MedicalForumWA 0518 Public Edn

Being a Woman Fertility & Glass Ceilings TV Mesh; Contraception; C-Section Future Medicine

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May 2018

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EDITORIAL Jan Hallam, Managing Editor

Power to the People The health of our community, and the individuals and families within it, are very much on our minds and in our pages this month.

and a slathering of UV 50+ onto our sun-worshipping bodies to reduce skin cancer, and he is now deeply involved in alcohol harm minimisation so we don’t pickle ourselves and the generations to come.

Public health, and more specifically, investing in and practising preventative health are increasingly viewed as the potential saviour of an ailing health budget groaning under the weight of chronic disease.

What is also starkly apparent is that while the health system has evolved and medical practitioners have accomplished extraordinary things, there has been a corresponding community expectation that the system can cure absolutely everything! All that’s required is a pill here, a nip and tuck there with maybe the odd ‘zap’.

Consequently our community is, with the help of some seriously influential corporate behemoths, living high on the hog. But what happens when the hog turns around and starts to live high on us? Cue the reassuring white coat, stethoscope and gleaming hi-tech hospitals.

One consultant cardiologist at the latest Doctors Drum breakfast begged to be put out of work by a community brimming with rude health…

Yep, that’s what we thought too.

We caught up with Terry Slevin last month as he was packing away 23 years of hard work with the Cancer Council of WA, the past decade or so as its Director of Education and Research, to take up the CEO’s role at the Public Health Association of Australia in Canberra.

Terry knows a thing or two about public health campaigns.

He was on the ground fighting Big Tobacco 30 years ago, he knows way too much about bad fat in an overweight person’s gut through Live Lighter, he’s put a big floppy hat

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

He’s seen all the Big Data linked with these issues, but what he knows most about is human nature.

He’s seen how inconvenient, incontrovertible truth is ignored when societal norms wilfully refuse to acknowledge them.

All of this gives serious cause for pause.

Of course we can stand idly by while people choose to kill themselves by living on fast food, drink to excess and smoke or gamble their children’s futures away. Yes, it’s their life! All these are legal activities, and they’re perfectly free to choose.

But do they have a right to follow such a course of action, particularly if it’s the community picking up the tab as a consequence of their actions?

Another doctor at the Drum coined the term, ‘Disease System’ because that’s what is left when both personal responsibility and public policy fail.

Perhaps Public Health will be the saviour of us all?

This isn’t a new song, by any means. But it’s now being sung with more confidence and gusto than it has been for years and, most importantly, decision makers are starting to tap their toes in time.

Sadly, like most of these discussions, it always starts with money. And, as is so often the case, a paucity of hard cash often results in bitter rivalries with interest groups squabbling like seagulls over the scraps.

Maybe it’s time to change the tune.

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

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

MAY 2018 | 1

CONTENTS MAY 2018

INSIDE 12

Close-Up: GP Obstetrician Dr Nikee Msuo

14 16 18

Spotlight: Dr Tracey Westerman

Birds, Bees & IVF Doctors Drum: Future Medicine – Playing the Change Game

18

16

NEWS & VIEWS 1 Editorial: Power to the People Jan Hallam 4 Letters to the Editor

12

14 MAJOR PARTNER 2 | MAY 2018

8 9 9 23 25 30 33 37

TV Mesh Update - Dr Jessica Yin Early Referral to Palliative Care - Dr Sarah Pickstock Future Fund for Prevention - Ms Nicolette Zingerle Never Too Late for Prevention - Dr Bret Hart Have You Heard?

Beneath the Drapes Curious Conversations - Dr Beverley Teh Pathways to Where?

Friends with Dignity CHATS in Vietnam Wings to Fly Smoking in Pregnancy

LIFESTYLE 46 Life on the Ocean Wave - Dr Revle Bangor Jones 48 My Local: Cambridge Corner Store 48 Recipe: Grilled Fish with Tangy Green Salsa 48 Wine Winner: Dr Murray Dixon 49 Wine Review: Oates End - Dr Martin Buck 50 Social Pulse: Rural Health West Doctor Awards 50 Funny Side 52 St Petersburg Ballet’s Swan Lake 53 Sondheim’s Assassins 54 Competitions

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CONTENTS MAY 2018 CLINICALS

5 New Era in Specialised Women’s Pathology Dr Adeline Tan

32 Prolapse Repair Post Mesh Dr Ron Jewell

39

37 Are LARCs Underused?

Dr Cliff Neppe

Subfertility Imaging in Women Dr Emmeline Lee

33 Mid-Urethral Sling: Should It Still Be Used?

Dr Fred Busch

35 Sexual Health What’s Happening in WA Dr Jenny McCloskey

43

41 C-Section for Maternal Request Dr Rae Watson-Jones

Ovarian Cancer: Symptoms & When to Act Dr Stuart Salfinger

44 Pudendal Neuralgia Dr Angamuthu Arun

GUEST COLUMNS

10 The Glass Ceiling is Real A/Prof Linley Lord & Prof Siobhan Austen

26 Time to Talk About Grief Ms Christine Richardson

27 Aerobic Exercise, Postpartum Ms Katie Stewart

45 HbA1c Insights Dr Tim Welborn

29 Planning for End of Life Dr Gillian Mitchell

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

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MAY 2018 | 3

LETTERS TO THE EDITOR TV Mesh Update Dear Editor, On March 28 the Senate report on TV Mesh was released. Apart from the seismic changes in the field of female urology and gynaecology, the recommendations may have ramifications for other specialties.

How does this change current practice?

Much hinges on the interpretation of Recommendation 7. Many specialists in the field feel that the Senate recommendations force us to favour colposuspensions and fascial slings over mesh MUS. The historical operations have identical complications but greater morbidity and longer recovery periods.

1. That there be a review of current system of reporting adverse events to the TGA to:

A recent study from the UK looked at the complications following mesh slings in 92,246 women over an eight-year period.

This is the largest studied cohort of any implantable device and clearly shows the safety of the MUS with a 2.4% periprocedural complication rate and 1.7% 30day complication rate in the unconfounded cohort.

Mesh complications and removal

It’s key recommendations were:

i.

Implement mandatory reporting of adverse events for use by consumers, medical practitioners and the device companies ii.

Simplify and improve awareness of the TGA reporting system

2. That the ACSQHC develop patient resources providing guidance on appropriate action to take in the event of an adverse event 3. That a registry be established for all high risk implantable devices 4. That the ACSQHC prepare guidance material on effective informed consent 5. That the ACSQHC provide guidance for credentialing of practitioners who perform TV mesh 6. That the Medical Professional Colleges implement governance arrangements for TV mesh procedures requiring members to work within a multidisciplinary team 7. That treatment guidelines developed by the ACSQHC clearly indicate that TV mesh should only be taken with fully informed consent and as a last resort when other treatment options have been considered and deemed unsuitable.

Many patients, particularly those experiencing autoimmune type symptoms, feel that only complete removal of the mesh will relieve their symptoms. There is no firm evidence to link polypropylene mesh with autoimmune deficiency. It is impossible to determine whether complete removal will alleviate symptoms in every patient and in some cases attempts at complete removal have, in fact, worsened the situation.

The belief that complete removal of mesh is the only acceptable management option for all cases is incorrect. For many of those patients who have voiding dysfunction from mesh mid-urethral slings, partial removal of the sub urethral mesh may completely alleviate symptoms. In addition, those who have urethral erosions benefit from removal of the eroding section and do not require removal of the arms for relief of symptoms.

Small vaginal erosions from POP mesh may be managed with topical oestrogen or isolated excision.

The removal of mesh is a developing area and whilst there are practitioners who actively advertise their services in this field the amount of published data on mesh

removal is relatively scant and difficult to interpret, as each case must be considered individually. There is no ‘one operation that fits all’.

Another unexpected outcome is the rise of self-determined care. Networking among mesh support groups has created a demand for investigations such as 4D vaginal US. One local private radiology firm has now ceased performing 4D ultrasound on these patients as they were getting multiple requests from GPs who had no information regarding what operation these patients had undergone or the clinical reasons for organising the test. They were simply requesting them as per patient demand.

And as such, the investigations were taking a long time and, not surprisingly, not well tolerated by the patients. As a radiological colleague stated "it's like having patients turning up demanding a CT for any symptom they are concerned about".

In addition, many mesh-injured patients are paying exorbitant fees to fly overseas to specialists who advertise their ability to remove ALL mesh.

While it is appreciated that consumers will ‘vote with their feet’, many are unlikely to find the solutions that they desire by selfmanaging their care.

Dr Jessica Yin, Urologist, Perth ....................................................................

Early referral to palliative care Dear Editor, Thanks to Cameron Wright for his interesting article Early Palliative Care Makes Life Easier

continued on Page 6

Blessed is the man, who having nothing to say, abstains from giving wordy evidence of the fact.

George Eliot (1819-1880)

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4 | MAY 2018

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New Era in Specialised Women’s Pathology Advancing technology and molecular diagnostics has made pathology one of the fastest changing areas in medicine.

NIPT. Non-invasive prenatal testing such as Generation® and Generation Plus®, based on Whole Genome Sequencing analysis of circulating cell-free fetal DNA from maternal blood sample as early as 10 weeks gestation, has already changed the way we screen for first trimester chromosomal abnormalities.

With astounding accuracy (less than 0.1% failure rate), molecular methods produce an objective, highly reliable quantitative result.

Cervical Cancer. In recent months, the basis of cervical cancer screening has been replaced by first line molecular testing. Instead of conventional screening of pap smears for morphological cellular changes, detection of HPV DNA types is used to determine which patients require further screening with liquid based cytology. This combination of molecular diagnostic methods and “traditional” cytopathology stratifies the risk of developing cervical cancer as well as the time intervals, subsequent investigations or recommendations required for patient follow up.

Lynch Syndrome etc. The integration of molecular pathology with traditional cytopathology/histopathology or “morphomolecular pathology” has also shown significant impact in the management of women’s malignancies.

It is known that up to 2-3% of all endometrial cancers arise in patients with Lynch Syndrome (LS). Of these women with LS, 60% will have an endometrial or ovarian tumour as the sentinel cancer.

Hence, reflex testing of all uterine carcinomas and certain types of ovarian cancers for mismatch repair (MMR) protein deficiencies using immunohistochemical techniques is a useful surrogate for genetic testing.

BRCA mutations. High grade serous caricnomas associated with BRCA mutations also commonly show histological features such as solid, endometrioid or transitional-like architectural patterns and tumour infiltrating lymphocytes. Specialised pathologists will be able to recognise this and correlate with genetic data to raise the possibility of BRCA mutation and referral for genetic testing. These cases usually have an improved prognosis, better response to chemotherapy and treatment with PARP inhibitors. Hence, it is important that they are identified by specialist pathologists during routine reporting.

Female cancers. New changes in surgical management of women cancers also affect pathology practices. For example, prophylactic “risk reduction surgery” for BRCA1/BRCA 2 patients require a specialised pathologist to sample and examine all macroscopically normal tubal and ovarian tissue as serous tubal intraepithelial carcinoma (STIC) can be very subtle. In recent years, near infrared imaging with fluorescent dyes are also used in sentinel node sampling of vulval and low grade endometrial cancers to assess the spread of early disease.

Ultrastaging in these cases are slightly altered to that used in the examination of breast sentinel nodes and is only done in some pathology centres.

Dr Adeline Tan

BMedSci (Hons) MBBS (Hons) FRCPA

ABOUT THE AUTHOR She is a gynaecological histopathologist and cytopathologist. After graduating with dual first class honours from the University of Tasmania, she started as a junior doctor at Royal Perth Hospital and completed her RCPA fellowship training in Sydney. In 2018, she joined Western Diagnostic Pathology as the Director of Western Women’s Pathology.

She is also Senior Clinical Lecturer at UWA, and reviewer for the Western Australia Gynaecological Oncology (WAGO) biobank, St John of God Gynaecological Cancer Research and the Ovarian Tumour Tissue Analysis (OTTA) consortium.

Pathologists need to rise to the challenge of incorporating new techniques (particularly molecular diagnostics) and keeping up with the latest clinical practices.

A specialised women’s pathology service is vital for this. Pathologists also play a role in supporting clinical research, biobanking and correlating molecular diagnostics for the understanding and characterisation of diseases. By embracing these changes, we can continue to improve the future of women’s health.

Key Points • Molecular diagnostics has changed the pathology landscape.

• Detection of HPV DNA (new cervical screening program), NIPT testing in early pregnancy and the use of “morphomolecular” characteristics in cancer diagnosis are some examples of impacts on general practice.

• Pathologists are crucial to identifying disease subtypes and incorporating clinical and genetic information — to establish an accurate diagnosis and choice of targeted therapy.

• Specialised women’s pathology services integrate all these technologically advanced techniques and recent knowledge to provide the best health outcomes for women.

References are available on request.

For more information please contact 9317 0800

General Enquiries: Ph (08) 9317 0999 Email: admin@wdp.com.au Website: www.wdp.com.au Results Enquiries: Ph 136 199 For a list of Collection Centres and Laboratories go to www.wdp.com.au

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MAY 2018 | 5

LETTERS TO THE EDITOR continued from Page 4 (April 2018); I couldn’t have said it better myself.

Studies have shown over a period of time that early palliative care referral: • Promotes good symptom control • Allows patients the option to die at home • Allows time to plan care, meet the family • Reduces admissions and therefore health care costs • Can improve survival • Allows relationship building which can promote bereavement follow-up and identify complicated grief.

So what stops us?

It can be a hard conversation to initiate because, for some people, palliative care means only terminal care, or means giving up. Family talk of loved ones ‘dropping their bundle’ if told the truth. Studies tend to show that patients expect us as doctors to start these tough conversations.

The SPICT tool can be a useful prompt when reviewing our patients. What symptoms and signs should alert us to the possible need for referral.

Palliative care can be provided in many settings, acute hospital, hospice, residential aged care, group homes, prisons, or at home. It can be provided by all of us.

Some people do need a comprehensive community palliative care team – one that can provide 24-hour back-up, medical home visiting, psychosocial support, equipment and more.

So what’s the problem?

Funding is a major one. Silver Chain is block funded and routinely cares for many more patients than our contract provides for. Resources can be stretched only so thinly.

We do not have a set prognosis as criteria for referral (unlike US models) and there is a challenge to balance best practice (early referral) with available resources.

It’s important to talk about this issue.

Dr Sarah Pickstock, Palliative Care Physician, Silver Chain ....................................................................

Future fund for prevention Dear Editor, The recently released Sustainable Health Review Interim Report has emphasised preventative health as a key to sustainability within the WA health system.

The Public Health Association of Australia (PHAA) WA Branch welcomes this focus on preventative health, and strongly

6 | MAY 2018

encourages adequate and sustained funding from both the state and federal governments towards primary prevention and health promotion strategies and activities across the state.

Evidence-based comprehensive health promotion and prevention strategies have proven to effectively change population behaviours, reduce the burden of disease, and contribute to people having a better quality of life and living longer. Adequately funded, these strategies assist with the reduction of cost to the health system by keeping people in the community healthy and, ideally, out of hospital.

There is no doubt that research is a key component in preventative health. It informs policies, strategy and clinical practice – but it should not just be focused within the clinical sphere and on treatment. The WA Government and Minister for Health need to ensure that the Future Fund contributes to the sustainability of the WA health system by ensuring that the funding encompasses all areas of health, with a strong focus on public health, prevention and the social determinants of health.

