththe Drapes u Prof Fiona Stanley is to retire from the Board of the Telethon Institute for Child Health Research at the end of this year. She will continue as Chief Investigator on a number of research projects that have funding into 2014.

A Glimpse Inside the Tackle Box

u UWA has appointed Dr Wendy Erber as Winthrop Professor, Chair and Head of the School of Pathology and Laboratory Medicine. She was recruited from Cambridge where she was the Director of Haematology and Head of the East of England Haemato-Oncology Diagnostic Service. Her expertise is around haematological malignancies.

As Prof Alan Wright mentions in his guest column, Andrology Australia has steered away from the usual car metaphors and delved into fishing for inspiration with their ‘Talk about your tackle’ campaign. The campaign aims to hook men into being more open with their GP about reproductive health. The fishy resources include an eight-page magazine-style flyer and an A2 poster, which both feature cricket legend Merv Hughes. The campaign is serious in its reach: Andrology Australia supplied more than 1000 organisations and individuals with resources in 2010. This tongue-in-cheek approach to the campaign is a smart move, backed up by research that shows men are often most comfortable with a thoughtful use of humour (rather than awkward attempts to crack a ribald joke). The logic follows that creating a friendly and laid back environment for blokes during a consultation will help them speak more openly about their health concerns.

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u Prof Jack Goldblatt was awarded a Member (AM) in the General Division in the Queen’s Birthday Honours for service to medicine in the area of human genetics as a clinician and researcher, and to professional associations.

Other qualities men value from their doctor when communicating include: • A frank approach.

• Professional competence. • Empathy.

• Quick resolution of health issues.

These and other useful, well-researched approaches to interacting with men during a consultation can be found in Andrology Australia’s Clinical Summary Guides (available for free from Andrology Australia: 1300 303 878 or

u Dr Mary Theophilus (surgeon and Research Fellow at the Colorectal Surgical Society of Australia & New Zealand) has been named as the inaugural recipient of the $20,000 Jean and John Tonkinson Research Foundation research grant. Her PhD (under the supervision of Prof Cameron Platell) explores new techniques for laparoscopic surgery for bowel cancer, in the hopes it could be a more effective surgical treatment.

u Amy Cuthbert will be replacing RACGP WA Faculty Marketing & Event Officer, Abby Roberts, who after three years of working for the College is relocating to Melbourne.

u Caroline Kirkby has been appointed Marketing and Communications Manager at Silver Chain, to replace Nick Harvey.

u Ear Science Institute Director Prof Marcus Atlas has received the AMA (WA) Award for his pioneering work in the field of otolaryngology.


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ith increasing and prolonged use of dual antiplatelet therapy following acute coronary syndromes and coronary intervention, and with current guidelines recommending vitamin K antagonist therapy for patients with atrial fibrillation and a CHADS2 score > 1, there are likely to be more frequent instances of patients receiving “triple antithrombotic therapy” to prevent coronary or stent thrombosis and cardioembolism.

A recent meta-analysis of 10 relatively small studies involving 1349 patients receiving triple therapy estimated a mean incidence of major bleeding at 30 days of 2.2%.1 By 12 months, however, the major bleeding rate in patients receiving triple therapy may rise to 12 - 15%.2

The following strategies may be helpful in reducing the risk of bleeding where multiple antithrombotic therapies are required:

• Minimising the duration of dual anti-platelet therapy. Current guidelines recommend dual anti-platelet therapy for a minimum of one month in patients with a bare-metal stent, and for a minimum of one year in patients with a drug-eluting stent. In acute coronary syndromes where intervention has not been performed there is evidence that clopidogrel may be helpful for up to 12 months, in addition to long term aspirin therapy.

• Minimising the dose of aspirin may reduce the risk of gastrointestinal bleeding. Aspirin doses of 75 to 100mg per day are no less

effective than higher doses of 300 to 325mg per day.

• Close monitoring of INR, with target 2.0 to 2.5 for subjects receiving triple therapy. • Use dual anti-platelet therapy without warfarin in patients at low risk of stroke (CHADS2 score 0 or 1).

• Using gastric acid suppressive therapy to reduce the risk of upper GI bleeding. This could be used for the duration of triple antithrombotic therapy, or long term in patients at high bleeding risk. Potential interactions between clopidogrel and PPIs that may reduce the efficacy of clopidogrel have not been shown in recent trials to be clinically relevant.

Dr Philip Cooke, Cardiologist, Western Cardiology. Tel 9346 9300


1.Jeremy S et al. Triple Antithrombotic Therapy in Patients with Atrial Fibrillation and Coronary Artery Stents. Circulation, May 2010; 121: 2067 - 2070.

2. Rikke Sørensen MD et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. The Lancet - 12 December 2009 ( Vol. 374, Issue 9706, Pages 1967-1974 ) n

Clearly, multiple antithrombotic therapy carries an increased risk of bleeding, and patients should be carefully assessed and monitored closely to avoid serious haemorrhage.

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Triple antithrombotic therapy: avoiding a ‘little Aussie bleeder’



eeping in touch with STI trends is an important preventive health initiative that can be rewarding for doctor and patient alike. Here are some management tips.


We are in the midst of a chlamydia epidemic, with notifications continuing to climb despite some levelling off in the past few years (see graph 1). Men still have lower rates of chlamydia reporting compared to women – a reflection of lower case detection rather than a true indication of disease burden, given that at least 50% of men will be asymptomatic (unlike 90% or more symptomatic with gonorrhoea infection).

in WA as well as predisposing to a poor clinical outcome.

Early signs of HIV infection that may be missed include: unexplained lymphadenopathy or weight loss, recurrent or multidermatomal herpes zoster, persistent and difficult to manage herpes simplex, persistent seborrhoeic dermatitis, persistent oral candidiasis, unexplained thrombocytopaenia or neutropaenia and widespread molluscum contagiousm. Early diagnosis is important as current therapy has excellent outcomes and is best initiated early. With good adherence to medication, patients survive for many years. Now that HIV has become a chronic infectious disease, HIV positive patients need the care of their GP for management of intercurrent lifestyle illnesses like hypertension, hyperlipidaemia and diabetes, and for assistance with smoking cessation. Shared care between the GP and HIV specialist is increasingly important.

n Graph 1

Opportunistic testing of those at increased risk is important, to improve case detection. Most young men visit a GP at least once a year. If those who are sexually active are routinely offered chlamydia screening, then many more men (and their partners) will be identified and treated, particularly if anyone who tests positive is encouraged to inform their partners and suggest treatment. Those at most risk are aged under 30, and have changed partners in the past year.