The different parts of the health sector – from research to primary health care to health promotion – can be, and often are, in competition for funding. But no one part of the health sector can work alone. PHAA encourages creating and strengthening partnerships and collaboration across the health spectrum, as there is no one agent for prevention. Researchers, doctors, nurses, public health professionals, and many professions and organisations, are all agents for prevention that need to work together to improve the health and wellbeing of all Australians.

Ms Nicolette Zingerle, PHAA WA Branch General Committee Member ....................................................................

Never too late Dear Editor, Having recently joined a group of medical students from Curtin and Notre Dame medical schools in the Wheatbelt Immersion program, I can testify that they have wisdom beyond their years. Experiences such as this should help some of them to build the much needed ‘global view’ to tackle these ‘desperate times in health’.

These desperate times could have been prevented. Early in the 2005-15 period – during which time there was a 49% increase in ED attendances and 39% in hospitalisations – the then Premier Alan Carpenter spoke on ABC radio about a meeting he had with “…Fiona Stanley and people from the State Health Review

team who have been looking at what we can do to ease the pressure on the public health system and their strong advice was more money needs to go into public health education programs, medical research and so on, so that we can reduce the number… of people attending hospital with obesity, diabetes…My point to them was, ‘Yes – we would love to do that …but there are huge immediate demands now – every day of the week for us to spend more dollars – not so much on the preventative side … but on responding to circumstances facing people every day…”

The time when this appeal was made was during WA’s boom time when resources could have been allocated. Had this happened we would be reaping the benefits now.

The Sustainable Health Review (SHR) has identified the need to do what was suggested over a decade ago but now it will be more difficult to implement during this post-boom period. While wages growth may have contributed to the problem, it is politicians and their departments ignoring the advice of experts who should be held accountable for the legacy of their shortsighted decisions and policies.

Meanwhile, even if all the SHR recommendations are implemented to make the healthcare system more sustainable, this will only have a small influence on the health of West Australians.

Most determinants of health stem from outside the healthcare system and relate more to the conditions under which people are born, grow, live work and age. All State Government Departments influence these conditions and if they collaborate more to promote health only then will demand on the healthcare system diminish.

This whole of government response will require leadership from Premier and Cabinet. Technology will not fix the problem.

As Albert Einstein once said: ‘It has become appallingly obvious that our technology has exceeded our humanity.’

Adj Clin A/Prof Bret Hart, Chair Social Determinants of Health Alliance

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✓ Histopathology reported by our specialist team ✓ Synoptic reporting according to RCPA college and International reporting guidelines ✓ Macroscopic and microscopic images available for review ✓ Adjunctive pathology tests: – Special stains – Immunohistochemical stains (including hormone receptors, mismatch repair studies, PDL-1 testing) – Cytogenetics – Flow cytometry ✓ Microbiology nucleic acid testing (STI screening inc. M.genitalium) ✓ ThinPrep® liquid based cytology and reliable high-risk HPV testing (COBAS 6800 HPV assay) ✓ All abnormal findings reported by specialised cytopathologists with ThinPrep® certification ✓ Pap test results with recommendations based on the Renewed Cervical Screening Program ✓ Cytology and histology results are correlated ✓ Fine needle biopsies ✓ Frozen sections and sentinel node reporting ✓ BRCA testing

Western Women’s Pathology comprise of a team of highly skilled histopathologists and cytopathologists, headed by Dr Adeline Tan (Director of Western Women’s Pathology) and Professor Colin Stewart. Our pathologists are experienced in many areas of women’s pathology and have ThinPrep® certification in cytology. They are also dedicated to research, teaching and hold academic positions in Western Australian universities.

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MBBS BMedSci FRCPA FFPath FASCP FRCPath DipCytol (RCPath) FIAC

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MAY 2018 | 7

HAVE YOU HEARD?

Pathology rents … again?

Taste of the Wheatbelt The Wheatbelt was buzzing with the excitement of about 160 medical students from Notre Dame and Curtin medical schools as part of an immersion program, a collaboration between the universities, Rural Health West, WAPHA and the Wheatbelt East Regional Organisation of Councils, to familiarise students with the challenges and delights of delivering health care to the regions. The hard-edge to the program’s aims is to encourage young doctors to head bush once graduated to relieve some of the pressure of WA’s acute doctor shortages in rural and remote areas. Students headed to Bruce Rock, Cunderdin, Kellerberrin, Merredin, Narrogin, Southern Cross and Westonia where they were billeted by local families and immersed into the life of these communities. Medical Forum spoke to Monica Zheng, 24, a first year Notre Dame student who found herself in Narrogin. The former podiatrist was aware of some of the shortfalls in health services in the bush through her own practice and was interested to see some of the fruits of the State Government’s infrastructure spend as part of Royalties for Regions program. She was amazed at Narrogin’s new hospital facilities. “When you have a hospital that draws in some of the best technology, it really encourages people to make that change (to head bush). And the visit certainly shaped her ideas about rural practice. “We have a lot of opportunities throughout our degree to further shape these ideas with the Kimberley immersion next year, Rural Clincial School in third year and rural GP placements dotted around the course. It’s really important they exist because there are very obvious differences in outcomes for rural patients, even those a couple of hours out of the city.”

How can we help?

The latest Doctors Drum breakfast produced its usual dose of fascinating insights. This time around, the world of Future Medicine was explored (see write-up from P18). The Chief Psychiatrist Dr Nathan Gibson impressed all when he asked the GP on the panel how the public mental health sector could better serve GPs. A refreshing sign in itself. The answer was equally telling.

Put simply, better communication: “I find inpatient and outpatient services don’t communicate with each other and that outpatient clinics are very bad at letting go of patients. When they do pass them on to GPs, we are not told what to do, so we send them back and GPs develop this learned helplessness”.

Worrying signs Also at Doctors Drum, the latest changes

by Bupa to its Medical Gap Scheme were tossed around by concerned practitioners.

Some in the room believe that health funds

8 | MAY 2018

are starting to direct “what we do and not do”. While docs say private health insurance is moving toward managed care, and the private health insurance companies say ‘nonsense’, somewhere in between is the confused consumer wondering if their doctor is charging too much or their insurance is a waste of money. Both perceptions need to be explained.

Fair deal for WA The Health Minister Roger Cook flagged a campaign to get fairer consideration for health funding for WA at the COAG Health Council. It’s not only GST where WA lags behind. The minister told the Doctors Drum breakfast that WA was being “ripped off” by the Commonwealth, “whether that’s in the numbers of GPs for WA (and the flowon Medicare benefits).” Apparently WA’s MBS outlay per head is about $670 a year, nationally its $866 a year. “That’s hundreds of millions of dollars in MBS payouts alone we don’t get in WA by the virtue of not

Is this issue about to blow up again? We have heard murmurings of disquiet in GP land that pathology companies are raising the issue of rents again, though we have done a ringaround and there seems to be no change in the policy in Canberra. We wrote to the Commonwealth Department of Health’s communication team asking if any complaints from WA had been received about unfair rentals as extra money has been invested in compliance. Our deadline has sailed passed with nary a word from the bugles in Canberra.

Frozen in time This issue we spoke to Prof Roger Hart who is on the WA Reproductive Technology Committee (RTC) about what he would like to see come of the current review into the Assisted Reproductive Technology (ART) legislation currently underway (P16).

In the course of research we stumbled on the judgement by the retiring Chief Justice Wayne Martin on the case of the woman seeking approval to have her dead partner’s sperm implanted. For that she must go to the ACT as it is not permitted by law here.

It was a complex case that crossed two Acts – one on donor tissue as well as the ART legislation. The judgement fuelled food for thought on a range of issues and makes for interesting reading. You can find it here: https://ecourts.justice.wa.gov.au (look for [2018] WASC 79).

Medicinal cannabis pathways State health ministers also agreed to support the Commonwealth’s proposal to develop a single national online application pathway to access unregistered medicinal cannabis products. The process would avoid duplication at the state level while maintain a separate approvals process by the states and territories to manage appropriate access to Schedule 8 products. It was greeted warmly by the president of the RACGP Dr Bastian Seidel but it might take some time for many others to be convinced. However, there were very few takers on the Greens proposal to legalise marijuana for private use.

Puff of smoke The report of the parliamentary inquiry into the use and marketing of e-cigarettes and vaporisers caused a hullabaloo with two dissenting reports, including one from the chair of the committee. MPs Trent

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having enough GPs. The average number of GPs per 100,000 nationally is 95, in WA it’s 77. If you don’t think that makes a difference to the way we deliver healthcare and the impact on hospitals, you’re kidding yourselves. We have a huge problem,” he said When it came to the number of aged care beds per 1000, nationally it’s eight, in WA six. “There needs to be a bilateral agreement to better balance commonwealth money that comes to WA for health and aged care.”

drapes beneath the

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Dr Shane Kelly is returning to Perth as CEO of SJGHC. He is currently group CEO of Mater Misericordiae in Queensland.

The retiring WA Governor Ms Kerry Sanderson is the new chair of the St John of God Health Care board replacing Mr Tony Howarth who is stepping down after 14 years.

The bare necessities Reliving the conversations at the latest Doctors Drum breakfast (see P18), the importance of good health – for doctors and the community generally – was a recurring theme. Of course there is an economic imperative but it’s not all about money. Slowing down, taking pleasure in small moments and enjoying how lucky we are here in our corner of the world, makes you feel better! So it brought a smile to our face when some entrepreneurial horticulturalist Georgina Reid got in touch with her greening the home tips for a healthier life. Gardeners will know this stuff intuitively … ‘cure claims’ aside, plants are powerful agents for good. Plant Life Balance and Georgina have created looks for the home, pictures of which are probably more suited to House and Garden, but we’re not opposed to a little style. More pertinently, however, is the University of Melbourne and RMIT study that reckons one medium-sized healthy plant to a medium-sized room (4m x 5m) increases air quality up to 25%; five or more plants leaders to healthy feelings. It’s a jungle out there!

Zimmerman (chair), Tim Wilson and Andrew Laming said on balancing the massive weight of conflicting evidence of e-cigarettes safety and place in smoking cessation attempts. They concluded that they were not as harmful as tobacco smoking and should be allowed and regulated. This was contrary to the majority report which recommends the entire issue be referred to the NHMRC for detailed investigation. There must have been some passionate words behind closed doors because the deputy chair Steve Georganas also released his own report condemning the invitation to ‘Big Tobacco’ to post a submission to the inquiry. He said it gave “Big Tobacco an appalling opportunity to influence tobacco policy in Australia.” He suggested this could violate the World Health Organization

Framework Convention on Tobacco Control. He concluded: “Governments should continue to follow the advice of the independent experts on nicotine e-cigarettes.”

Curtin’s digital spoils Curtin University was one of the winners from the Government’s digital health investment. It’s partnering with the new Digital Health Cooperative Research Centre (CRC) to develop Australia’s digital health technology and services industry.

The grant of $55m will help the Digital Health CRC leverage new technologies across a range of health areas. Curtin’s data science capabilities through Curtin’s Health Research and Data Analytics Hub will lead the charge.

Cancer Council WA stalwart Terry Slevin will take up the position of CEO of the Public Health Association of Australia in Canberra in May. Medical oncologist and senior researcher at the National Centre for Asbestos Related Diseases, Prof Anna Nowak, was named Cancer Council Western Australia’s WA Cancer Researcher of the Year.

Former MercyCare CEO Chris Hall will take up the chief executive’s position at Juniper, replacing the retiring Vaughan Harding.

Kimberley emergency doctor John van Bockxmeer was awarded a Commonwealth Point of Light in recognition of his voluntary work establishing ‘Fair Game’, a charity that donates recycled sports equipment to benefit underprivileged communities in remote areas of Australia.

Former Assistant Police Commissioner Michelle Fyfe will replace Tony Ahern as CEO of St John Ambulance WA when he retires in October.

Former Lotterywest CEO Jan Stewart is the new chair of the Raine Study.

Ian Craig is the new CEO of Asthma WA. Felicity Beaulieu is Bethanie’s new Chief Operating Officer.

CURIOUS CONVERSATIONS The Art of Flexibility Dr Beverley Teh is a dog lover, human yoga-pretzel and a brilliant linguist.

I’ve always wanted to be a doctor because…

I love science and people. We’re detectives, confidants, problem solvers, owners of absorbent shoulders and amateur comedians.

The best patients are… the ones who don’t ask me if I’ve reached puberty.

The most embarrassing moment of my life (up to now) was… an insufferably smug moment in Japan. I wanted to display my outstanding vocabulary so I asked the teacher if I could go to the ‘toilet’ using the actual Japanese word. She looked shocked and raucous laughter ensued. The word I’d used was ‘shitter’!

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One thing I’d like to do before I turn 50 is … skydive. Once will probably be enough unlike my insane partner, Pål who’s done about 100 jumps. You can do one naked, apparently. Did someone mention, ‘chafing’?

When I’m not working I love to… read, pat my long-suffering canine Seamus, cook and bend myself into pretzel yoga shapes without farting.

MAY 2018 | 9

INCISIONS

There aren’t enough women at the top of the tree in medicine, and there are figures to prove it, say A/Prof Linley Lord and Prof Siobhan Austen.

Women currently represent more than 50% of medical graduates so why do they remain under-represented in senior medical leadership roles and some specialisations?

Data from the Workplace Gender Equality Agency (WGEA) on Australian hospitals shows that women hold 35% of all CEO positions, but only 10% of CEO positions in hospitals with more than 5000 employees.

The gender pay-gap among professionals in Australian hospitals is 25% and increases to 29.7% among key management personnel.

While women’s under-representation in leadership roles is a concern, it isn’t a surprise.

Medicine is not alone in this. Across all the organisations reporting to WGEA, only 6.3% of CEO positions are held by women.

And women comprise only 28.5% of key management personnel and it’s these roles that provide a natural pathway to CEO positions.

More worrying is a 2014 Oxfam report suggesting that pay equity is at least 70 years away based on current rates of progress.

What does this mean for women in medicine? Does the glass ceiling still exist?

It would certainly seem so, given the above

numbers. Is change likely to occur? No, at least, not without significant resolve and agitation. At the current rate of progress in some specialist areas such as surgery, it has been suggested that gender parity at the academic professorial level won’t be achieved until 2036. Currently, only 12.5% of Australian hospitals have specific pay equity targets in their formal remuneration policies or strategies. Remuneration gap analyses remain rare.

Pay equity is at least 70 years away based on current rates of progress.

So, what needs to be done? There has been research to identify reasons why women remain under-represented in senior leadership positions in medicine.

A number of medical practitioners in formal leadership roles were interviewed and relayed their belief that the absence of women in leadership roles was a result of ‘preventable gender-related barriers’ that impeded women’s progress. Coupled with this were negative perceptions regarding the capability, capacity and credibility of women fulfilling medical leadership roles.

A lack of female role models and a lack of access to mentors and sponsors, combined with the fact that many women encountered bias and discrimination within their career, contributed to their ongoing underrepresentation at senior levels.

The challenge, therefore, is to implement strategies that will result in systemic and cultural change.

Studies have shown that identical CVs, one showing a male name and another that of a female are evaluated differently. More questions are raised about the woman’s experience and achievements compared with her male counterpart despite there being no appreciable differences between the two. One positive way to address this would be to implement training programs in ‘unconscious and/or implicit bias.’

Perhaps this should be the first step in addressing women’s under-representation in leadership roles within medicine?

References available on request.

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MAY 2018 | 11

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The Call of Africa Africa has always held a special place in Geraldton GP Dr Nikee Msuo’s heart and her desire to contribute has led her down some interesting pathways.

G

rowing up in Sierra Leone and Bougainville Island as a child of ex-pat Australian miners, Nikee Msuo dreamed of a day when she would return to Africa in a capacity that could help change lives. Along the way to achieving this childhood dream, she has crammed in more experiences than seems possible in her 48 years.

Currently, Nikee is a GP proceduralist in Geraldton with a formidably long obstetrics list and a GP practice with the Panaceum group.

Thirty years ago, she took a gap year after high school to ponder whether the expected route of engineering was the right one for her. With her father stationed at the Argyle diamond mine, she set off for Kununurra, grabbing every opportunity to explore this part of the world. As a consequence she has been a hand on a professional fishing boat, worked with a team shooting feral donkeys for pet meat and generally lived an outback life.

“It was there I first heard about apprenticeships and I managed to secure one, becoming one of the first dualtrained female tradespeople in WA with an electrician’s and an instrument fitter’s ticket,” she told Medical Forum.

It was stage one of her journey – being useful – completed.

“I worked two weeks on, two weeks off and in the off weeks I became involved with

12 | MAY 2018

St John Ambulance and because I worked on a remote diamond mine I soon became part of the paramedic team.”

Then, like many of her peers, in the 1990s she set off to see the world.

Lifeline Sudan “I thought I’d get a job as an electrician but became involved with Operation Lifeline Sudan working at a UN feeding centre,” Nikee said.

Operation Lifeline Sudan was established in 1989 in response to the warinduced famine and other humanitarian catastrophes caused by the civil war between the Sudanese government and the South Sudanese rebels. Refugees in their hundreds of thousands were displaced and starving.

“I went there thinking I could be useful with my electrical qualifications but in the end it was those skills and my paramedic experience that got me the UN job. We were the largest feeding centre in the Sudan at the time, feeding children in a village of about 12,000 displaced people.”

“They had been running away from war for many years and had lost a lot of their agricultural skills, so part of our work was to encourage their building and planting skills.

I was there for six months, mixing food, supplementing children’s diet with vitamins.

I wish I had known a little bit more.”

Inspiring nurses “Red Cross and Medecins Sans Frontiers were working in the camp and I got to see

the amazing things nurses, in particular, were doing. They were so useful in that environment. The doctors were a little out of their depth in those circumstances with the limited facilities.”

“I returned to Perth keen to do nursing with every intention of going back and saving the world after graduation. I returned to Australia with a husband and pregnant.

I had my second child during my nurse’s training but decided that I wanted to do medicine. I had my third child in my second year of medical school and my fourth in my intern year.”

She described the time as “a particularly busy time of my life”. And with that understatement, Nikee went on to describe her O&G training.

“I was keen to specialise in O&G and started my training with amazing support from the KEMH powers that be. But those were the days of 15-hour back-to-back shifts and 80-hour weeks and I just wasn’t seeing my children. I thought I’d have to give it away but the then Director of Obstetrics Dr Anne Karczub suggested rural proceduralist work.”

“I completed an Advanced DRANZCOG and next minute Geraldton was calling.”

Geraldton calls “There was only one specialist O&G in town when I arrived and she was exhausted, so I took a load off her and it’s worked very well for 11 years. I have a public and private

continued on Page 14

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MAY 2018 | 13

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Making a Positive Difference Psychologist Dr Tracey Westerman knows the hard work required to stem the tide of Aboriginal suicides but there are success stories to inspire.

T

he 2018 WA Australian of the Year, Dr Tracey Westerman, is committed to reducing the incidence of mental illness within indigenous communities. Tracey is well aware of her unique opportunity to broaden the cultural competencies of clinicians working with Aboriginal people.

“I grew up in the Pilbara and saw some of the social problems first-hand from a very young age. Entrenched disadvantage obviously still exists and until quite recently there have been relatively few people dedicated to unlocking the underlying reasons behind escalating rates of depression and suicide.”

“And sadly it’s now an issue affecting the entire country because Australia has one of the highest child suicide rates in the world.”

The Australian of the Year award has given Tracey a bigger platform to tell her story, and it’s an inspiring one.

“I knew from very early on that I wanted to study psychology but it was obviously quite difficult to find any peers in the Pilbara. And it was certainly a big step from the School of the Air to university in Perth. Everything, from catching a bus to walking into a library, was a culture shock.”

Academia disconnect “As an Aboriginal person I felt pretty much invisible. I came down to Perth in 1988 straight from school and after finishing three years of tertiary study I never wanted

WA Australian of the Year Dr Tracey Westerman to see another university in my life. I really did think that if this was what Psychology was all about then I’d got it all wrong!

I started to doubt my own ability and wondered if I could do this job at all.”

“Then I got a job out in the Western Desert region, places such as Warburton, Warakurna and Blackstone. It was

challenging and confronting but it gave me back my confidence and I realised that I could make a difference to the lives of my own people. It was pretty confronting, though. Petrol sniffing and solvent abuse had reached epidemic proportions in places such as Warburton and the plastic bags they used were hanging from trees and fences as far as the eye could see.”

continued from Page 12

The Call of Africa practice and am on call almost every day, so I haven’t got away all that much.”

“My children are now 22, 19, 16 and 13 – the youngest two are at school in Geraldton and the older two are at university in Perth. The time is almost ripe for making a change.”

That change is a tropical medicine course in the UK later this year as part of a public health diploma with a view of returning to the Middle East or Africa for more aid work.

Balancing the books “I went into this life from my experience in the Sudan and the motivation has always been to go back to Africa. So many doctors head to Australia from Africa and not so many go back. I’m at the

14 | MAY 2018

stage in my life and my children’s lives where I can take up this opportunity.”

“I’ve seen a lot and done a lot and had some amazing and varied experiences and it’s helped me as a doctor to communicate with people from different walks of life.”

Nikee says to her children to pursue what they’re interested in and seize the opportunities. She’d say the same to any young medical student, adding that country practice is special.

“It’s an incredible privilege being part of people’s lives. I have such lovely patients who make every day interesting and worthwhile. It is a two-way street where I help them and they help me. Country practice offers so much – the medicine is varied and you a become part of a close team and a community. It’s a really nice existence.”

By Jan Hallam

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SPOTLIGHT “It was a good training ground for me.”

Tracey carried that momentum into courses she runs for clinicians under the auspices of Indigenous Psychological Services (IPS) on culturally-appropriate psychological services.

“Right from the outset of my studies at university I was struck by the fact that indigenous people were all but invisible in basic text-books. And that made me wonder how any trained psychologist could possibly engage with an Aboriginal person in a meaningful way?”

“You can’t even begin to help a patient unless you have some understanding of their world and how they perceive it.

It seemed to me that many of the key ideas and concepts within the profession hadn’t been tested within an Aboriginal cohort at all.”

Finding what works “A lot of my research, particularly in the area of mental illness, focused on unpacking those misconceptions and coming up with a better model.”

Tracey is a firm believer in early intervention and the value of hard-data stemming from transparent measurability.

“One of the most crucial strategies is to screen for the likelihood of risk at a very early age. And that meant clearly identifying just what the risk factors were before trying to implement any prevention strategies. If the latter aren’t tailored and targeted effectively then the entire process will be a waste of time.”

“It’s no surprise that anxiety and depression linked with alcohol and drug use are significant risk factors and when I went to Canada and New Zealand the same issues were readily apparent.”

“It’s important to get more people on the treatment side of the equation and ensure that programs are properly funded. And this is certainly the case with Closing the Gap here in Australia.”

“There has to be some form of ‘measurability’, too. It’s absolutely imperative that everyone can see just what these intervention programs are doing, or if they’re doing anything at all.”

Suicide prevention strategies developed by Tracey have been implemented within First People’s communities in Canada, which begs the question – have they been taken up here in Australia?

Refocusing direction “It was clear that in both Canada and Australia there had been a focus on the wrong risk factors so there’d been no real reduction of pretty significant problems.

I helped design unique programs that stepped outside the boundaries of mainstream psychology and mobilised them within indigenous communities.”

a lot of people because it places them in situations that are really challenging.”

One misconception that Tracey would like to challenge is the idea that all indigenous communities are the same.

“It’s important to highlight that a lot of Aboriginal communities are doing extremely well and that these troublingly high rates of suicide occur in relatively few places.

In many ways the latter are carrying the burden for the entire Aboriginal population.”

Work with the few “In Canada 90% of suicides occur in just 10% of indigenous communities and in the Kimberley this isn’t a major issue at all.”

“It’s not helpful to view suicide in a generic manner because the risk is that you create a normalisation of suicide. There are a lot of success stories out there and we don’t hear enough about them.”

Tracey is keen to accentuate the positive, and finishes on that note.

“These were intervention programs that made sense. In terms of take-up here at home there’s been real progress within the training sphere.”

“I’m an eternal optimist and this is a great story! In just a few years we’ve gone from one trained Aboriginal psychologist to around about 60 so that’s pretty good going.”

“I’ve been doing workshops for 20 years to give clinicians a comprehensive, culturallyappropriate checklist and the tools to implement effective strategies. I’ve also developed a Cultural Competency Test to identify some of the constructs relating to Aboriginal people.”

“I’ve exceeded most of my expectations already. It’s important that young professionals carry this momentum on and my award as WA Australian of the Year gives me so many opportunities to help that process along.”

“At times, for want of a better word, it’s outright racism.”

By Peter McClelland

“In the workshops we go through five different stages of analysis, unpack some of the misconceptions and apply a scientific approach to these blind-spots. It disarms

Breaking down barriers There are few people working in the area of women’s health who haven’t experienced the passion of Kath Mazzella.

The 66-year-old was named 2018 WA Senior Australian of the Year in recognition of her work raising community awareness of gynaecological health. She established the Gynaecological Awareness Information Network after her own experience of gynaecological cancer at the age of 39.

Kath was convinced she was alone so instead of shutting herself away she put an advertisement in Woman’s Day magazine and had 38 responses from women all over Australia who felt the same sense of isolation and embarrassment.

Speaking to Medical Forum, Kath is committed to reducing the stigma of gynae health and believes that educating young girls and women about their own bodies and how to keep them healthy is of the utmost importance.

“Endometriosis and polycystic ovaries are realities for a number of girls and young women and there is not enough information out there,” she said.

“From there it becomes embarrassing and stigmatised and that has to stop. These conversations should be open and honest because lives are at risk.”

Kath began International Gynaecological (GYN) Awareness Day on September 10, which is supported by KEMH with special events but she calls on doctors to help break down the stigmas, particularly among their young female patients.

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WA Senior Australian of the Year Kath Mazzella with PM Malcolm Turnbull

MAY 2018 | 15

FEATURE BACK TO CONTENTS

Birds, Bees & IVF The 27-year-old laws governing assisted reproductive technology in WA are being reconsidered and about time. The world and medicine have streaked ahead.

O

n July 25, the world’s first IVF baby, Englishwoman Louise Brown, will turn 40; on June 23, Australia’s first IVF baby Candice Reed will turn 38. At the time they were dubbed ‘test-tube’ babies and, given the scrutiny under which they have lived their lives, its arguable they’ve never left one.

Louise Brown has written a book about being the first person born by assisted reproductive technology (ART), chronicling the support – and condemnation – her parents, Lesley and John, received when she was delivered at Oldham Hospital by registrar John Webster (and a phalanx of specialists including IVF pioneers gynaecologist Prof Patrick Steptoe and biologist and physiologist Prof John Edwards) weighing 2608kg.

Things have come a long way – just run your eye along some of the most recent statistics in the Australian and New Zealand Assisted Reproduction Database on the following page.

The frontier of the science continues to spin heads – the latest being the concept of the three-parent child using mitochondrial transfer – but for the tens of thousands of people having children through ART and the community around them, assisted reproduction is almost next to normal.

Changing community values But that’s not to say anything goes. The fertility ‘industry’ is tightly controlled by state-based legislation and overseen here in WA by the Reproductive Technology Committee (RTC). The Act was promulgated in 1991 and given the much-expanded boundaries of science and society (in particular the legalisation of same sex marriage) since then, it is somewhat apt that it is now undergoing review in WA by Deakin University health law expert A/Prof Sonia Allen.

Submissions closed in March and she has since been meeting interested parties as well as conducting public forums to gauge where the likely intersection of science and community values lie in our state. A report is expected soon.

Prof Roger Hart, who is chair of Reproductive Medicine, Division of Obstetrics and Gynaecology at UWA, and

16 | MAY 2018

medical director of two Perth infertility clinics as well as UWA’s representative on the RTC, spoke to Medical Forum about the medical issues he’d personally like to see addressed in any amendment of the legislation. First and foremost is the number of embryos a woman is permitted to freeze before she is allowed to embark on a further IVF cycle.

embryos to test rather than just test one or two or even three, because, unfortunately, they may all be abnormal.” Roger said.

“A woman can’t start on another IVF cycle if she has more than two embryos stored, it is a fact of life that age is a factor affecting many women who seek fertility treatment,” he said.

The IVF landscape is a rapidly changing place and it is understandable that laws struggle to keep up.

“So a woman of 38 who needs IVF to conceive – perhaps because her egg quality or her partner’s sperm count has deteriorated – goes through a cycle and generates three embryos. However, those have to be used as she’s not permitted to ‘bank’ more with a further IVF cycle.”

“If that woman returns for treatment for a second or even a third child, she has to start her IVF treatment again, and given that she is likely now to be at a minimum nearly 40, the success of that treatment is low. A more pragmatic, and successful approach would be to have given her the opportunity to freeze enough healthy embryos at 38 for her to complete her family.”

“This was not the vision of the future when the laws were couched originally, plus back then, the pregnancy rates using frozen embryos was poor. There was a significant chance that at least one embryo would not thaw, so generally more than one freshly generated embryo was placed in the uterus, to avoid freezing embryos. Hence years ago twins and triplets were more common than they are now. Australia has one of the lowest multiple pregnancy rates in the world.”

Adding to the case for a greater number of embryos frozen first time round is the issue of genetic testing, to which Roger would add ‘irrespective of a woman’s age’.

“A woman in her late 30s faces an increased risk that her embryos may be chromosomally abnormal and it is the general wisdom to have a critical mass of

“Batching embryos derived from a couple of IVF cycles would be a good idea for perspective parents to ensure they have a reasonable number to undergo testing.

This, in turn may help to ensure they have a normal embryo to transfer. Unfortunately they will pay a lot of money to test these embryos, so it is pragmatic and emotionally less draining to generate several embryos for testing,” he said.

“Compared with even 10 years ago, when we were routinely transferring embryos after three days, we are now transferring blastocysts after five days of culture, so their potential is much greater and as a result the single embryo transfer rate has improved,” he said.

Multiple births low “Australia has one of the lowest multiple pregnancy rates in the world. We are currently 4.6% where the UK is 22% and its 33% in the US.” “One in 25 Australians are born from IVF treatment, and by 28 years of age an adult born resulting from IVF treatment becomes financially a net contributor to the state. Medicare is supportive of couples undergoing fertility treatment which in turn helps fertility clinics adopt appropriate and safe practice, to avoid multiple pregnancies, premature deliveries and the attendant social, medical and financial costs that would result.”

“In contrast, in the UK, where there is limited public funding for fertility treatment, patients have to pay the whole cost. Many patients opt to have two or more embryos implanted in one procedure to try to maximise their chance of conceiving because they believe they may not be able to afford another treatment.”

“In Australia, we’re transferring just one embryo with similar pregnancy rates.

A singleton pregnancy is not only better for the mother, but it is better for the baby’s long-term health outcomes.”