For GPs inexperienced with HIV, particularly in giving a new diagnosis, the Australian Society of HIV Medicine (ASHM) coordinates a service to offer support and mentoring. Details are provided by PathWest when a new positive result is reported to the GP. See also default2.asp?active_page_id=315

n Graph 2

HIV infection

Almost all HIV is transmitted sexually in Australia. The early and ongoing use of needle and syringe exchange programs has kept infection in injecting drug users to low levels in Australia. However, in WA the epidemiology has changed over the past 10 years. Unlike other States we now have more cases acquired through heterosexual sex than from male to male sex (see graph 2). Australian men continue to acquire HIV heterosexually overseas, principally in SE Asia (see graph 3). Many present late with an AIDS-defining illness as no one has ascertained their risk of STI acquisition due to unprotected heterosexual sex in SE Asia. Late diagnosis makes them an infection risk for their partners


risk and syphilis should be excluded in anyone presenting with genital ulceration. Recently, we have seen cases where secondary syphilis has presented as hepatitis, uveitis and widespread rash, and diagnosis was delayed as no risk history was obtained and thus no testing done early on.

All MSM should have syphilis serology and HIV testing when other STI tests are performed. All laboratories have an algorithm for dealing with positive syphilis serology so just asking for syphilis testing results in the appropriate tests being done. Unfortunately, serology does not differentiate between old treated and old untreated syphilis, so a good treatment history is important to help interpret the results. Advice in interpreting syphilis results can be obtained from the Sexual Health Clinics at both Fremantle and Royal Perth Hospitals.

Penicillin is still the treatment of choice but it needs to be Benzathine Penicillin, which although a PBS item is sometimes difficult to obtain. The dose is 1.8g IMI once for infectious syphilis and 3 doses, one a week, for latent syphilis (using two 900mg prefilled syringes, one injection into each buttock).

Other notes

Gonorrhoea: Please remember this infection in the metro area needs to be treated with Ceftriaxone 500mg IMI as there is too much resistance to rely on any oral antibiotics. This is a PBS item for this indication. Gardasil (the quadrivalent human papillomavirus vaccine) now is indicated for males aged 9-26. While it is not subsidised by the government there are good data to show its efficacy in preventing genital warts and precancerous conditions. Obviously it is best given prior to the patient becoming sexually active.

The sequelae of chlamydia infection in men are still debated but data shows that men who attend infertility clinics have higher rates of prior chlamydia 1.

Treatment is simple and effective (1g azithromycin oral stat) and testing is very simple in men – 20mls of first voided urine, collected anytime (importantly, not an MSU). If the man can manage to pass a sample, use the opportunity!

By Dr Lewis Marshall, Sexual Health Specialist, Fremantle Hospital

Important Points

• Opportunistic testing for chlamydia is needed for case detection in men (and women) • HIV should be thought about in those with overseas exposure risk • Benzathine Penicillin is the drug of choice for syphilis • Ceftriaxone is indicated for all cases of gonorrhoea diagnosed in the metropolitan area and in anyone acquiring infection interstate or overseas. Further Resources:

STI management in general practice www. n Graph 3


This infection is still with us. Men who have sex with men (MSM) in Perth are at the greatest

Desk-top STI quick reference guides for testing and management, or patient hand-out for STI specimen collection – contact Miriam Venosa on 9388 4841 or email

1 Joki-Korpela P et al Fertil Steril. 2009 Apr;91(4 Suppl):1448-50 n



Update: Sexually Transmitted Infections

Technological Influences on Knee & Shoulder Surgery

By Dr Michael Ledger, Orthopaedic Surgeon, Mercy Hospital. Tel 0412 785 234


echnological developments continue to refine and improve orthopaedic surgery, especially for shoulder and knee procedures. Many shoulder operations that previously required open exposures can now be performed arthroscopically thanks to improved instrumentation, better implants designed for arthroscopic work, and surgeons who have developed the clinical usefulness of new arthroscopic techniques. significant muscle atrophy are difficult to satisfactorily repair, either arthroscopically or using standard open techniques.

Knee surgery has a similar story. The improved accuracy and better results that computer navigation has brought to total knee replacement (TKR), have more recently been extended to uni-compartmental knee replacement and high tibial osteotomy.

Navigation systems and knee surgery

Computer navigation systems give the surgeon real-time measures of accuracy that allows for precise component implantation and improved lower limb alignment. The aim is to enhance the longevity of a joint replacement and reduce the need for revision surgery.

Arthroscopic shoulder stabilisation

Shoulder dislocation is most common in younger active patients, often during sport. Typically, the ligaments and labrum at the front of the shoulder joint tear as the shoulder dislocates. Thereafter, contact athletes and younger active people may develop ongoing shoulder instability, and will require surgical stabilisation.

n A . Arthroscopic view of rotator cuff tear.

The keyhole arthroscopic technique aims to restore the soft tissue “bumper” at the front of the glenoid, to prevent the shoulder from dislocating forwards again. Small bone anchors are inserted into the rim of the glenoid, and the torn labrum and capsule are brought back to their normal position with sutures, so they can heal and attach to the bone. The capsule at the front of the shoulder (in the interval between biceps and subscapularis) can also be tightened arthroscopically if necessary, without overly restricting external rotation.

The arthroscope has also improved our understanding and treatment of other associated but less commonly seen injuries. For example, a large anterior labral tear can extend circumferentially to involve the posterior labrum – this can be repaired with the same techniques. Or the attachment of the long head of biceps may be torn (a SLAP lesion) or inferior glenohumeral ligament tears visualised and repaired.

Patient selection: Arthroscopic stabilisation is suitable for most patients. Pre-operative imaging studies (x-ray and MRI) will determine if there is a significant bone defect at the anterior glenoid margin (Bankart lesion) or at the back of the humeral head (Hill-Sachs lesion). If this is the case, an open stabilisation procedure may be necessary.

n B. Anchors in place and sutures ready for tying knots.

Additionally, the trackers are active throughout the surgery, providing the surgeon with intra-operative feedback regarding the accuracy of bone cuts and overall alignment and balance, prior to final implantation of the prosthesis.

This translates into maximal consistency and accuracy for each patient.

Newer systems have been developed that are easier to use, add no extra time to the procedure, and have distinct advantages for the patient. Navigation avoids the use of intra-medullary jigs that can cause problems associated with systemic fat emboli.2 The “lighter” version of navigation does not require navigation pins to be inserted separately; rather, the navigation trackers are mounted on new specialised TKR instrumentation.

n C . Final tendon repair using the arthroscope.

Arthroscopic rotator cuff repair

This relatively new technique is considered advantageous due to small skin incisions and less extensive damage to extra-articular structures (than open repair). Other advantages include reduced blood loss and less muscle damage, resulting in less postoperative pain.1 The technique may also reduce post-operative shoulder stiffness, sometimes seen after rotator cuff repair.