Something the law can’t change is the

MEDICAL FORUM

FEATURE

ART Snapshot In October each year, a report compiled by the University of NSW into the state of Assisted Reproduction Technology in Australia and New Zealand is published; 2017 was no exception.

Its source is the Australian and New Zealand Assisted Reproduction Database (ANZARD) to which fertility centres across Australia supply data. Here in WA, Concept Fertility Centre, Fertility Great Southern, Fertility North, Fertility Specialists South, Fertility Specialists WA, Hollywood Fertility Centre, PIVET and the Keogh Institute contributed to these 2015 statistics, which unfortunately are not broken down by states.

• 71,479 and 6242 ART treatment cycles were reported in Australian and New Zealand clinics (respectively), a 5.6% increase in Australia and 6% increase in NZ on 2014.

• The proportion of cycles where all oocytes or embryos are cryopreserved for potential future use (freeze-all cycles) has increased from 5% of initiated fresh cycles in 2011 to 17.2% in 2015.

increasing trend among couples to delay having children. While it might seem on paper a promising component of a business model, there are not too many fertility specialists who would recommend it.

Counselling essential For starters, the process, no matter what spin is put on it, is tough on the woman’s physical and mental wellbeing. This psychological component is one of the reasons why WA’s oversight has such a strong emphasis on counselling and support for couples going through treatment.

And ART is not a magic bullet. According to the ANZARD figures for IVF cycles commenced in 2015, of the 77,721 initiated cycles, 22.8% (17,726) resulted in a clinical pregnancy and only 18.1% (14,040) resulted in a live delivery.

Roger said treating medical teams had a significant responsibility to optimise a woman and a man’s health for conception before starting treatment, and in this age of obesity, chronic disease and delayed family planning, that’s easier said than done but essential for both the couple and the community.

“Fertility specialists have been urging women to have children earlier but society is not listening. The common belief is that it is okay to leave it till later. The reality in Australia for children born to women over the age of 37 years or older, one in seven will be IVF babies. A third of IVF cycles in Australia are for women over 40,” Roger said.

“Society needs a discussion about this. The message has been widely disseminated but there is a lot of pressure on women in the workplace because they believe having a family at an earlier age will be detrimental to their careers. That’s not fair.”

“Men throughout all workforces need to be strong advocates for women. After all they all have a mother, and many have wives, daughters or sisters. I strongly believe that we need that dialogue. I certainly urge my junior doctors and medical students to consider this. They shouldn’t feel that they must get the career first and then think about family after.”

• Of the 77,721 initiated cycles, 22.8% (17,726) resulted in a clinical pregnancy and 18.1% (14,040) in a live delivery. The overall clinical pregnancy rate for cycles reaching embryo transfer was 31.9%. The live delivery rate per initiated autologous fresh cycle was 17% after freeze-all cycles were excluded. The live delivery rate for fresh cycles reaching embryo transfer was 23.7%. The live delivery rate per initiated autologous thaw cycle was 25.3% and for thaw cycles reaching embryo transfer cycle was 26.8%.

• Women used their own oocytes or embryos (autologous cycles) in 94.5% of treatments.

• The number of cycles where embryos were selected using preimplantation genetic testing (PGT) increased by 65.5% from 3488 in 2014 to 5773 in 2015.

• The average age of women undergoing autologous cycles was 35.8 years in 2015, similar to previous years. The average age of women undergoing ART treatment using donor oocytes or embryos was 40.6 years; 24.8% women who underwent an autologous cycle in 2015 were aged 40 or older.

• The average age of the male partner was 38.1 years, with 33.8% aged 40 or older.

• For women aged under 30, the live delivery rate per embryo transfer was 38.4% for autologous fresh cycles and 32.6% for autologous thaw cycles. For women aged over 44, the live delivery rate was 0.7% and 7.6% per embryo transfer for autologous fresh and thaw cycles.

• 14,791 babies were born (including 14,655 live-born babies) following ART treatment; 78.8% of live-born babies were full-term singletons of normal birthweight.

• Multiple deliveries have decreased by 36% from 6.9% in 2011 to 4.4% in 2015. This was achieved by clinicians and patients shifting to single embryo transfer, with the proportion increasing from 73.2% in 2011 to 85.7% in 2015.

• The average gestational age of babies born following autologous and recipient embryo transfer cycles was 38.1 weeks; the average age for all babies born in Australia in 2014 was 38.6 weeks.

• The average birthweight for live-born babies to women who had autologous and recipient embryo transfer cycles was 3219 grams; 11.2% of these babies were low birthweight (less than 2500 grams); the average birthweight was 3305 grams and 2299 grams for live-born ART singletons and twins respectively. These were slightly lower than the mean birthweight of all live-born singletons (3380 grams) and twins (2347 grams).

By Jan Hallam

MEDICAL FORUM

MAY 2018 | 17

As topics go, discussing community health needs over the next 20 dynamic years and how the system can get there sustainably, is a big one to tackle over breakfast. However, panellists and audience alike recognised its vital importance and got straight to the heart of the matter.

The release of the Sustainable Health Review (SHR) interim report formed a reference point for much of the discussion and gave the panel – which comprised political and professional change-makers across WA representing primary, tertiary, government and administrative sectors – an opportunity to tease out those parts that would have most impact.

Rethinking the parts For the Health Minister, the key words for the future were innovation, integration and culture change. “We have to seize the opportunities of this era we live in.”

Unpicking that, another panellist saw the system surviving through precision, personalised medicine. “In the acute sector, we’re set up for volume but we’re not set up for value and that must change. In 20 years’ time the huge focus will be on chronic disease and not on the acute care sector.

Are we set up to meet that challenge?”

The view from the primary space was clear.

“We know what we need to do, we’re just not doing it and the future health of the community depends on us doing, not just knowing; and using systems to care for people, not just having good intentions.”

He added that integral to success was a funding system that was “not centralised and monolithic but distributable, nimble and responsible with grassroots input”.

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18 | MAY 2018

A cautionary note was sounded early that “health funds and governments were hurtling us to manage care … but that’s not a game to play, that’s a nightmare.”

Spiralling costs The SHR identified the high and unsustainable cost of delivering care in WA. And it was acknowledged “front and centre” as the biggest challenge the WA government faces in the short term.

“In 2008, health represented just over 26% of the budget. Today it’s around the 30% mark and if we continue the current trajectory, by 2026 it will be 38%,” one said.

“The review is about looking at new ways of delivering care within our capacity to pay for it. So we have to be more efficient.”

The cost of the WA healthcare workforce was substantially more than in other states, but there was good reason for that.

“We are the biggest and most isolated health jurisdiction in the world so we have to find new ways of delivering health care to remote regions and that’s where technology will play a part. Telehealth and a strong primary health care system integrated with WACHS and organisations such as the RFDS and AMS will play a part in overcoming that tyranny of distance.”

“But we also have an obsession with putting people into hospitals and need to find ways to keep people living longer and healthier lives in the community.”

Division is killing us For the bureaucrat, it has become a daily reality that WA Health must live within its means.

“About 50% of the mechanisms are in our control and 50% are not. Why are

we so more expensive? Some of that is the choice made a decade ago to pay workforce 30% more than other jurisdictions. That was in our control but how we are funded by the commonwealth for rural and remote healthcare is not. For instance, if you live around Launceston you have a loading of 1.8% for health services, if you live around Fitzroy Crossing, you get about 0.9%. How is that right?”

While commonwealth funding is one for the politicians, WA Health has restricted its expenditure growth from 12% five years ago, to 1.6% this year to give other essential services such as education of police a drink at the trough.

“My worry is about the future and the activity that will come into the public sector and the waiting lists because we are already seeing a shift from private to public activity. Activity is hospital based but we have to shift that paradigm and work with the commonwealth because in 20 years’ time the focus will be on chronic diseases which are not best treated in acute tertiary hospitals. We need to invest in that subacute, step-down area and in the aged care sector.”

For a GP on the Home Care Trial, this dichotomy between federal and state is an enormous barrier.

“It galls me that someone walks out of my surgery past a physio, a dietitian, a podiatrist, a psychologist and a pharmacist to go 10km down the road to a tertiarybased health care system. The state is bearing an unnecessary load of the chronic disease burden. Community care should be provided in the community. Secondary and Tertiary centres of excellence should do excellent things for acute-care patients.”

www.doctorsdrum.com.au

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FUTURE MEDICINE - Playing the Change Game?

Prevention and wellness

Was wellness for the leisured few?

The interim SHR is urging the government to commit more funds to preventative health and the idea was taken up with gusto by a number of attendees.

“Absolutely not,” was the reply. “We all have the capability, but the issue many in the health profession face is the time. So if we change the whole model and provide the time, it is much easier to offer a prescription for exercise and nutrition. We talk about individualised, personalised medicine and that is definitely the way to go as everyone can have access to that and it doesn’t have to be expensive. For a start we won’t be relying on medication as much.”

Are consumers taking responsibility for their own health? Many thought no but many added that some vulnerable people needed support to make healthy choices because their lives were not easy.

A question from the floor struck home.

“The medical paradigm is wrong. We talk money, money, money, when the vast majority of people I see don’t have a disease or anything particularly wrong with them.

What we have developing is the US option of shaking the tree because that’s all you can do in 10 minutes, resulting in a huge number of investigations and people with anxiety ending up in cardiology clinics. I could have easily told them it was stress if I had enough time. We’re looking at things the wrong way round. We need to start talking about wellness and getting away from the disease model and treat it like a business.”

GP life coaches?

A former GP who now works as a lifestyle practitioner agreed that the health system was topsy-turvy.

“When you hear the health budget is $9b with $1b for mental health, you have to say the 2.7% spent on prevention is miniscule and yet we know from all the research that going back to basics, looking after and managing people’s moving, eating, sleeping and anxiety would cut the potential for future disease extraordinarily.

We are looking at the outcomes rather than the causes,” she said.

This is bigger than us While some sought solutions at the individual level, another doctor felt the vision had to be much broader.

“We can talk about constraining costs but eventually that is not going to work.

To its credit the SHR has asked us to look upstream for the causes of ill health and I don’t think individualised medicine is the answer. That will just create more work. Keeping people healthy isn’t just a healthcare problem; it is a societal and cultural problem,” he said.

“And yet as a group of doctors we don’t talk about things like that, we talk about reactive consumption of health services.

Do you think it is for doctors to talk about the future health of our society, or is it something that should be taken out of our hands and put into the hands of a wholeof-government approach?”

While the room erupted with applause, the enormity of the proposal was not lost on the politician in the house.

“I am constantly confronted by policy put forward in good faith by colleagues supporting the work they are doing in their portfolios that I know will create more ill

health in the community and put more people into the health system. I absolutely think we need a public health approach to these issues. We can’t at the end of the day ignore that people will have ill health and episodes of ill health in their lives, but certainly looking at the underlying causes of those episodes or patterns of ill health is fundamental to how we will move forward as a community.”

But it is apparent that the road will be long and difficult with a deep undercurrent of resistance around healthy living issues.

Working smarter One doctor, who originally hailed from the UK, floated the idea of GP co-operatives and patients as registered members.

“At the moment there is duplication of skillsets with Practice A and B offering identical services and patients prizing convenience over continuity. So how can we use technology to start working better together?” he asked.

The obvious response was My Health Record, which one doctor suggested was being stymied by the medical profession itself.

“The barriers are with medical practitioners over issues of privacy – our patients thought it was already available.”

One hospital doctor pointed to the SHR which saw an integrated health record and system as a vital means to become more efficient and enable evaluation of the value and quality of services being delivered. She asked if there was a commitment for this digital integration.

The Health Minister said an electronic

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MAY 2018 | 19

continued from Page 19 health record was a fundamental building block of future health care.

“When people go to a doctor they assume the doctor has a line of sight of all their ailments and medications. This obsession of keeping records away from other doctors and medical practitioners is an obsession with the health system alone. In voter land they want you to have access to as much of their data as possible because that’s the key to making them feel better.”

The newly introduced laws on data breach notification had several doctors urging caution but, as one pertinently pointed out, the various systems needed to talk to each other and that was easier said than done.

might just be able to do some medicine,” one said.

The younger fraternity at the breakfast couldn’t quite comprehend why so much of their medical degree had been conducted online yet as junior doctors they were spending so much time waiting around fax machines.

“If we had a digital working platform, we

The integration of health records across sectors and silos is the golden prize but it seems a long way from being plucked.

However, the strategy seems to be to seek exemplars and to avoid pitfalls rather than a “big bang approach”.

The earlier discussion which looked encouragingly on constructive shared-care models, including aged care, between the state and federal government, was

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MEDICAL FORUM

MC Ms Andrea Burns

music to the ears of one geriatrician in the audience. Her concerns were how the commonwealth’s community directed care model of in-home services was collapsing in on itself.

“The waitlist for a level 3-4 package for a patient or elderly person needing daily assistance is now over 300 days. My concern is that this frail, elderly group will be bouncing in and out of ED and sitting in hospitals waiting prematurely for an aged care bed, when they could be cared for in the community and in their own home.”

The state & aged care It was also the concern of the state’s top health bureaucrat who has been agitating for the WA Department of Health to take a role in aged care.

“I don’t want to run an aged care home but we have over 200 patients, and that’s the ones we know about, waiting for transfer to an aged care facility. We have bought, over the years, more transitional beds but it is just scratching the surface. We are 3000 aged care places short in WA, which is a matter of money or reallocation of money, and we’re raising that with the commonwealth. It is cheaper for us to purchase those types of services and they will relieve huge pressure on our acute services.”

the wealthy now but over time will be a sensible approach to public health.”

A campaign to contain Big Alcohol and Big Food was met with strong support. There was a suggestion that a percentage of the budget was quarantined for prevention and a proposal for research into sustainability.

“We invest in translational research but what are the exemplars for making our systems sustainable. I don’t think we have looked broadly enough at that and we don’t have a sustainability agenda.”

While technology was the tool, one argued that a change of culture was required “so we can embrace sound opportunity”.

“There are protections out there but the one thing we can’t protect people from, and we shouldn’t be protected from, is change.”

One doctor believes in individualised health care and turning our back on it was emblematic of our failure to embrace change.

“If nothing else, the 21st century is the age of the individual – everything is down to the granular level, we just don’t have the systems to run it so we run on single issues and good intentions. That won’t work.”

For another, proper integration of general practice into the tertiary model is of vital importance. While only a mention in the SHR, the breakfast was assured that it would play a more prominent role when the final report is handed down in November.

“Something like this can’t be prescribed from the centre. It won’t work unless it is locally driven and that means local GP practices and the local hospitals working out their own innovations. There are some exemplars around WA where that integration is taking place and they need encouraging because they will grow.”

By Jan Hallam

So what are the game-changers?

A wise head, while reminding the room that there will always be heavy costs in health care, asked what would be the big breakthroughs that would change the game and rid society of inequality?

For the senior consultant on the panel – he wanted a system that will put him out of work with policies that will attack obesity in the same way the tobacco industry was met head on. “And I like the idea of wellness clinics which may be for

The Doctors Drum panel: Dr Mark Hands, from Western Cardiology, Dr David (Russ) Russell-Weisz, DG of Health, Minister for Health, Mr Roger Cook, Bayswater GP Dr Rohan Gay, and Dr Rebecca Wood Registrar FSH and DiT representative.

www.doctorsdrum.com.au

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MAY 2018 | 21

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NEWS & VIEWS

Pathways to Where?

HealthPathways is a growing force in WA. Medical Editor Dr Rob McEvoy explores where they came from and where they’re going to.

The HealthPathways community in Australia will pay $373 each to register for a conference in Newcastle this May 12-14 (see website courtesy of the Canterbury District Health Board, and Streamliners NZ). HealthPathways originated in New Zealand.

What is wrong with our system that HealthPathways are needed in the first place? On the one hand you have substandard (“please fix”) referrals from GPs. Then you have hospital specialists who hold onto patients for too long for whatever reasons. Communication over patients is poor but will more bureaucracy solve this problem?

The idea appears to be centralised information adapted for local use. At the recent 13th Doctors Drum, panellist Dr Rohan Gay was referring to mental health clinics in public hospitals when he said: “This is all about empowerment and HealthPathways is a good initiative along these lines.” He was referring to GPs fulfilling public specialist requirements and vice versa during patient referral in the public sector.

Currently, there are 29 HealthPathways sites listed in Australia, just one in WA (see https://wa.healthpathways.org.au/index. htm), and nine in NZ. The system appears complicated and specific.

The website says: “At the heart of the HealthPathways Community is Canterbury District Health Board (CDHB) which developed the initial 500 pathways, agreed to share them with other members of the Community, and continues to review and update the core pathways based on current evidence and specialist opinion.”

The parent company for the idea appears to be Streamliners NZ. The idea is sound – to link doctors and other health professionals who care for “over 550 conditions” within a geographical area. GPs can be the main drivers of information that can include CPD and job information, and is not for access or use by non-registered health professionals or patients (doctors have to log on).

Do they run the risk of becoming defacto clinical guidelines, although their stated purpose is online information services? It

will be as good as how well it can be kept up-to-date and relevant.

Pressure for a system like this will come from increasing time blowouts in referrals being seen and use of HealthPathways exclusively. GPs have a chance to get in on the ground floor and use HealthPathways to improve communication between public hospital specialists and community GPs. HealthPathways WA has just celebrated its 300th pathway under the WA Primary Health Alliance (WAPHA), described as a “significant milestone for HealthPathways WA and a sign of the team’s tenacity and commitment. HealthPathways WA now records over 1000 users, 3000 sessions, and 18,000 page views per month – a clear indication that HealthPathways is becoming more valuable and usable to GPs in Western Australia.”

On the HealthPathways WA website under “contributing to reduced ENT waitlists” is written: “The HealthPathways WA team recently collaborated with the metropolitan Local Area Health Services and the

continued on Page 29

Marker Clips - info for GPs Patients returning from BreastScreen WA’s Assessment Clinic may ask their GP about marker clips.

A marker clip is a small metal clip (a few mm long) that may be inserted into the breast by a radiologist to mark the site of a biopsy when the imaging detected lesion has been substantially removed during the core biopsy process. Marker clips may be required when multiple lesions are present to differentiate between lesions. This allows the biopsy site to be located if surgery is required, at which time the marker clip is removed.

All marker clips have a small metallic component which is visible on X-ray.

If the area of breast tissue containing the marker clip does not need to be surgically removed, the marker clip will indicate on

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Are marker clips safe?

• The marker clips used at BreastScreen WA clinics are not harmful to the body, and have been approved for use in Australia by the Therapeutic Goods Administration.

• It is safe for a marker clip to stay in the body if it does not have to be removed.

• The marker clips do not rust or corrode.

Women will be able to have an MRI examination if required. The clip will not set off a security metal detector.

• International medical studies have not shown an increased risk or any long term complications associated with having a marker left in the breast.

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

Mar ‘18

What if your patient has any questions?

If your patient has any queries about marker clips, she can call 9323 6710 to speak to a breast assessment nurse.

MAY 2018 | 23

24 | MAY 2018

MEDICAL FORUM

NEWS & VIEWS

Supporting A Friend in Need WA has again posted disturbingly high statistics for Domestic and Family Violence. Help is at hand – great and small.

The cost of Domestic and Family Violence (DFV) is staggering in both financial and emotional terms. Zoe Scharenguivel from community organisation Friends With Dignity speaks with Medical Forum about the organisation’s increasing presence in WA and the services it offers.

“It’s a sad fact that children are badly affected when they witness acts of family violence and the ramifications take many different forms. That’s one reason we initiated the Little Friends Scholarship which makes funds available to give parents a helping hand with things such as school uniforms and book lists.”

“We insist that this process is referred through a third party such as a support agency. This ensures that the people receiving help will be assisted in a holistic way which may well include ongoing counselling. We provide 10 scholarships per round to the value of $500 and we never know the names of the children. It’s all about making a difference to ‘one friend at a time’.”

a school principal or a GP so there’s clearly a significant role for doctors in this endeavour.”

Friends With Dignity (FWD) is hosting a High Tea With Friends on the May 6 at the Swan Yacht Club, East Fremantle, in support of Family Violence Awareness Month to contribute to the awareness raising of this serious social issue, which sees two-in-three assaults in WA linked with domestic violence.

Statistics just the tip “We’re trying to raise the profile of FWD in WA, which has the second worst statistics in the nation. There were 792 victims of assault by a partner or family member per 10,000 people in WA and we believe that represents around 20% of what’s actually happening out there in the real world.”

“It’s a large and increasing problem in WA, hence our plan to widen our role here.”

“There are obviously a high number of remote indigenous communities and it’s self-evident that they’re not as well served for support services compared with the city. And it’s also been no surprise that the downturn in the mining sector is an economic reality which has impacted severely on many people.”

“Some families have been used to a certain level of income and when there’s not as much to go around it can cause a spike in levels of tension within the home.”

FWD was founded in September 2015

by Ms Manuela Whitford in Queensland and it has since begun spreading across the country. It is run by volunteers and its essential brief is to provide practical services to people who are rendered homeless due to family violence.

“It’s a sad fact that some women will intentionally commit a crime in order to escape from a threatening family environment. Manuela worked as a nurse in the prison system and saw this sort of thing first-hand on many occasions,” Zoe said.

Help after prison “That’s bad enough in itself but very often there isn’t much in place to support these women when they’re released. We started the Sanctuary program to address this because many women are forced to flee their home with only the clothes on their backs.”

“Here at Friends we use social media to put our volunteers in touch with members of the community who have household items they’d like to donate.”

“We collect beds, cupboards and linen and transform a house into a comfortable home so that these women and their children can begin a new journey in a safe space without having to continually look over their shoulder.”

“An application for a ‘Little Friends Scholarship’ must be co-signed by

“It’s as much about giving these women a sense of dignity as much as anything else.”

It’s an unfortunate reality that those on the receiving-end of domestic violence comprise increasingly disparate groups within our society.

“As we all know, more often than not the perpetrator of family violence is living under the same roof as the victim. But we’re now seeing some disturbing trends involving a new subset of people.”

“For example, Elder Abuse and violence directed towards members of the LGBTIQ community are becoming increasingly common. These areas aren’t getting anywhere near the media attention they should be and we’re hoping to address that with our increasing presence in WA.”

The type of support offered by Friends with Dignity

MEDICAL FORUM

“There have been some important legislative changes involving restraining orders but it varies enormously around Australia. In all areas of family and domestic violence there’s still a long way to go.”

By Peter McClelland

MAY 2018 | 25

GUEST COLUMN

Society needs to talk more about grief, says Ms Christine Richardson, co-founder of the Grief Centre of WA, and the workplace is a good place to start.

Grief in the Workplace – a New Conversation was the title of a nationwide series of workshops initiated by the Grief Centre in 2015.

We felt there was a real need for a program to meet a specific gap relating to unresolved grief as a mental health issue in the workplace.

As a community we don’t do death well.

This was brought home a few years ago when death came to my door and I was swamped. I was also disappointed by the lack of useful information from those who professed to have some expertise on the process of grief.

There is a range of support material – from academic articles and books to information supplied by specialised services. But some seems of rather limited use and often costly.

Working in the area of corporate training linked with stress management it became

obvious that many of the people I was dealing with had issues with unresolved grief.

underestimated. And part of the reason is that a death has serious impact across a number of generations.

So, how do we begin to change the way grief is addressed in the community?

From prisoners to professors to defence personnel and factory hands many of the stories surfacing during training were grief stories. And it wasn’t restricted by age, gender, social, cultural or religious background.

So I began my own research into the grief process and after interviewing hundreds of people on their experiences with loss, the Grief Centre was established.

There’s nothing new about grief, and there’s no ‘quick-fix’ pill either.

Education plays a big part, and for many people that begins with the GP. It’s important for people to know that their responses are ‘normal’ and actually form an important step in the healing process.

Thankfully, more people are now willing to address the issues arising from grief more openly.

What we need is a new conversation in the workplace regarding grief that embraces families, individuals and colleagues. And it needs to be a courageous conversation that acknowledges the gifts of grief, and an ensuing life of laughter, learning and love.

The physical, mental, social and financial burden of grief is massively

Western Cardiology Partners In Heart Research Western Cardiology has contributed a financial leadership gift to help establish a chair in cardiovascular disease at the Harry Perkins Institute at the Fiona Stanley Hospital campus.

Western Cardiology chair Clinical A/Prof Mark Hands said more medical research into the genetic and environmental triggers of heart disease was urgently needed. Despite remarkable advances in the treatment, Dr Hands said there was surprisingly little understanding of the basic causes of heart disease.

Western Cardiology’s Dr Michelle Ammerer said whoever was appointed the cardiovascular chair would be working closely with local cardiologists so research could inform best-care practices for doctors, and important clinical issues would guide research choices creating a bench-to-bedside, bedside-tobench loop of healthcare improvements.”

Visit www.westerncardiology.com.au 15 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services

26 | MAY 2018

Clinical A/Prof Mark Hands, Prof Peter Leedman and Dr Michelle Ammerer

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Time to Talk About Grief

GUEST COLUMN

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Aerobic Exercise, Postpartum

Looking for a new challenge?

Prescribing aerobic exercise after birth is the ideal way to look after mum’s mental and physical wellbeing, says exercise physiologist Katie Stewart.

In 2011, the Australian Institute of Family Studies reported a 20% increase over two decades in the number of women having their first child over the age of 30. Around half of those women were classified by the Australian Institute of Health and Welfare as overweight or obese.

The period after a woman gives birth is known to affect mental and physical health, both acutely and in the long-term. Traditionally, postpartum recovery usually involves acute Kegel and physiotherapy exercises to restore pelvic floor integrity, pelvic stability and joint integrity as the uterus returns to its non-pregnant state.

Kegel exercise and Pilates play an important and successful role in this process, but there’s also a place for exercise medicine prescription around the hormonal disruption that happens postpartum. Hormones can have a big impact on postpartum fatigue, depression and additional weight gain, and fatigue is one of the realities of having a baby after 30.

As a mother of four children aged between six and 16, I can speak from experience about how fatigue changes as you age.

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

GP Emergency Medicine Fellowship of ACRRM or RACGP extensive generalist experience significant emergency department skills primary health care knowledge and skills GP Obstetrics or GP Anaesthetics

I had my first child at 26; my second at 28. No fatigue concerns at all. By the time I had my third I was 32 and my fourth 37, and my fatigue increased dramatically with each.

Post-partum fatigue can contribute to the incidence of post-natal depression. If you add in the metabolic concerns of excess weight, there is a strong argument for post-natal, low-moderate aerobic exercise to be included in the postpartum exercise prescription.

We know that low-to-moderate intensity aerobic exercise can significantly reduce depression symptoms. There is also some evidence which shows that low-to-moderate aerobic exercise may even be as effective in reducing symptoms as psychological or pharmaceutical therapies.

The ideal prescription to reduce the increased heart and breath rate brought on by anxiety in the six weeks after giving birth should include a combination of Kegel, Pilates and mindfulness and breathing exercises three times a week. This combination will help improve transverse abdominal activation and pelvic floor integrity, while stabilising mood and coping mechanisms.

As above, plus formal qualification in obstetrics or anaesthetics ability to practice without clinical supervision in procedural area

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

Resistance exercises that restore and rebalance the spinal muscles and the hips’ strength, stability and function, along with aerobic exercise can help reduce fatigue, increase energy and improve mindset.

The best support a post-partum woman can secure is through a combined allied support team of physiotherapy, psychology and exercise physiology. It will deliver the best mental and physical patient outcomes over that first postnatal year reporting to the central managing GP. ED: Katie Stewart is an accredited exercise physiologist in Mosman Park.

MEDICAL FORUM

MAY 2018 | 27

28 | MAY 2018

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GUEST COLUMN

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Planning for End of Life Having a considered Advanced Health Directive on hand in any circumstance makes living what life there is left that bit easier, writes Dr Gillian Mitchell As the medical registrar in a busy tertiary hospital I have whispered a silent ‘thank you’ to patients whose Advance Health Directives (AHD) have avoided difficult conversations in emotionally fraught circumstances.

While benefits of an AHD are clear clinically, it was not until I spent two weeks with the Great Southern Palliative Care Service (GSPCS) recently that I truly appreciated the benefit of an AHD from a patient’s perspective.

Members of GSPCS and the Rural Clinical School of WA spent five years researching Advanced Care Planning in the region.

Their work has been embraced by their patients who feel safe that their wishes will be respected. The team have made documenting patients’ wishes in Advance Health Directives and ensuring copies are sent to all key stakeholders in their care a priority.

I picked up many tips from the skilled doctors and nurses of the GSPCS, which I have enjoyed integrating into my own practice.

Here are some gems: • Determining when to initiate discussion about advance care planning can be challenging. A change in health or new

diagnosis can be a good trigger to start.

The most important thing is just to start!

• Asking patients who they would like to speak for them if required can be a good way to introduce advance care planning. People often volunteer their wishes, making the discussion much easier.

• You cannot cover every eventuality in an AHD. The conversation around its completion is as important as the document itself as it assists doctors and families understand what a patient’s wishes are likely to be in a given situation, even with a clear surrogate decision maker.

• When someone no longer has capacity to complete an AHD, completing an advance care plan with them and their family is a good way to document their wishes, even if it is not legally binding.

Information regarding advance care plans is available at: http://healthywa. wa.gov.au/~/media/Files/HealthyWA/ Original/ACP_A_Patients_Guide.pdf The Metropolitan Palliative Care Consultancy Service (MPaCCS) has extensive experience with advance care planning for residents of aged care facilities in the metropolitan area (see www. bethesda.org.au/MPaCCS.aspx for referral forms and information about the service.)

In the following circumstances: I need hands-on help for activities such as toileting, showering and feeding AND / OR I can no longer communicate meaningfully with my family

I refuse consent to the following treatment: life-prolonging treatments such as artificial nutrition, feeding tubes, breathing tubes, life support or intravenous therapies such as antibiotics or fluids

• Building therapy into the Advance Health Directive can express a patient’s wishes e.g. someone with emphysema wrote: In the following circumstance: I continue to deteriorate despite 72 hours of intravenous antibiotics, corticosteroids and supportive care in hospital for an exacerbation of my lung disease.

I consent to the following treatment: for the above treatment to be stopped and to change to palliative care including medications for breathlessness.

• There is no centralised means of storing Advance Health Directives in WA. I advise patients to keep a copy with their medications as ambulance paramedics are likely to ask for a patient’s medications. Having the AHD stored in the same place helps trigger patients and families to take it with them to hospital.

• Asking patients what an unacceptable quality of life looks like to them can help them to express their wishes and plan for the future e.g. a patient with early dementia wrote:

Information about completing an Advance Health Directive in WA and kits can be found at the public advocate website www.publicadvocate.wa.gov. au/A/advance_health_directives.aspx

“Early indications suggest that all three metro tertiary hospitals with ENT clinics have experienced a decrease of 50% or more of patients being added to the waiting list. This means that patients who require specialist intervention will be seen within the recommended timeframe for the triage category assigned.”

elective services and increase assistance to primary care.