Improvements in instrumentation and expertise over time now means we are able to arthroscopically repair partial thickness tears, full thickness tears, subscapularis tendon tears, and even larger cuff tears involving more than one tendon. At the same time, if necessary, long head of biceps pathology, subacromial spurs and impingement, and acromioclavicular joint degenerative changes can be addressed. Patient selection: All patients with a symptomatic rotator cuff tear be considered. Very large chronic retracted tears associated with


Minimally invasive wireless “pointers” and “trackers” send data about knee movement (kinematics) to the computer. This information is translated into real-time images that provide the surgeon with a comprehensive understanding of the knee mechanics before any bone is cut.

Applying the same navigational accuracy to medial unicompartmental knee replacement and high tibial osteotomy also should benefit both of these techniques. n


1. Tsuyoshi Shinoda et al. A comparative study of surgical invasion in arthroscopic and open rotator cuff repair. Journal of Shoulder and Elbow Surgery 2009;18, 4 : 596-599

2. J. S. Church et al. Embolic phenomena during computer-assisted and conventional total knee replacement. J Bone Joint Surg Br, Apr 2007; 89-B: 481485.

Mercy Hospital Mount Lawley, Thirlmere Road, Mount Lawley 6050 • Tel 08 9370 9222 • Fax 08 9370 9488 • Email:



By Assoc Prof Jonathan Rampono, Head of Department of Psychological Medicine, KEMH


Specialists in Reproductive Medicine & Gynaecological Services


Medical Director Dr John Yovich

Top of the Wazza The latest ANZARD data reports on 61,929 ART treatment cycles undertaken in Australia (90%) and New Zealand (10%) during 2008 and follows the resultant pregnancies through the ensuing year. The live delivery rate per initiated fresh cycle varies widely among the 33 Fertility Centres and is reported in quartiles. I am very pleased to report that PIVET is performing at the highest level of the highest quartile with a live birth rate of 36%..

Live Deliveries from Initiated IVF cycles 27.4-36.0 35.6










ANZARD PIVET PIVET’s results are an extract of the data recorded by ANZARD which provides the worlds most comprehensive, reliable and best database; a credit to Australia’s continuing leadership position in the field of Reproductive Technology.

Live Deliveries from Initiated FET Cycles






4.5-12.9 0





% Pregnancy Rate (Max)



The live delivery rate per initiated thawed embryo cycle (FET; frozen embryo transfer) also showed wide variations in success rates around Australia. Again I am very pleased to report that PIVET is performing at the highest level of the highest quartile with a live birth rate of 31%.


For ALL appts/queries: T:422 5400 f: 9382 4576 E: W:


Anxiety in pregnancy and the postnatal period lacks the effective screening tools that we have for depression. Clinical acumen comes into play. Anxiety has relevance through the entire pregnancy and postnatal period. The higher risk groups include the long term worriers (aka Generalised Anxiety Disorder) and, in my experience, first time mothers over the age of 35.

• E  xercise – get out in the morning for exercise. Doing it with a friend is social support and limits the excuses • C  utting down on alcohol, which dissolves anxiety and then multiplies it.

• Relaxation programs or meditation.

• P  sychological strategies. Education about the fight-or-flight mechanism is often enlightening and of significant benefit for a number of patients. Cognitive Behavioural Therapy includes, amongst other things, challenging the automatic catastrophising that some people with anxiety disorders engage in.

Benzodiazepines are not recommended in the first trimester to manage the anxiety but mirtazapine is an option, given there is early data on its safety. In my experience, it works rapidly and fairly effectively in about 90% of patients.

22.4-31.5 1


t pays to be aware of perinatal anxiety disorders because effective management can make a huge difference for patients and their families. While there has been strong focus on the recognition and effective management of depression, yielding good results, anxiety has not had as much attention despite the fact that it is more prevalent and often more disabling than depression.

• Reducing work and personal stress loads.

% Pregnancy Rate (Max)



Early interventions in anxiety can include:



Anxiety in Pregnancy and the Postnatal Period

In the first trimester, a very small but significant group of women develop escalating anxiety with prominent vomiting from about six weeks gestation (often hyperemesis gravidarum).




In the second and third trimester, untreated anxiety disorders are associated with a rise in maternal cortisol that has been linked to a doubling in the incidence of conduct and behaviour disorders in children born to these women. In mild to moderate anxiety, nondrug interventions would be recommended. For moderate-to-severe anxiety, antidepressants, atypical antipsychotics and (for short periods) benzodiazepines may be additional options.

Postnatal anxiety is often disabling or distressing and appears on the increase amongst women having their first baby over the age of 30. Longstanding low grade anxiety that the patient has managed throughout her life may escalate in the postnatal period. Perhaps misdiagnosed as postnatal depression, it is important to tease out the differences between the two overlapping disorders and treat appropriately. Anxiety is often the more disabling. It presents with pervasive tension, inability to settle, great difficulty falling off to sleep in the early evening, physical symptoms of anxiety and sometimes fears about harming baby and others. High functioning mothers will often keep soldiering on and appear well, superficially. Postnatal anxiety can profoundly reduce bonding with the baby, which further compounds the woman’s distress, particularly if she develops ideas of harming her baby. An explanation to patients and their families is important. n




n accurate family history is valuable in the better health management of an individual and their family. While its importance is stressed to medical students, in practice, broad application of this important tool has long been problematic. This is largely due to time constraints in consultation, limited means for recording, variable patient recall and reliability of information. However, the recent emphasis on the genetics of family health has brought resurgence in interest.

For specific cancers and a range of common diseases, family history may be critical for timely and appropriate recognition, investigation and management. It may benefit various identified subgroups through awareness of particular health risks and possible preventive measures.

Recording family health history is simple, free and can be done at home. From a genetic aspect, a three generation family history from both sides of the family provides the most reliable indication or means of assessment of particular genetic risk. To that end, a pamphlet History Repeats; Know your family’s health history has been trialled and prepared by the WA Health Department’s Office of Population Health Genomics. The pamphlet emphasises those common conditions where a history amongst first and second degree relatives (i.e. mother and father, brothers and sisters, aunts and uncles, grandparents) may significantly raise an individual’s health risk. Heart disease, diabetes, cancer, hypertension, hypercholesterolaemia, stroke, mental illness,

asthma and osteoporosis are used as examples.

With reliable collection of information, there is the potential to uncover other significant genetic disease, such as specific breast/ ovarian, skin or thyroid cancer, or a range of cardiovascular or neurodegenerative conditions. Sudden or unexpected medical deaths, particularly while young, might also be highlighted. The motivation to fully document three generations of family history could be instigated by the family doctor – women and young people respond best, often with family planning in mind. Applying this effort to those with a perceived susceptibility or vulnerability would also be appropriate, with care. Reassurance or confirmation of concerns may result. However, it is important that the collection of family health information is as accurate as possible to make the “History Repeats” tool most useful. Collection or recall under duress, in haste, or during an acute illness is mostly inappropriate.

By Dr Ian Walpole, Clinical Geneticist, Office of Population Health Genomics, HDWA

The “History Repeats” pamphlet was well received amongst 600 adult women in WA – the vast majority of respondents to a follow-up questionnaire reacted positively to the health information presented and found the messages informative, plus awareness of the importance of family history health was raised and better appreciated(1). Motivation to act upon important information gleaned from a family history lies with patient, family, and family practitioner. Any interventions required are likely to be relatively clear but more complex or rarer diseases may be clarified through specialists or the Genetic Services of WA, King Edward Memorial Hospital. Further details about the History Repeats pamphlet are available at

(1) Molster C, Kyne G, O’Leary P. Motivating intentions to adopt risk-reducing behaviours for chronic diseases: Impact of a public health tool for collecting family health histories. Health Promotion Journal of Australia, 2011;22:57-62. n


Angiography Suite P R O V I D I N G R E V O LU T I O N A RY I MAG I N G T E C H N O LO G Y

Hollywood Private Hospital’s angiography suite boasts the most advanced medical imaging in Western Australia offering increased efficiency and safety to both patients and doctors. The suite includes Siemens Artis Zeego technology, with fully flexible C-arm, allowing unparalleled access to patients.


Services and procedures at the Hollywood Angiography Suite: • • • • • • • •

Cardiac angiograms and angioplasties Electrophysiology ASD/PFO closures Pacemakers and resynchronization devices Right heart studies Vascular angiograms and angioplasties Endoluminal stent grafts Radiological procedures such as peg tubes, uterine embolisation, ureteric stents etc. • SIRS spheres • Vertebroplasty and pain management.

Each of the suites has 3D imaging capabilities, to remain at the forefront of technological advances, and all labs are equipped with Siemens CCTV integration which can be used for conferencing and teaching purposes. For further information, please contact: Christine Moody (CNM) and Yolandi Theron (MIT Manager) Angiosuite: 9346 6042, 9346 6045 or 9346 6591



‘History Repeats’ – using the family health history




Public Health and medical practice (Part 2) By Dr Revle Bangor-Jones, Acting Principal Medical Officer, Regulatory Support Unit. Tel 9222 2380


hese continuing insights into some of the Public Health laws and regulations are designed to give ‘coal face’ doctors a concept of how they work for the welfare of the community. From the Cremation Act 1929 to the Drugs of Addiction Notification Regulations 1980, the Regulatory Support Unit (RSU) assists the Department of Health (DoH) to administer a larger number of Public Health regulations – as well as provide advice to other agencies, health professionals and the public (see

Perinatal and Infant Mortality Committee

All deaths of children from 26 weeks gestation to age 12 months are reported and investigated by PIMC, a statutory committee under the Health Act 1911. Its deliberations are confidential and privileged (i.e. exempt from the Freedom of Information Act) and the committee’s main function is educational. An attempt is made to determine the degree of preventability of a death and to use this information to drive improvements in clinical care. Confidential letters are sent to each medical practitioner involved in care, providing a brief summary of the Committee’s conclusions. A triennial detailed analysis of all deaths, along with recommendations for future improvements, is released for public scrutiny (see subject_index/).

Pesticides Advisory Committee

The Principal Medical Officer in RSU, as the delegate of the Executive Director Public Health (EDPH), chairs this committee that serves to advise the EDPH on any matters relating to the use of pesticides. Committee representatives are from the Dept of Agriculture and Food, Chemistry Centre, Dept of Environment and Conservation, Dept of Commerce, and Dept of Water and Pesticide Safety. A comprehensive ‘Guide to the Use of Pesticides in WA’ is available at: Pesticides.pdf

The Cremation Act 1929

To sign a Permit to Cremate, a Medical Referee requires (as a minimum) the information provided in Form 6 (from the applicant) and Form 7 (from the doctor). Both forms are available from:

Have you considered becoming a Medical Referee? A registered medical practitioner, who is in active practice and has practised for at least five years, is eligible to apply and a fee is chargeable for each completed Permit to Cremate. Information is available at www. The medical referee’s role is broader than you might imagine. Before signing a Permit to Cremate the referee must be satisfied with three criteria: • the deceased has died from natural circumstances

• there is no indication of any non-natural process • cremation can safely proceed

Explosions of pacemakers in crematoria continue to happen, damaging the crematorium and risking injury to staff (three such events in recent months). Other safety considerations are battery operated implants and the presence of radioactive substances in the body (for which the Cremation Form 7 lists the radioactive treatments and time factors of concern). If there is a concern, safety advice is taken from the treating institution. n





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Laser Refractive Surgery: in a nutshell

By Dr Ian Chan, Ophthalmologist. Tel 9388 1828


isconceptions surrounding laser vision corrective surgery and other forms of refractive surgery are not uncommon. It is hoped this somewhat simplistic overview of LASIK (laser assisted insitu keratomileusis), the most common form of laser vision correction surgery, will assist the reader. The corneal surface is the main refractive apparatus of the eye and therefore a change in corneal shape can correct refractive error. These lasers sculpt the cornea by precisely removing tissue, like a lathe.

How safe and successful is it?

LASIK is 20 years old and over 18 million patients worldwide have had this treatment. A number of large series have been published. For example, the US Army offers laser correction for active soldiers to improve their combat effectiveness and in 2005, a series involving 32,068 eyes from this program was published (Ophthalmology 2005;112:184190); 85.6% achieved over 6/6 unaided vision following treatment; only 3 cases of infectious keratitis; and no patients had worse than 6/12 vision. A ten-year series from Singapore involving 37,932 laser treatments was recently published, with similar results.

How is the treatment performed?

LASIK involves cutting a circular corneal surface flap and laser treatment is applied under this flap to reshape the cornea. The average procedure takes 10-20 minutes per eye and the laser is active for only 1 to 2 minutes. Both eyes can be treated in the same session.

What about reading glasses in a 50-year-old?

Topical anaesthetic is used as the patient needs to actively look at a fixation light during treatment. Some parts of the procedure may be uncomfortable, however, most patients do not experience pain during treatment.

In presbyopia the problem is the inability of the eye to change focus between distance and near, which is an ageing effect. LASIK can only correct the overall focus of the eye to one distance. It cannot restore the ability to change focus due to ageing. However, we can still help these patients using LASIK and other refractive surgery by utilising multifocal optics or monovision.

What is the recovery period?

What are the risks and side effects?

What anaesthetic is required? Is it painful?