Pathways to Where? continued from Page 23 Central Referral Services to review, agree, and document referral criteria for seven common ENT conditions. Referrals which don’t meet the referral criteria published after 1 July 2017 are no longer accepted onto a waiting list. The referrer is pointed back to HealthPathways for advice on managing the patient in the primary care setting, or completing the referral if information is missing.”

“These changes are designed to ensure relevant information is provided to the triaging clinician in order to identify the patients who would benefit from specialist review and therefore proceed to a waiting list.”

MEDICAL FORUM

“The HealthPathways WA team look forward to continuing this work in the hope of reducing inefficiencies and streamlining the patient journey in line with WAPHA’s aim of the right treatment, in the right place, at the right time.”

The stated hope, using the NZ experience, is to free up resources and provide more

Prior to the launch of HealthPathways in WA, then Perth Central & East Metro Medicare Local chief executive officer Learne Durrington (now WAPHA chief) said the introduction of this online portal was designed to make a real difference to patients, the first of its kind in WA, and would help “GPs provide the right treatment or specialist care with less waiting time for patients.”

Time will tell.

Dr Rob McEvoy

MAY 2018 | 29

FEATURE

CHATS in Vietnam WA GPs are being urged to consider joining multidisciplinary health teams providing visiting care to the disadvantaged in Vietnam.

A

number of WA doctors are donating their own time and money to provide a medical component to free dental clinics in Vietnam seeing up to 1600 people a year. Drs Melanie Chen (pictured below) and Fraser Moss have made numerous trips to Vietnam with the Christian Health Aid Team (CHATS) and were packing their bags as this edition of Medical Forum went to press. Both Mel and Fraser are active recruiters and would encourage their GP colleagues to become involved.

“Each dental team has an accompanying doctor who goes along to both triage the kids attending the clinic and look after any health concerns of the team itself,” Mel said.

“I began in 2010 and I’ve probably done about nine trips to Vietnam. Some years I’ve done more than one and I’m now the secretary for CHATS and a keen spruiker on its behalf. It’s a very worthwhile

endeavour and it makes you realise just how spoilt we are in Perth.”

“The clinics in these places are much noisier than anything we’re used to and often you’re working in a school-room with free-standing fans and some pretty basic toilet facilities.”

“On occasion a CHATS doctor will have worked for another charity working in the region such as Burma or Cambodia.

There’s quite a bit of movement between similar organisations.”

Perfect experience for GPs “We do get a lot of younger, hospital-based doctors volunteering but I think older Perth GPs would love the experience. It’s certainly ruined travelling as a ‘tourist’ for me. I just couldn’t do that sort of travelling anymore.”

CHATS began in 2005 when now retired oral and maxillofacial surgeon Dr David Booth became aware that basic medical and dental services were not being provided to a vast majority of Vietnamese people, particularly children. Many of the latter live in Vietnam’s numerous orphanages.

“The children we treat are usually aged between six and early-teens from local schools or orphanages. In fact,

we sometimes treat the monks who accompany the kids even though this project is not specifically designed to treat adults,” Mel said.

“Parents will often get their children all dressed up in nice clothes for their visit to the clinic but just as many are from very poor families with kids in dirty T-shirts. I listen to their chests before they go on to the dentist and I’ll always remember one little kid who quickly pulled his shirt back down.

He was embarrassed because he only had a piece of string holding up his shorts.”

“There are a few things that have surprised me, in a positive sense, over there. I’ve seen kids who’ve had heart surgery and in one village I saw children with cochlear implants and hearing aids.”

“We were working in a hospital clinic and they had a laminated board recording the inoculation regime for the children. It was every bit as comprehensive as you’d see in Perth and the drugs came from Cuba, which was interesting.”

“These trips are a wonderful experience and I’d recommend them to everyone.”

Passport Stamp #3 Dr Fraser Moss will be sitting in a village somewhere in rural Vietnam as you read these words. This will be his third trip providing GP clinical support and triage prior to much needed dental treatment.

“The children are in remarkably good health with very few signs of disease, which is a testimony to the public health system.

Mind you, their teeth aren’t too good. There aren’t enough dentists in Vietnam but there are a lot of readily available sugary drinks.”

“I’ve been twice now and the last trip was based around Long Tan, which is quite close to Ho Chi Minh City. I had no idea of just what to expect but what I do know now is that we get through an enormous amount of work.”

Dr Fraser Moss gives a young patient an ENT health check before seeing the dentist.

30 | MAY 2018

“My nephew is a dentist, he introduced me to the CHATS program and I’m so glad he did. It’s such a worthwhile thing to do for a GP. It’s also something of an adventure, plus we don’t get many opportunities to work with colleagues in different professions, particularly dentists. We seem to function in a bit of a parallel universe, which is a shame.”

MEDICAL FORUM

FEATURE “And there’s also the added bonus of meeting Vietnamese doctors when we do a clinic in a hospital.”

to clean their teeth and maintain good oral hygiene.”

“It can get pretty noisy and chaotic, often we’ll have hundreds of people milling around so the numbering system is absolutely vital.”

A regular part of the workload is the setting up and dismantling of the clinic. It’s very much a ‘mobile’ operation and the working day begins with some heavy lifting.

“Each child is given a pack of goodies with toothpaste and brush, plus a small teddy-bear.”

“The entire operation, despite some complex logistics, is very well organised and highly efficient. Good teamwork is crucial because we’re picked up in a bus and transferred daily to a clinic where we usually stay for about one week.”

Despite the religious connection of ‘Christian Health’ in the CHATs title, Fraser underlines the fact that there is no proselytising whatsoever.

The travelling fixers

“It’s completely non-denominational, even though a Christian ethic underpinned the original idea of CHATs. Any sort of religious component is just not part of the picture in any way. And, of course, you don’t have to be a paid-up church member to go on these trips.”

“There’s a team of about 16 people ranging from dentists, dental assistants, administrative staff and the all-important interpreter.”

“We unload the registration and triage work stations first of all so that we can get the registration process under way.”

“Every child has a number stamped on the back of their hand and that ensures full documentation throughout the whole process. While the autoclaves and suction hoses are being set up in the dental stations, we’ll triage the kids with an overview of their general health and have closer look at any ENT issues.”

Founder of CHATS, retired Oral and Maxillofacial surgeon Dr David Booth triages a young patient.

“The next stop is anaesthesia, all the dental work is done pain-free thanks to a small jab with a needle. We have a team of young local people who both entertain and distract the kids by showing them how

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

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

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

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

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

MEDICAL FORUM

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

“I’d encourage every doctor to think about getting involved with CHATS. You get to see the real Vietnam and work with some really nice people. And the interaction with colleagues in Vietnam is an added bonus.”

ED: The next CHATS trips to Central and Southern Vietnam are July 14-21 and November 24 to December 1. www.chatinc.org.au

Dr Tamara Hunter MBBS, BSc, FRANCOG, CREI

Prof Roger Hart MD, FRCOG, FRANZCOG, CREI

MAY 2018 | 31

Claremont Pain Clinic

CLINICAL OPINION

By Dr Ron Jewell, Obstetrician and Gynaecologist, Bunbury Dr David Holthouse Neurosurgeon/Pain Specialist FRACS FRACGP FPMFANZCA

Dr Pat Coleman Anaesthetist/Pain Specialist

FANZCA FPMFANZCA FRACGP DRCOG

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

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

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

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

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

32 | MAY 2018

It is an interesting Prolapse management has been situation where a upended by a Senate Inquiry.

Senate Inquiry can Where do we go to from here? be set up by an ex radio ‘shock jock’ to look into a complex medical situation. The Inquiry was made very emotive by describing women as ‘victims’. One patient who testified to the Inquiry was proven in the past to have Munchausen syndrome.

Certainly, there are women who have had real problems post mesh, particularly those who have fibromyalgia.

The situation is similar in Scotland. The ‘Prospect’ trial was run by an epidemiologist and published in the Lancet. It was meant to show that there was no advantage to mesh repair over native tissue repair with many more side effects but the groups and surgeons were not comparable. Many prominent pelvic surgeons have written to the Lancet attempting to point out the shortcomings of the ‘RCT’ but none of these articles or letters have been published.

Management of prolapse in post-mesh Australia has several aspects.

Prevention includes consideration of elective LUSCS in some women and caution with operative vaginal delivery. Use pessaries post-delivery and while breast feeding to give support to healing tissues.

Non-surgical management may be acceptance of prolapse without treatment, pelvic floor physiotherapy, and pessary management.

Physical modalities include ThermiVa (diathermy technology) and MonaLisa Touch (laser technology).

Other meshes are being trialled in various countries. Most meshes used in vaginal surgery were polypropylene. Research is being done on PVC mesh, platinum mesh and mesh which will change its properties with various physical agents used in the vagina. It can be made to absorb and to release antibiotics, amongst other functions.

The main problem with prolapse repair is that the vagina is a fibroelastic sheath, ideally with properties like a cycle tube. It has to be strong but distensible allowing a baby's head to descend, allow faecal and urinary flow on either side and to allow sexual function.

This function peaks early in the reproductive years.

The aim is to be able to do conventional repair, maintain elasticity and not have rigid scar tissue. Dr Andri Niewoudt from the Netherlands has done over 680 repairs and kept impeccable records; the concept is tissue regenerative surgery with meticulous dissection of tissue planes and haemostasis as well as using multiple fine monofilament sutures and no distention of tissues with local anaesthetics; no packs are needed. I attended one of his workshops in Belgium last year and have adopted his techniques with pleasing results thus far.

There are also many similar techniques used around the world – ‘site specific repair’ is one. The cosmetic gynaecologists also have other techniques which can be learned but have not had the same audit as Dr Andri Niewoudt.

Author competing interests: nil relevant disclosures.

Questions? Contact the author ronjojewell@gmail.com

MEDICAL FORUM

BACK TO CONTENTS

Prolapse repair post mesh

CLINICAL OPINION

By Dr Fred Busch, Obstetrician and Gynaecologist, West Leederville

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Author competing interests: No relevant disclosures.

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2. Transobturator (TOR) such as TVT-O and Obtryx-II. The incisions are vaginal and in the groins.

The risk of bladder perforation with MUS is 4-5%; provided the complication is identified, long term sequelae are uncommon. The risk of tape exposure is around 2% (compared to 3-18% with mesh for prolapse repair).

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1. Retropubic (RPR) such as TVT. The incisions are vaginal and just above the pubic bones.

The efficacy of RPR and TOR are similar in the short to medium term but some evidence suggests that in the longer term (> 5 years) RPR are more effective. Further long-term studies are required.

While women considering MUS surgery should be appropriately counselled, they may also be reassured that the likelihood of complications, including chronic pelvic pain and dyspareunia, is much less likely than with mesh POP repair. It is incumbent on the surgeon to communicate clearly and be as confident as possible that their patient is making an informed decision when contemplating MUS surgery.

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There are three types of MUS:

In patients who are willing, a trial of conservative management in the form of pelvic floor exercise therapy (PFE) should be attempted. Where there is mixed incontinence, anticholinergics should be offered. Overall, the efficacy of PFE is around 40% and MUS around 70-80% in treating SUI. While weight loss significantly reduces the number of incontinence episodes in obese women, studies report similar efficacy rates for MUS in obese and non-obese patients.

data suggesting that TOR halves the risk compared to RPR. However, the requirement of urethrolysis is less than 3%. TOR MUS have a higher risk of groin pain which is usually transient. When intrinsic sphincter deficiency is found on urodynamic studies, RPR has a greater chance of success.

)

Media attention around mesh for pelvic floor repair has caused unnecessary concern and fear amongst Australian women seeking treatment for stress urinary incontinence (SUI), a common and debilitating condition.

When conservative measures fail, MUS is often the best option.

RANZCOG supports the use of traditional MUS (RPR and TOR) for the surgical treatment of SUI. Currently available SIS have not demonstrated equivalent efficacy to traditional MUS and should only be used in properly conducted clinical trials in selected women. The TGA has removed SIS from the Australian Register of Therapeutic Goods.

ars

It is unfortunate mid-urethral slings (MUS) have often been included in criticism of synthetic implants since MUS carry less risk (when comparing with most other available continence surgeries) and should be seen as a separate entity from mesh used for POP repair. The mean total complication rate for mesh POP repair is 20-40% while for MUS it is 4% at 24 months following surgery.

Finding the middle road on the use of pelvic mesh is not easy for procedural gynaecologists, let alone GPs who advise patients on their best course of action.

3. Single incision slings (SIS). The incision is vaginal.

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The development of pelvic mesh products was not the profession’s ‘finest hour’. Women face many barriers when seeking treatment after things have gone wrong following mesh pelvic organ prolapse (POP) repair surgery. Getting diagnosed can be very difficult, and most of the care is poorly co-ordinated and mainly in the private sector, which costs the women impacted.

Age

BACK TO CONTENTS

Mid-urethral sling: Should it still be in use?

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GPs Giving Wings to Fly With older GPs beginning to hang up their stethoscopes in increasing numbers, there’s a shortage of qualified Designated Aviation Medical Examiners (DAME). Dr Rob Liddell, no stranger to the world of aviation, is helping to run a new course at Jandakot Airport.

course here in Perth so that’s what we’re doing next month. It will give doctors an insight into just what’s involved for a career pilot and we’ll be having a look at issues such as hypoxia. Plus there’ll be a chance to see what an aircraft simulator looks like and gain an understanding of how Air Traffic Control (ATC) runs their side of the show.”

“A GP is required to have training approved by the Civil Aviation Safety Authority (CASA) before being delegated to conduct aviation medicals. These courses have previously only been done in Melbourne under the auspices of Monash University.”

“It’s an interesting and enjoyable course.

And even for doctors who may not intend to pursue the CASA approved DAME qualification it can be quite useful for any GP to have a greater insight into the potential problems for any of their patients thinking about a long-haul flight.”

“I thought it would be a great idea to run a

WE HAVE TOOLS TO HELP GPs FIND CANCER EARLIER Download our new cancer risk assessment guides today.

Find out more at cancerwa.asn.au/gp/fce

MEDICAL FORUM

MAY 2018 | 33 CCW1042_GP Press_61x125.indd 1

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34 | MAY 2018

MEDICAL FORUM

CLINICAL UPDATE

BACK TO CONTENTS

Sexual health what’s happening in WA

By Dr Jenny McCloskey, Sexual Health Physician, Royal Perth Hospital Gonorrhoea Gonorrhoea is significantly increasing in metropolitan Perth, with cases having more than doubled in the last five years. In all my years as a sexual health physician I have never seen STI rates so high in the metropolitan region.

may lead to the end of HIV. In WA there has been a 47% reduction in HIV amongst MSM in the last 12 months. Patients taking the medication are still encouraged to use condoms to reduce their risk of exposure to HIV and other STIs such as gonorrhoea, chlamydia and syphilis.

In 2017 there were over 3300 cases of gonorrhoea in WA with 20% being in women in their twenties. Why younger women are increasingly infected is unknown – do you have the answer?

Write to us with your ideas? Cases in heterosexuals now outstrip those in men who have sex with men (MSM).

However, there is emerging evidence the use of condoms is falling.

Women may not develop a symptomatic discharge so the diagnosis can be missed until their partner develops symptoms.