Problems from LASIK are rare, as illustrated by series above. Major sight-threatening complications occur in less than 1 in 10,000; and dry eyes and glare at night are uncommonly recognised side effects.

Patients typically recover in 1-2 days after LASIK. (Other forms of laser correction directly applied on the corneal surface can take up to 4 weeks to recover.)

Who is suitable for the treatment?

A detailed initial eye examination, which includes various computerised scans, determines the patient’s suitability based on the degree of refractive error, corneal thickness, ocular health and other factors. In short, LASIK can treat +5 to -10 diopters of spherical error and up to 6 diopters of astigmatism. This range covers most patients with reasonable thickness glasses.

Eye Surgery Foundation Perth’s only freestanding Ophthalmic Day Hospital • Supporting ophthalmic research and development • Certified to ISO 9001 Standard Expert day surgery for • Cataract Extraction and Lens Implant • Pterygium • Glaucoma • Oculoplastic Surgery • Strabismus • Corneal Transplant • All types of Refractive Surgery – LASIK, LASEK, PRK, CTK, Phakic Lens and Refractive Lens Exchange (RLE)

How much does it cost?

Bilateral treatment costs around $6000 in WA. More than half of this sum is related to technology. For instance, the brand new, stateof-the-art laser at the Eye Surgery Foundation costs more than an average house. Medicare and most health funds do not cover these treament n

Our Vision Is Improved Vision Dr Ross Agnello Tel: 9448 9955 Dr Ian Anderson Tel: 6380 1855 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco D’Souza Tel: 9258 5999 Dr Graham Furness Tel: 9440 4033 Dr Richard Gardner Tel: 9382 9421 Dr Annette Gebauer Tel: 9386 9922 Dr David Greer Tel: 9481 1916

Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156 Dr Brad Johnson Tel: 9381 3409 Dr Jane Khan Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600 Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Andrew Stewart Tel: 9381 5955 Dr Michael Wertheim Tel: 9312 6033

Contact: Matthew Whitfield Ph: 9216 7900 Email: 42 Ord Street West Perth WA 6005 medicalforum





Dermatology Update: Vitiligo By Dr Prasad Kumarasinghe, Dermatologist, Hollywood Private Hospital. Tel: 9389 6736


itiligo causes patchy or generalised depigmentation of the skin. It occurs in about 0.5%-1% of the population and affects people of all skin tones but is more noticeable in darker skinned people. It can be psychologically devastating, severely affecting quality of life. Famous people with vitiligo include Michael Jackson and Lee Thomas an American TV presenter who has become a spokesperson educating people about vitiligo and motivating people to cope with the condition.


Vitiligo is an autoimmune disease and as such, can be associated with autoimmune thyroiditis, diabetes mellitus, and alopecia areata. The depigmentation is due to destruction of melanocytes in the affected areas. There is a familial tendency, indicating a polygenic inheritance, but the exact triggering factors for initiation of the cascade of cellular changes that lead to melanocyte destruction are not known.

laser-abraded vitiligo area to be treated. This method is not available widely in Australia yet, due to the high cost and the practical difficulties of establishing a sustainable cellular grafting set-up. Currently, a commercially available cell separation unit (ReCell) is being evaluated for surgical treatment of stable localised vitiligo lesions. If vitiligo has caused near complete depigmentation the remaining normally

pigmented areas can be depigmented with monobenzyl ether of hydroquinone or with pigment laser therapy. The aim is to obtain a uniform colour.

Vitiligo patients need empathy and understanding. We must appreciate the psychological suffering they go through when vitiligo develops, particularly in young people. Sometimes professional counselling is needed to assist patients cope with the condition.

Vitiligo Support Group established in Perth

Clinical pattern

Vitiligo can start at any age, but the average age of onset is around 20 years. The common type of vitiligo (vitiligo vulgaris) is symmetrically distributed. If often affects skin on the fingers, feet, elbows, knees, axillae, around the mouth, around eyes, and the chest. Occasionally it can progress to the whole body (vitiligo universalis), whereas segmental vitiligo affects roughly a dermatome area, unilaterally. Rate of progression is variable in both nonsegmental and segmental vitiligo. However, on some occasions rapid progression is seen in generalised vitiligo. There can be quiescent periods and rapidly progressing periods in the same patient.

Treatment and progression

For generalised vitiligo, narrowband ultraviolet B light therapy (NBUVB) and topical steroids are useful. The evolution of generalised vitiligo is rather unpredictable. The lesions on the face respond better to treatment, except the lips. Finger tips also respond poorly to treatment.

Topical tacrolimus and topical calcipotriol are some other creams used for vitiligo. Targeted phototherapy and excimer laser are some other methods of treatment for localised vitiligo.

Segmental lesions respond better to surgery than generalised vitiligo. For limited stable disease surgical minipunch grafting and cellular grafting may be used. In cellular grafting, a normally pigmented piece of skin is taken from the same patient and trypsin enzyme is used to separate the melanocytes and keratinocytes from intercellular bondings. Then, the cell suspension is grafted (squirted) on to the dermabraded or 46

This is a largely neglected group with significant unaddressed needs. In line with most developed countries worldwide, Australia established a patient support group for vitiligo in October 2010 –Vitiligo Association of Australia. Those involved include dermatologists, vitiligo patients, psychologists, relatives of patients, nurses, medical students and some other members of the public.

In WA, there are currently about 10-15 patients/families attending meetings. The group is expected to steadily expand as awareness increases. The Sydney branch has another group of 15-20. There are representative s in Queensland and Victoria as well.

Vitiligo Association of Australia

n Inaugural meeting of the vitiligo patient support group at the Hollywood Medical Centre, Nedlands (October, 2010).

A major aim is to minimise/eliminate social stigmas by increasing public awareness about the condition, while additionally striving to advocate in health policy planning and Medicare planning for services for vitiligo patients. Basic aims of this association are to:

• Educate, support and advocate for vitiligo patients, • Provide a forum for informal interaction, • Promote research to increase understanding of pathophysiology and improve treatments, and

• Link with other associations around the world.

Activities include a new website (vitiligo., a recent booth at the recent national Australasian College of Dermatologists meeting in Perth, and membership of the World Alliance for Vitiligo Support (connect patient support groups). Feedback from patients, dermatologists and visitors of the website has been very fulfilling. Several research projects on vitiligo have been started, in Perth and Sydney.

n Dr Kumarasinghe addressing the gathering.