Even if they are asymptomatic they are still at risk of complications such as pelvic inflammatory disease and consequent ectopic pregnancy and infertility. Pregnant women need to be screened to prevent transmission to their child at birth and in high prevalence areas screening should be done a second time prior to delivery.

Long term there is a slightly increased risk of osteoporosis and in older men the long term effect on renal function is not fully understood, however compared to the risks of HIV acquisition this prophylactic medication is being rapidly taken up and promoted.

Given the escalating gonorrhoea infections in Perth, antibiotic resistance will be a real public health problem as a satisfactory alternative to the currently used ceftriaxone/azithromycin combination does not exist for routine use. If you have a patient in whom you have made the diagnosis it is really important to have tested all possible sites of infection and this includes the throat and rectum as these are the sites where treatment failures occur.

Patients are quite obliging with doing many of their own swabs these days but they are not able to successfully perform their own throat swabs.

HIV PrEP Treatment to prevent HIV infection by taking emtricitrabine/ tenofovir daily has just been released on the PBS. Guidelines for its use are listed on the ASHM website and training courses for doctors interested in providing this to their patients are rapidly being developed.

PrEP has been shown to significantly reduce HIV acquisition and it is thought it

MEDICAL FORUM

In addition to encouraging condom use, three-monthly screening for STI’s (HIV, syphilis, oral, rectal and urethral gonorrhoea and chlamydia) is recommended as well as a check of renal function (protein/creatinine ratio).

For those who want access to free medication rather than through the PBS system the Fremantle and Royal Perth Hospital Sexual Health Clinics, and the M clinic are running a clinic trial with the HDWA and Kirby Institute to see how quickly the roll out of this medication can reduce the incidence of HIV in WA. The trial ends in April 2019.

Findings from the RPH Anogenital Wart Database A recently published paper in Papillomavirus Research (McCloskey et al) has provided a novel understanding of cofactors in the development of anal intraepithelial neoplasia.

Using patients with genital warts co-infected with a high-risk strain of HPV as the baseline the authors found that the risk of anal precancer was increased by HIV infection (odds ratio 11.1) as well as other STI’s such as syphilis (OR 5.58), gonorrhea (OR 6.45), chlamydia (OR4.80) and genital herpes (OR 7.85). Therefore, with the reduction in condom use the authors

Sexual mores are changing and with it the incidence and pattern of STIs, which family doctors may have some ideas on. predict there may be a serious increase in anal pre-cancer particularly among MSM. The paper discusses the various mechanisms as to how the increase may occur such as chlamydia increasing the persistence of high-risk HPV, gonorrhoea acting similarly by the inflammation it causes and genital herpes is recognized to be a mutagen so it may work synergistically with HrHPV to increase the risk of anal pre-cancer. This work highlights the importance of vaccinating MSM. Changes to the treatment of NSU As antibiotic resistance to Mycoplasma genitalium is emerging, the days of single dose treatment for STI’s are fading rapidly.

At most world sexual health conferences the emergence of highly drug resistant gonorrhoea is discussed. Doxycycline 100mg bd for 7 days is now the recommended treatment for NSU. Testing for Ureaplasma sp is not recommended.

Mycoplasma genitalium. A new diagnostic test for Mycoplasma genitalium is available which also provides azithromycin sensitivity/resistance data at the time the diagnosis is released. This will enable appropriate treatment to be given. Guidelines for treatment vary on the sensitivity and are evolving so it is a good idea to discuss treatment with a Sexual Health or ID Physician.

Acknowledgments: HDWA for provision of data.

LINKS FOR PREP: Risk for HIV, guidelines and procedures for PrEP http:// viruseradication.com/ journal-details/Australasian_ Society_for_HIV,_Viral_ Hepatitis_and_Sexual_Health_ Medicine_HIV_pre-exposure_ prophylaxis:_clinical_guidelines/ Australian Federation of AIDS Organisations and ASHM fact sheet. Google ASHM_AFAO_PrEP_ Fact_Sheet.pdf

Author competing interests: nil relevant.

Questions or feedback? Contact the author on editor@mforum.com.au

MAY 2018 | 35

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CLINICAL UPDATE

BACK TO CONTENTS

Long Acting Reversible Contraception – underused?

By Dr Cliff Neppe, Director Obstetrics and Gynaecology, Joondalup Health Campus Despite more effective hormonal contraception options, the combined oral contraceptive pill (COCP; released in 1961) remains the preferred contraceptive for Australian women.

Data suggests that 33% of women use the COCP, 30% condoms, 19% permanent sterilisation and 15% a combination of other options including Long Acting Reversible Contraception or LARC (e.g. Implanon, Mirena, Copper IUD and Depo Provera.)

Inconsistent contraceptive use plays a major role in putting women at risk of an unintended pregnancy; 60% of women with an unintended pregnancy were using at least one form of contraception (COCP 43%, condoms 22%).

Compliance remains the leading cause of COCP failure. A key way to reduce these unintended pregnancies is using a more effective, less user-dependent method of contraception - LARC. As well as being indicated for contraception, certain LARCs are also indicated for the treatment of idiopathic menorrhagia and the prevention of endometrial hyperplasia during oestrogen replacement therapy.

Why are LARC’s not more widely used?

When women are provided with comprehensive, accurate and unbiased

Smoking in pregnancy The AIHW’s Child and maternal health in 2013–2015 has just been released and contains some disturbing stats on smoking in pregnancy.

Nationally, one in 10 (11%) mothers smoked at some point during their pregnancy. In regional PHN areas (17.4%) smoking rates were more than double those of mothers in metropolitan PHN areas (7.9%).

Nearly half (46.5%) of Aboriginal and Torres Strait Islander mothers smoked during pregnancy, with rates slightly higher in regional (47.8%) PHN areas, compared with metropolitan areas (42.6%).

The lowest percentages of mothers who smoked during pregnancy were in Northern Sydney (1.3%) while Perth North with 6.4% had WA’s lowest. Perth South recorded 9.7% while Country WA had 18.5%.

The highest percentages were in Western NSW (22.9%).

MEDICAL FORUM

counselling, LARC methods are preferred and have been shown to have higher rates of satisfaction and 12-month continuation compared with combined hormonal methods.

Papers give us some clues about reduced use.

An estimated 40-50% of Australian women have an unintended pregnancy. An estimated 80 000 abortions occur each year in Australia. Why aren’t LARCs the leading option for reproductive years?

An opinion paper cited knowledge gaps in healthcare providers and insufficient training in LARC insertion as reasons for low uptakes in LARCs. Family planning Alliance of Australia (2014) agreed with the low uptake but stated that there is no conclusive evidence that identifies the reasons.

The benefits of LARCs is clear. Our challenge is to increase uptake. In hospital post-partum insertion of LARCs would certainly increase uptake. A single dedicated LARC inserter in each practice as well as same day insertion could also possibly increase uptake.

A paucity of Australian research impedes closure of evidence gaps regarding contraceptive prescription and use. Barriers identified include lack of familiarity with LARC, misconceptions about its use; and lack of access to GPs trained in LARC insertion and removal, plus affordability.

References available on request

Training enables GPs to insert IUDs in their practices but follow up revealed 68% fitted fewer than 12. Inadequate remuneration, time constraints and lack of appropriate patients are barriers.It has been found that most IUDs, even in nulliparous women, can be inserted in a primary care setting and that access to training and ongoing support for practitioners willing to develop and maintain this procedural skill are essential to enhance uptake of IUDs in Australia.

KEY MESSAGES LARC is an effective underused contraception method Better GP support and training is needed Adequate patient counselling and same day insertion could increase uptake

Author competing interests: nil relevant disclosures. Questions? Contact the author at drcliff@cliffneppe.com.au

Designated Aviation Medical Examiner Training Program Saturday 16 – Sunday 24 June, 2018 Perth, WA

Hosted by Australasian Society of Aerospace Medicine This intensive nine-day course will cover the competencies set out by the International Civil Aviation Organisation (ICAO) for training of Designated Aviation Medical Examiners. It is a highly interactive course, with only 15 delegates, and includes practical exposure to aviation workplaces (flight simulators and air traffic control facilities) as well as the opportunity to undergo hypoxia familiarisation.

Enquiries to secretariat@asam.org.au or 0418 890 641 Registration information at www.asam.org.au/event

MAY 2018 | 37

get your patient’s spine working Workspine’s team of hand picked specialists provide comprehensive occupational spine injury management under one roof.

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38 | MAY 2018

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MEDICAL FORUM

CLINICAL UPDATE

BACK TO CONTENTS

Subfertility imaging in women

By Dr Emmeline Lee, Gynaecological Radiologist, Murdoch Imaging investigations in women with subfertility not only aids diagnosis of the different structural abnormalities but it also aids some therapies requiring imaging guidance.

Reduced fertility affects at least 50 million couples worldwide each year with ‘infertility’ meaning no children conceived despite regular unprotected intercourse for at least a year and subfertility meaning any form of unwanted reduced fertility over a prolonged time.

and to aid assessment of deep infiltrating endometriosis (particularly if bowel involvement is suspected).

Imaging is pivotal in couples with subfertility, both in diagnosing structural abnormalities and guiding therapeutic options.

Investigations for subfertility involve assessment of ovulation (serum progesterone, luteinizing hormone, and follicle-stimulating hormone), androgen profiling, evaluation of ovarian reserve (anti-Mullerian hormone), thyroid function, and semen analysis. Imaging can assess structural pelvic abnormalities which may contribute to fertility issues and as well as exclude tubal occlusion.

Imaging as treatment

3D VCI plane coronal image obtained via transvaginal ultrasound demonstrates a Septate uterus, with two uterine cavities, and one cervix.

Imaging methods 3D Transvaginal Ultrasound (US) is the first-line imaging modality for investigating subfertility. Structural Mullerian duct abnormalities, intracavitory lesions (such as endometrial polyps and fibroids), endometriomas, polycystic ovaries and hydrosalpinx are common causes of reduced fertility easily diagnosed on a good quality transvaginal scan.

Hysterosalpingography (HSG), performed since 1914 to investigate tubal patency, involves giving contrast into the uterine cavity, with visualisation under fluoroscopic guidance that usually gives excellent pictures of the fallopian tubes/spillage into the peritoneum. Despite a small dose of ionising radiation, this is the investigation of choice if tubal disease is suspected.

Hysterosalpingo-Contrast-Sonography (HyCoSy) or Hysterosalpingo-Foam Sonography (HyFoSy) is increasingly popular for assessing tubal patency.

Contrast/foam/saline is instilled into the uterine cavity during an internal ultrasound.

The fallopian tubes are usually very well visualised, and spill can be seen in real time. This is a minimally invasive, ionizing radiation-free way of assessing the uterine cavity and tubal patency. It is best used for women where tubal disease is not suspected. HyCoSy’s strength is that it is easily combined with saline infusion sonography (usually at no extra patient cost) if there is suspicion of intracavitory abnormalities such as polyps, fibroids or adhesions, and/or if a Mullerian duct abnormality is suspected.

MEDICAL FORUM

Transvaginal ultrasound with Doppler imaging during Saline Infusion Sonography clearly outlines a small polyp containing distinctive vascularity.

The therapeutic benefits of HyCoSy/HyFoSy and HSG are well known, with increased pregnancy rates in the six months following these procedures.

Lipiodol flushing is being increasingly used as a therapeutic option, particularly in women with endometriosis without tubal involvement. Lipiodol is an oil-soluble contrast medium derived from poppy seeds, first used in 1924 as a contrast agent for HSG. A recent meta-analysis suggests that flushing of the fallopian tubes with Lipiodol has 3.6 times greater odds (OR 3.6) of pregnancy compared with no HSG or HyCoSy, and that pregnancy/live birth rates increase by 10% when Lipiodol is used over water-based contrast media, such as in HSG or HyCoSy. If a structural cause of subfertility is found, treatment via imaging guidance may be of value. For example, select patients may benefit from Uterine Artery Embolisation or image-guided ablation via MRI-guided focused ultrasound.

During a HyCoSy examination, demonstrating a normal sized fallopian tube, with contrast spilling from its fimbrial end, indicating tubal patency.

Saline Infusion Sonography is performed to interrogate the cavity. Saline is infused after cervical cannulation under transvaginal ultrasound visualization. With distension of the cavity, intracavitory lesions can be characterised well, and guide later surgery.

Asherman syndrome is diagnosed best using this method. Mullerian duct defects can also be further characterised this way, with accurate measurements of the cavity easily obtained with concurrent 3D ultrasound.

Magnetic Resonance Imaging (MRI) is second-line, used as an adjunct to transvaginal ultrasound, usually to clarify and/or confirm Mullerian duct abnormalities, further characterise fibroids,

In the oncologic setting, where women are diagnosed with cervical, endometrial or ovarian cancer before they have completed their families, imaging is important in stratifying those patients suitable for fertilitypreserving surgery.

KEY MESSAGES A transvaginal ultrasound with 3D reconstruction should be the first test when investigating a woman with subfertility Tubal patency can be established by either HSG or HyCoSy/HyFoSy Lipiodol flushing is a minimallyinvasive technique that increases pregnancy/live birth rates

Author competing interests- nil relevant disclosures. Questions? Contact the author at emmeline@westernultrasound.com.au

MAY 2018 | 39

WA COUNTRY DOCTORS’ AWARDS 2018 Congratulations to all award recipients Long Service Awards

Special Awards

Proudly sponsored by

People’s Choice Dr James Bowie

40 years of service to rural and remote Western Australia Dr John Rosser Davies Dr William Dewing Dr Michael Hall Dr Malcolm Hodsdon Dr Yet Chee Low Dr Hoon Loom Wu

Procedural GP/District Medical Officer of the Year Dr Alan Kerrigan Rising Star (Emerging Doctor) Dr Khean Shang (James) Wong GP of the Year Dr Johannes Grobbelaar

30 years of service to rural and remote Western Australia

Specialist of the Year (non-GP) Dr Sean George

Dr Geoffrey Augustson Dr Carol Fitzpatrick Dr Trenton Healy Dr Leslie Jones

Proudly sponsored by

20 years of service to rural and remote Western Australia

Metropolitan-based Specialist Bush Champion Dr Narelle Hadlow and Dr Andrew Wesseldine

Dr Eleonora Brusasco Dr Ian Catto Dr Keith Figueiredo Dr Charles Greenfield Dr Craig Hendry Dr Geoffrey Menezes Dr Hermann Meyer Dr Nicholas Newman Dr Gavin Osgarby Dr Melanie Pountney Dr Paul Salmon 40 | MAY 2018

Medical Leadership Dr Kirsten Auret and Dr Patrick Glackin

Chairman’s Award Dr James Bowie and Dr Johannes Grobbelaar Proudly sponsored by

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CLINICAL UPDATE

BACK TO CONTENTS

Ovarian cancer symptoms & when to act

By Dr Stuart Salfinger, Gynaecologic Oncologist Ovarian malignancy presents a difficult dilemma for all practitioners especially the GP. The vast majority of women are at low risk with a lifetime risk of the disease in the order of 1-1.5%. A smaller group are at higher risk coming from families with known BRCA 1 & 2 gene mutations or HNPCC. Others come from a difficultto-define increased risk group with strong family histories of breast and ovarian cancer but no detected genetic mutation.

Symptoms provide a weak clue Most women who are diagnosed with ovarian carcinoma report symptoms, usually for a reasonable period of time before diagnosis. As the symptoms are vague and generalised and not classically “gynaecologic” in nature the diagnosis is usually made at an advanced stage of disease.