President: Dr Prasad Kumarasinghe Secretary: Dr Benjamin Daniel Treasurer: Ms Lisa Brown Main source of funds: Donations Contacts: Via or Dr Ben Daniel Email:

Much more needs to be done. Hopefully, with everyone’s support and encouragement, we can help the vitiligo patients not only in Western Australia but also in other parts of Australia. Due to the aesthetic impact of vitiligo it has a potentially very significant psychological impact on the sufferers and this group was formed to provide them with much needed support and advocacy. n

This update is supported by an educational grant to Medical Forum by Hollywood Private Hospital


On the Grapevine By Dr Martin Buck

Rusden Wines Rusden Wines are in the heart of the Barossa and are developing a cult following through their innovative labelling and use of the great Barossa varieties. The Canute family purchased the run-down vineyard in 1979 and slowly moved from grape growing to wine making. The business remains family owned with son, Christian, being in charge of winemaking, having served his time with a great Barossa icon, Rockford. Varieties in the stable are the original Shiraz, Grenache, and Cabernet as well as Mataro, Zinfandel, and Chenin Blanc. All viticulture and winemaking is traditional Barossa with an emphasis on an honest expression of the fruit. The 2010 Christian Chenin Blanc is a wine I have tried many times before and it is a chenin like few in Australia. It is hand-picked, basketpressed, barrel-fermented, and then matured in French oak. A style most similar to chenin from Vouvray where the flinty clay soils give great acidity and ageing ability to the wines. The Christian has a great tropical nose with grapefruit aromas and a limey, acid-persistent palate. Subtle oak provides balance and complexity. The alcohol is 10.5%, and this is a great wine for seafood. Fruit for the 2009 Driftsand comes from grafting traditional Grenache and shiraz back into the vineyard after being removed in the seventies. It is a 60% Grenache and 40% shiraz blend made from a warm vintage and with strong Rhone links. Smouldering aromas of

caramel, mocha, and plums make this a fruitdriven wine. This wine has a full palate of ripe Grenache with soft tannins and a clean acid finish. A true classic Barossa blend and very enjoyable (15.5%).

a tough vintage and required only 5% new American oak. It is a surprisingly soft, delicate cabernet, with a distinctive warm Barossa style. It is a ripe wine (14.5%), which is great to just sit and savour.

There is a lot of Rockford influence in the 2009 Ripper Shiraz Cabernet with basket pressing and open fermenters followed by ageing in large, old oak vats. Another warm vintage with 55% ripe shiraz makes this a full-bodied wine with the classic features of the blend. Soft tannins and restrained fruit result in a classic ready to drink and suited to a winter dinner (14.0%). Very approachable now.

Lastly, the 2008 Black Guts Shiraz is the flagship of this range, and what a ripper! Old vines nurtured with traditional techniques and grapes picked at full ripeness (15.0%) to go into this wine. This has all the big shiraz characters wrapped into a boxing glove! Superb oak handling gives the wine power and persistence. This is clearly my favourite wine, and to quote Robert Parker, “There is virtually nothing like it produced anywhere else in the world.”

Cabernet sauvignon is less appreciated in the Barossa but nevertheless contributes fruit to the iconic Penfolds wines. The 2008 Boundaries Cabernet Sauvignon came from

WIN a Doctor’s Dozen! Courtesy of Medical Forum DOCTOR’S DOZEN COMPETITION


Which Rusden wine is considered the “flagship of the range”?



Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, July 31, 2011. To enter the draw to win this month’s Doctors Dozen, return this completed coupon to ‘Medical Forum’s Doctors Dozen’, 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.


Rusden is a beacon of Barossa traditional winemaking, and this has been one of my most enjoyable tastings for a while.

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Recipe Provided by Allrecipes

Spicy BBQ Pork Ribs Pork ribs are among a bloke’s favourite meal. He gets to strap on a bib and dive in with his hands … it’s a meal high on flavour that brings back the magic of childhood. This foolproof recipe is guaranteed to be a big hit with the men in your household. It’s simple enough that even inexperienced cooks can create a meal that tastes and smells sensational. Cook it outdoors to make the neighbours envious! Before barbecuing, the ribs are coated with a dry rub of cumin, chilli powder, and paprika to give them plenty of flavour and colour. During the last minutes of cooking, baste them with your favourite BBQ sauce. Preparation Method Preheat barbecue for high heat. In a small jar, combine cumin, chilli powder, paprika, salt, and pepper. Close the lid and shake to mix.


Trim the membrane sheath from the back of each rack. Run a small, sharp knife between the membrane and each rib, and then snip off the membrane as much as possible.

Ingredients • • • • • •

1 tablespoon ground cumin. 1 tablespoon chilli powder. 1 tablespoon paprika. Salt and freshly ground black pepper to taste. 2 x 750g racks of short pork ribs. 1 bottle barbecue sauce.

Sprinkle as much of the spice mixture onto both sides of the ribs as desired. To prevent the ribs from becoming too dark and spicy, do not rub the spices into the ribs. Store any unused spice mix for future use. Place aluminium foil on lower part to capture the dripping and prevent flare-ups, and lay ribs on the upper shelf of barbecue if possible. Reduce heat to low, close lid, and leave undisturbed for 1 hour. Do not lift lid at all. Brush ribs with desired amount of barbecue sauce, and cook an additional 5 minutes. Serve ribs as whole racks or cut between each rib bone and pile on a serving platter.

funny side

n n n You know you’re Australian if: • You believe that stubbies can be either drunk or worn. • You waddle when you walk due to the 53 expired petrol discount vouchers stuffed in your wallet or purse. • You’ve made a bong out of your garden hose rather than use it for something illegal such as watering the garden. • You believe it is appropriate to put a rubber in your son’s pencil case when he first attends school. • You understand that the phrase ‘a group of women wearing black thongs’ refers to footwear and may be less alluring than it sounds. • You pronounce Melbourne as ‘Mel-bn’. • You know that some people pronounce Australia like “Straylya” and that’s ok. • You can translate: ‘Dazza and Shazza played Acca Dacca on the way to Maccas.’ • You believe it makes perfect sense for a nation to decorate its highways with large fibreglass bananas, prawns, and sheep. • You call your best friend ‘a total bastard’ but someone you really, truly despise is just ‘a bit of a bastard’.


• You’re secretly proud of our killer wildlife. • You believe it makes sense for a country to have a $1 coin that’s twice as big as its $2 coin. • You understand that Wagga Wagga can be abbreviated to ‘Wagga’ but Woy Woy can’t be called ‘Woy’. • You believe that cooked-down axle grease makes a good breakfast spread. You’ve also squeezed it through Vita Wheat biscuits to make little Vegemite worms. • You believe all famous Kiwis are actually Australian – until they stuff up, at which point they again become Kiwis. • Hamburger with Beetroot? Of course! • You know that certain words must, by law, be shouted out during any rendition of the Angels’ song “Am I Ever Gonna See Your Face Again” • You believe that the confectionery known as the Wagon Wheel has become smaller with every passing year. • You wear ugg boots outside the house. • You believe that every important discovery in the world was made by an Australian but then sold off to the Yanks for a pittance. • You believe that the more you shorten someone’s name the more you like them. • Whatever your linguistic skills, you find yourself able to order takeaway fluently in every Asian language.

• You understand that ‘excuse me’ can sound rude, while ‘scuse me’ is always polite. • You know what it’s like to swallow a fly. • You shake your head in horror when companies try to market what they call ‘Anzac cookies’. • You understand men will feel the need to offer an excuse whenever they buy lowalcohol beer. • You have some time in your life slept with Aeroguard on in the summer. Maybe even as perfume. • You know that the barbeque is a political arena; the person holding the tongs is always the boss and usually a man. And the women make the salad. • You say ‘no worries’ quite often, whether you realise it or not. • You’ve drank your tea/coffee/milo through a Tim Tam. • You’ve ordered a steak the size of your head and only paid $5 at your local RSL. • You know that roo meat tastes pretty good, but not as good as barra – or a meat pie. • You know how to abbreviate every word, all of which usually end in -o: arvo, combo, garbo, kero, lezzo, metho, milko, muso, rego, servo, smoko, speedo, righto, medico, etc.


Technology By Shane Cummings

How to Choose the Right Smartphone Gone are the days when a mobile phone was only capable of calls and text messages. Those pioneering bricks of the late 90s have been replaced by smartphones that are handheld computers, packed with processing speed and memory capacity that would put your desktop computer from a few years ago to shame. And then there are the apps (applications, or specificallydesigned software add-ons for your phone). If you’re looking to upgrade your phone, the choices can be dizzying, if not downright terrifying for the uninitiated.

The basics When confronted by the bewildering array of choices, ask yourself, what do I really need? If that question is still too broad, then consider the following: •

Budget. The better smartphones cost between $500 to $900 for the handsets alone (such as Apple’s iPhone or the Samsung Galaxy S), but if you’re savvy, you can get them for free (or maybe $5 per month) if you sign up to a two-year plan (also known as ‘post paid’ plans). The golden rule is the more expensive the plan, the better selection of phones you get for free. If you feel it’s not worth investing in a phone with all the bells and whistles, consider a cheap monthly plan and aim for a more modest phone such as the lower end Nokias, Samsungs, or LGs.

your options carefully before committing to a two-year contract on a phone incapable of accessing apps. •

Compatibility. Some smartphones aren’t compatible with Windows, which could cause heartache if you’re swapping files between your phone and PC. Blackberries, for example, can interface with Windows but often don’t allow you to make modifications. Of course, if you’re an Apple diehard, you’re probably already swapping files between your iPhone, iPad, and your MacBook Air like a pro.

Camera. Why buy a separate digital camera when so many smartphones come packed with megapixels? Most mobiles have a camera built in, and the better ones have lenses of 8 megapixels or more, multi-zoom, and image stabilisation.

Number pad. The feel of a phone is the most underrated, and almost certainly the most important, consideration when upgrading to a new phone. The transition from the standard ten digit number pad is particularly jarring when upgrading to a touchscreen smartphone (such as the iPhone), which has a fully QWERTY keyboard activated at a touch. For many, touch screens are the future, but for the sight-impaired or those who like their phone to feel like a phone, suppliers such as Nokia still sell phones with large number pads. Other keypad options include a physical (rather than virtual) micro QWERTY keyboard (ideal if you have tiny fingers!), notably on Blackberry models, and slide phones, which are a good compromise between screen size and physical number pad size.

Now that you’ve narrowed down the type of smartphone you want, the final step is to choose a carrier. Current marketplace leaders are Telstra, Optus, Vodafone (including the old 3 network), and Virgin. Their most fiercely contested battleground is unlimited plans, which have no monthly cap on phone calls or text message costs.

Screen size. This follows directly on from the choice of number pad. If you’re aiming for a smartphone with a touchscreen and plenty of apps, then the top-of-the-range models with four inch screens such as the Sony Ericsson Xperia or Apple iPhone are the way to go.

Optus trumps both with the Timeless Extreme package, which comes with 5GB of data and unlimited calls and texts for $99 per month. The $129 Timeless Extreme option bumps the data up to a huge 6GB per month.

Apps. The true power of smartphones comes from apps. Want to learn a language, access the latest GPS map data, download games, or use your phone like a lightsaber? More seriously, according to a recent statement from the TGA (about regulating the medical app market for smartphones), at least 1,500 medical apps have been designed for health professionals (such as apps allowing you to access patient e-health records), and there are thousands more that contain health-related information targeted at the lay public. To access these apps, you need to buy a smartphone that comes with an app store. Right now, the market leaders are Apple’s app store (for the iPhone only) or the Google Android market (for the non-Apple smartphones such as the LG Optimus, the Sony Ericsson Xperia, and the Samsung Galaxy). The technology is evolving at breakneck speed, and without apps, you might be missing out on important technological innovations for your practice, so weigh

Lagging behind the rest is Telstra. While it has the best Australia-wide coverage of all networks, its best (and only) unlimited deal is the $129 Freedom Connect plan, which includes just 3GB of data.


Plan for a plan

Vodafone’s entry-level Infinite cap costs $45 per month, although the kicker is it comes with only 500MB of data per month. Their top-ofthe-line $100 Infinite cap, which comes with an iPhone 4, boasts an impressive 4GB of data per month. Virgin’s best deal is the Big Cap 29, which includes $450 worth of calls and texts and 200MB of data for just $29 per month, while their best unlimited plan, the Topless 89, undercuts Vodafone by $10 per month.

So why is data allowance so crucial? As more smartphone users are conducting their internet browsing and emails on their phones rather than PCs. A half hour session of watching YouTube videos, for example, can burn through 200MB like nobody’s business, and those all-important apps need to be downloaded (ranging from 2MB to 20MB or more a pop), so consider the data limit before locking yourself in for two years. The tricky bit is linking your plan with your desired smartphone. Most plans come with free phones, but at the bottom end of the spectrum, the choices are limited. Fortunately, the more expensive your plan, the more choice you get, with the unlimited plans securing just about any phone you desire.


Satire Wendy Wardell

It’s All Done with Mirrors The fable of Snow White gets a 21st century cosmetic makeover. If only dermatological science had been more advanced in the days of the Brothers Grimm, the fairy tale Wicked Queen/Evil Stepmother might have had better press. Quite honestly, having pouting teenage princesses under your feet and slobbering over every spotty amphibian they see would test the patience of a saint, let alone a middleaged power-crazed psychopath. The last thing you need on top is hairy moles and liver spots.

her feet. She immediately stacked on ten kilos, dialled out for pizza, and switched on the latest reality TV show. It was about seven vertically challenged men of uncertain sexual orientation who lived together. By night, they laboured in the secret underground office of a skin care

Snow White had been given breast augmentation for her 18th birthday and had streaked ahead in the competition.

With more sage skin advice, the world could have been spared the environmental impact of all those poisoned apples. Although nature will, it seems, win in the end. Cue wavy lines and eerie flashback music For years, the Wicked Queen had asked questions that enabled the Magic Mirror to help her arrest dermatological decline. “Mirror, mirror on the frescoed ceiling, Do I need dermabrasion or glycolic peeling?” Fortunately, being an Internet-enabled magic mirror, it had been able to browse the latest offerings from New Idea during downtime. But now the mirror knew it was on a sticky wicket. Snow White had been given breast augmentation for her 18th birthday and had streaked ahead in the competition.

White had hidden in the fridge behind the jar of toadstool pickle. Overnight, Snow White’s face blossomed with warts and her chin became astro-turfed with whiskers. Her designer gown transformed itself into the lint-balled polyester tracksuit of an old crone and grubby ugg boots sprouted on

company, producing made-up scientific names for new products to sell to gullible victims. (The theme song was “Retinol, retinol, it’s off to work we go…”) By day, they searched for beautiful young girls to keep house for them. “Geez” thought Snow White as she reached out to grab another handful of chocolates “What sort of mug would fall for any of that rubbish?”

The next time the Queen posed a question, had the mirror got feet, it would have been shuffling them. “Mirror, mirror on the wall, The sands of time I’ve tried to stall I’ve bought lotions for lines, stuff for my thighs Fillers for wrinkles and lifts for my eyes Tell me pseudo-science and marketing might Beats the pants off the beauty and youth of Snow White.” The response was swift and brutally honest. “Let’s get real, you’re 64. Your skin’s ageing is not premature The kid’s young and fresh and quite a cutie You got cellulite where she got booty.” Naturally, the Wicked Queen threw the Magic Mirror into the recycling bin with the old gin bottles, ate three packets of Tim Tams, had a good cry, and went shopping. By the time she returned, she had planned her revenge. From her environmentally-friendly shopping bag she pulled a small glass vial labelled ‘Menopause Accelerant’. The Wicked Queen injected the potion into a tin of Bacardi Breezer that Snow



Car Review By Drs Daryl Sosa and Peter Bradley

BMW 730d: A Luxury Limousine with Grunt Daryl and Pete hit top gear when they tested the mettle of BMW’s flagship luxury sedan. But did the 730d meet their expectations? Remember the 70s? A pie and sauce or a Coke cost 13 cents and so did a litre of gas (petrol, of course). And diesel was that dirty by-product from old trucks that created black plumes. Five bucks filled the tank and that was good for about 500 km ... sweet! Then the first “energy crisis” came along, and we all thought we were witnessing the end of our gas guzzling incarnations. Fortunately, that was just a bit of hype and manipulation by the oil producers (OPEC) to ramp up prices and profits for a while. The hysteria gradually faded, but manufacturers responded in the 80s by downsizing us and making vehicles more efficient. Now, almost 35 years later, we’re witnessing a similar process. We’ve seen a plethora of new diesel engines filtering through almost every segment of the auto industry, from compacts to convertibles, luxury sedans to SUVs. The European manufacturers have led the way in developing user-friendly diesel-powered cars so that now, especially with the modern turbo-diesel, these vehicles compete with petrol cars for performance but are more economical. Gone are the days of the diesel cars sounding and driving like trucks. Recently, we had the opportunity to test BMW’s 730d, the 5th generation 7 Series launched in 2009, with its 3rd generation turbo-diesel power plant. Interestingly in Australia, the 730d is the “entry level” model of the 7 Series. The 7 series is the largest and most luxurious of the BMW range and truly qualifies as a luxury limousine. At this level ($224k drive away), it comes packed with performance, technology, and creature comforts. The first impression is that it is big! However, with small overhangs and a crisp accentuated shoulder line, it still looks sporty! A few minutes of orientation with the salesman at Auto Classic paid dividends. We found the latest version of the iDrive controller simple and intuitive to use. The 10.2 inch widescreen high resolution TFT sat nav/control display was excellent, especially in 3D single view mode. The heads up display (of either navigation or

just current speed) was equally impressive and allowed precise control of vehicle speed whilst using cruise control, which is crucial in avoiding (unhappy) “snap shot moments”. For the technically minded, the 730d has a Common Rail Intercooled (single) turbo in line 6-cylinder diesel that packs 180 kW and 540 Nm from 1750 to 3000 rpm, mated to a 6-speed automatic transmission. The individual Piezo injectors are force fed at 2000 Bar! The vehicle has an all-aluminium crankcase, and combined with other features such as regenerative braking, low CD, and extensive use of lightweight aluminium parts in the chassis, makes it one of the quietest and most efficient vehicles in its class. BMW call it Efficient Dynamics or ED (we medicos generally think of something else!) This all adds up to impressive performance with torque that is useful for quick acceleration in city driving and safe overtaking on country roads. Initially, we found the test vehicles tyre noise a little intrusive on coarse bitumen, but then we discovered that it had Goodyears on the front instead of the original “run flat” Pirelli’s. Hard acceleration produced engine noise reminiscent of an Australian Big 6 (Petrol), but it was still quite acceptable for a diesel. On a spirited drive to Gingin loaded up with five passengers, the 730d achieved an average 7.3 litres/100 km over approximately 200 km of combined suburban and highway cruising, which is almost exactly what BMW claims (7.2 l/100 km). These are very impressive figures for a car that does 0-100kmh in 7.2 secs and weighs in excess of 1900kg. The centre console-mounted Dynamic Driving Control allowed the driver to select from Comfort, Normal, Sport, or “Sport Plus” settings. Unfortunately, my partner found the Comfort setting made her feel a little “sea sick” so most of the drive was done in either Normal (the best compromise) or Sport, which stiffens up the dampers to reduce body roll and changes the auto’s shift points. It kicked down earlier and held onto gears longer, which was really not necessary in such a high torque diesel. I have the same complaint with the EVO X’s TCCT [Daryl’s daily drive]. For a large luxury sedan, steering was sharp and the handling was very predictable. Overall verdict: This is a very impressive Teutonic technological Tour de Force that would make any owner proud. It’s a little like going on a cruise – the destination is not that important. Getting out of a BMW 730d says, “I’ve arrived!”. So what kind of people would want to drive this car? Is the 730d suitable for a retired farmer or doctor who wants to treat themselves after a lifetime of work? Not necessarily. We all deserve to be driving this vehicle, as it is safe, comfortable, and economical, but most of all, it’s fun and easy to drive. Unfortunately, entry into this league will be restricted to a privileged few! Enjoy!



Medical Forum 7/11  
Medical Forum 7/11  

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