Criteria

Scoring System

Menopausal status (A) Premenopausal Postmenopausal

1 3

Ultrasound features (B) Multiloculated Solid Areas Bilateral Ascites Metastases

No feature = 0 One feature = 1 >1 feature = 3

Serum CA 125 (C)

Absolute level

Risk of Malignancy Index (RMI) = A x B x C The classic symptomatology includes, abdominal bloating or increased abdominal girth, indigestion, early satiety or indigestion, change in weight or urinary/ bowel habit. Pelvic pain or more commonly pressure is also reported but the majority

This uncommon gynae cancer proves a real dilemma for GPs who may be unfairly seen as overreacting or ‘too little, too late’. of symptoms (75%) tend to be abdominal with only around 25% of women reporting “pelvic” symptoms.

Given these symptoms are very common, vague and non-specific, it is persistence of these symptoms for more than a month that should trigger further investigation.

After history and examination, ultrasound scan (USS) and serum ca125 levels are next in line.

Tests need experienced interpretation A good quality trans-vaginal USS has a better sensitivity for detection of ovarian

continued on Page 43

PERTH HIP & KNEE WELCOME SAM YOUNG INTO OUR PRACTICE Sam is a locally trained surgeon who brings with him a wealth of experience from interstate and overseas fellowships and will be a valued addition to our team of experienced hip & knee surgeons.

We are a specialist practice focused on treating all aspects of hip and knee pathology, from knee arthroscopy through to complex joint replacement and revision surgery.

We look forward to delivering to your patients excellence in care using state of the art techniques and advanced technologies.

Perth Hip & Knee Suite 1/1 Wexford Street Subiaco WA 6008 SANI ERAK | SAM YOUNG | DERMOT COLLOPY | GAVIN CLARK

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P 6489 1700 E admin@hipnknee.com.au W www.hipnknee.com.au

MAY 2018 | 41

we've got you covered

Working together to provide comprehensive urological care Dr. Jeff Thavaseelan Dr. Shane La Bianca Dr. Andrew Tan Dr. Akhlil Hamid Dr. Trenton Barrett Dr. Matt Brown

Hollywood Clinic Suite 15 / Ground, Hollywood Medical Centre 85 Monash Avenue, Nedlands WA 6009 Phone (08) 9322 2435 / Fax (08) 9322 5358

www.perthurologyclinic.com.au refer@perthurologyclinic.com.au 1800 4 UROLOGY (1800 487 656) Healthlink: jthavase

Wexford Clinic Suite 23 / Level 1, Wexford Medical Centre 3 Barry Marshall Parade, Murdoch WA 6015 Phone (08) 6189 2970 / Fax (08) 6225 2105

Also consulting at Joondalup, Mandurah, Geraldton and Albany

42 | MAY 2018

MEDICAL FORUM

CLINICAL UPDATE

BACK TO CONTENTS

Caesarean section for maternal request

By Dr Rae Watson Jones, Obstetrician and Gynaecologist, Mount Lawley Clinicians can be polarised on this question. Most private obstetricians will readily agree, and women often choose a private obstetrician to have this option easily available. In the public system, there are generally more hoops to jump through.

What are the typical reasons for the request?

For first-time mothers, these include: • fear of labour (tocophobia),

reducing this figure argue there are longterm costs to women, the health system and the economy.

Advantages of a Caesarean section • Risk of ending up with a Caesarean section after attempting labour and an elective Caesarean has less risk of complications than emergency Caesarean • Less chance of pelvic organ prolapse and urinary incontinence

• family pressure e.g. my mother and my sisters all had Caesareans, I don’t believe I can have a successful vaginal birth,

• No risk of perineal trauma

• previous trauma or surgery to bony pelvis or hips (belief that she cannot extend her hips or tolerate lithotomy position),

Disadvantages of a Caesarean section:

• chronic back pain (fear that labour will exacerbate symptoms) • believing Caesarean section is “more dignified” and controlled For women not having their first baby, a common reason is a previous successful vaginal birth perceived as traumatic but with no ongoing physical complications.

Is there any problem with this request? One third of babies born in Australia are born by Caesarean section, above the OECD average and well above the WHO recommendation of 15%. This figure predominantly consists of women with a previous Caesarean section so efforts to reduce the rate are usually targeted towards improving the vaginal birth after Caesarean (VBAC) rate or preventing index Caesarean section. Proponents for

• Planned procedure and controlled birth experience • Surgical complications (e.g. haemorrhage, bladder, bowel or urinary injury, wound infection) • Limit to family size (increased risk of complications with each Caesarean) • Slightly increased risk of stillbirth in future pregnancy compared with never having had a Caesarean • Risks of placenta praevia accreta in future pregnancy • Neonatal risks – transient tachypnoea of the newborn • An association with delayed cognitive development and childhood asthma compared with children born vaginally A suggested approach to women requesting a Caesarean is to explore the reason for the request and have a frank discussion about the pros and

When a woman requests a Caesarean section with no medical or obstetric indication, should the obstetrician just say ‘yes’? Counselling women about the pros and cons before making a decision is vital. cons. Involving other clinicians (e.g. the GP, a second obstetrician), once the reason for the request has been elicited, is useful. A midwife providing continuity of care during the antenatal period and labour may ease fears regarding labour.

A clinical psychologist can be consulted if there is a history of anxiety or depression or to determine if there is true tocophobia that may have a detrimental effect on the woman’s mental state during the antenatal or postnatal period.

By going through this process, the woman will be empowered in her decision-making and the obstetrician will have truly met the requirements of informed consent.

KEY MESSAGES Requests for non-medical Caesarean sections are more common today.

Women should be thoroughly informed of the pros and cons.

Author competing interests – nil relevant disclosures Questions? Contact the author admin@integralwomenshealth.com.au

continued from Page 41

Ovarian cancer... masses. Ca125 may be helpful but can be normal in 50% of women with early stage disease and can be elevated in many benign conditions.

Abnormalities on these tests should lead to referral to either an experienced gynaecologic surgeon or gynaecologic oncologist for ongoing care (depending on degree of risk). With the USS features such as complex areas with septations, papillary projections, solid elements or ascites are recognised as high risk. The Risk of Malignancy Index (RMI) scoring system is a useful triage tool but is not an absolute guide (see graphic).

Value of screening?

The current evidence and National

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recommendations are to not screen asymptomatic women. The UKCTOCS trial reported last year that there is no benefit to screening. The US Preventative Services Task Force (USPSTF) re-issued their guideline early this year reinforcing the decision against screening, as it does not improve survival and may carry unnecessary risk and also potentially be falsely reassuring.

For such a rare disease the current specificity of tests is not adequate in the general population. The risks and benefits of screening in the high-risk situation needs a careful and individualised discussion in conjunction with the known proven benefits of surgery in these women.

In the mean time we hope for better more specific and sensitive tests and better risk

assessment tool to alter the course of this devastating disease.

KEY MESSAGES Symptoms are vague and non specific – most disease presents late Always investigate persistent symptoms Ultrasound and Ca 125 good first line for investigations Ovarian cancer screening is not recommended in line with national and international guidelines

Author competing interests – none to declare.

MAY 2018 | 43

CLINICAL UPDATE

By Dr Angamuthu Arun, Gynaecologist, Waikiki

Pudendal neuralgia (prevalence unknown) is long-term pelvic pain that originates from damage to or irritation of the pudendal nerve, one of the main nerves in the pelvis. The nerve supplies areas such as the lower buttocks, the area between the buttocks and genitals (perineum) the area around the back passage (rectum),vulva, labia, and clitoris in women (scrotum and penis in men).

(Fig.1). Pudendal neuralgia pain affects more women (60%) than men. The problem is commonly misdiagnosed.

The difference in pudendal neuralgia symptoms The main symptom is pelvic pain affecting any of the areas supplied by the pudendal nerve.

Pain characteristics may: • feel like a burning, crushing, shooting or prickling sensation, • develop gradually or suddenly, • be constant or fluctuate, • be worse on sitting and better when standing or lying, Other symptoms can include: • numbness and pins and needles in the pelvic area,

1. Pain in the anatomical territory of the pudendal nerve; 2. Pain aggravated by sitting; 3. No nocturnal waking due to pain; 4. There is no objective sensory loss on examination; 5. A positive response to anaesthetic block of the pudendal nerve.

Other symptoms can also suggest pudendal neuralgia, such as sexual dysfunction, defaecation difficulty and/or urinary symptoms.

Management depends on the cause Physical therapy has been considered the first-line treatment by many investigators.

The management of pudendal neuralgia also includes behavioural modifications, pelvic floor physiotherapy, analgesics, pudendal nerve block, injections of botulinum toxin A (in case of muscle spasms).

Pharmacological treatment varies. Some of the more common medications are gabapentin, pregabalin, cyclobenzaprine, and tricyclic antidepressants. Local medications, such as intravaginal diazepam have also been applied.

Nerve block or surgical decompression can be considered if conservative treatment fails.

• frequency or urgency,

Pudendal block. The pudendal nerve carries sensations to and from the vagina, part of the buttocks and the skin between the genitals and the back passage. A pudendal nerve block of local anaesthetic and steroid medication is often done to temporarily reduce pain and aid diagnosis.

• pain during sex, difficulty reaching orgasm, and erectile dysfunction in men.

In a recent study by Antolak et al, where 52 men received a therapeutic pudendal block

• increased sensitivity – just a light touch or wearing clothes can be uncomfortable, • feeling as though there's swelling or an object in the perineum (“like a golf or tennis ball”),

Unless an obvious cause or pattern of symptoms presents, a diagnostic trial of pudendal nerve block may be warranted. in a Minnesota Urology Pain Clinic, local anaesthesia affected all 6 pudendal nerve branches in only 13.2% of patients and complete pain relief occurred in 39.2%.

Surgical decompression is offered when entrapment is suspected and pudendal nerve blocks have provided minimal or no relief. Following this surgery, approximately 40% of patients are pain free, 30% have some improvement in pain, and 30% patients show neither improvement nor worsening.

KEY MESSAGES Avoid delays in diagnosis and treatment.

Pudendal neuralgia may be confused with a form of vulvodynia.

Diagnosis is based on the Nantes criteria.

Treatments can be conservative (behavioural modification, physiotherapy, analgesics) or not (nerve block, surgical nerve decompression).

Author competing interests: no relevant disclosures. Questions? Contact the author 9550 0300

Possible causes of pudendal neuralgia These include:

Fig. 1 Pudendal Nerve Anatomy

• compression by nearby muscles or tissues (pudendal nerve entrapment or Alcock canal syndrome) • prolonged sitting, cycling, horse riding or constipation causing repeated minor damage to the pelvic area • previous surgery to the pelvic area • pelvic fractures • damage to the nerve during childbirth • a tumour pressing on the pudendal nerve Diagnosis using Nantes critea Five of these criteria are required for diagnosis:

44 | MAY 2018

MEDICAL FORUM

BACK TO CONTENTS

Pudendal neuralgia

CLINICAL OPINION

BACK TO CONTENTS

HbA1c insights

By Dr Tim Welborn, Endocrinologist

Glycated haemoglobin (HbA1c) measures long-term glycaemia in most diabetic patients and has recently been approved as a screening test for undiagnosed diabetes and prediabetes. Glucose is chemically an aldehyde with affinity for protein, so it attaches itself to haemoglobin in the red cell. HbA1c is commonly expressed as a percentage of the total haemoglobin and it estimates the average blood glucose levels for the preceding 2 to 3 months (red cells survive ~120 days).

Glycated haemoglobin can be misleading when there is abnormal red cell turnover. Sickle-cell anaemia and other haemolytic states, and the anaemia of renal failure, can cause falsely low levels.

Cases of thalassaemia trait can have prolonged red cell survival, with higher readings than expected. Therefore, be guided by the patient’s home blood glucose monitoring where possible.

Fructosamine is an alternative measure of short term glycaemia in the preceding 2-3 weeks. It reflects glycosylation of plasma proteins, predominantly albumin. Order this when misleading HbA1c readings are suspected, or when ascertaining recent blood sugar control after short-term improvement. The formula for equivalent conversion of Fructosamine to HbA1c is: HbA1c = Fructosamine x 0.171 +1.61

Explaining how the HbA1c works helps us understand the value and limitations of the test, which Medicare has approved as a screening test for diabetes.

Table: Easy approximation of blood glucose HbA1c (%)

Lab estimated av.

Bl. glucose approximation

7.0%

8.6 mmol/L

8.0 mmol/L

8.0%

10.2

10.0

9.0%

11.8

12.0

References Position statement of the Australian Diabetes society. MJA 2009:194;339-344 Accord study. NEJM 2008:358;2545-2559

HbA1c for diagnosing diabetes and prediabetes has recently been approved as an annual test in those at risk (Medicare rebate available); more patient friendly than a 2-hour glucose tolerance test, and there is no need to fast. Results are much less influenced by recent illness or stress, although there is caution with interpretation in abnormal red cell states.

In general, an HbA1c of 6.0–6.4% is consistent with pre-diabetes, and values > 6.5% indicate probable diabetes. It is recommended that a fasting random glucose is also measured to support the diagnosis.

KEY POINTS VT/VF therapy (shocks) affects quantity not quality of life and can becompeting simply electronically turned on Author interests: nil relevant.

Questions?

Contact the author on and off.

Glycated haemoglobin enables the doctor and patient to set agreed targets. In general “satisfactory” control is described as HbA1c <7.0%, “fair” control 7.0-8.0 % , and suboptimal control > 8.0%. Targets must be individualised and realistically adjusted for the elderly and the cognitively impaired. Females with gestational diabetes should be given a target of 6.0–6.5%.

The pivotal ACCORD study (2008) aimed to achieve “normal” glycated haemoglobin levels in type 2 diabetes (target <6.0%), and the intensively treated group did achieve steady levels of 6.5% (on multiple medications plus insulin). But the study had to be terminated because of increased mortality in this group as compared to conventional treatment.

Most laboratory reports interpret HbA1c by including a statement of “estimated average blood glucose”, derived from a complex formula (but in day-to-day practice, a simple and quite accurate way of doing this is: “Double the number and subtract 6” (see Table).

Expressing HbA1c as a “percentage” is a time-honoured format, and should be retained because we are all familiar with it. Some authorities say the measure should properly be expressed as mmol/mol., yielding numbers that will be difficult for most of us to interpret. Let’s stay with the old way!

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officetimwelborn@iinet.net.au

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

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

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Suite 112 / 1 Silas Street East Fremantle WA 6158 P 6244 3344 F 6244 3346 E admin@integratedradiology.com.au www.integratedradiology.com.au

MAY 2018 | 45

FEATURE

Life on the Ocean Wave Getting life’s priorities right can sometimes require dealing with wild seas and nausea but for Dr Revle Bangor-Jones it’s been worth every minute.

I

t’s not just casting-off on an ocean-going catamaran that reduces the stress levels for Dr Revle Bangor-Jones. Choral singing is another passion and when this current sailing trip draws to a close it’s highly likely that the next port-ofcall will be a Perth performance of Handel’s Messiah.

“When I think about sailing, music and being a doctor I always wonder which particular bit is really me? But what I do know is that it’s very important to have an interest outside the practice of medicine. I find being a doctor quite stressful at times, and music has always been an escape from that.”

“I discovered sailing later in life but it certainly fulfils the same role as music in many ways.”

“We bought a French-made catamaran in 2014 after looking at a lot of other boats, including ones here in Australia. We named her Intrepid Elk. It’s 51 feet-long which is about as large as my husband and I. We can comfortably manage it on our own and it’s quite a fast boat, too.”

So, why a catamaran made in France?

The perfect boat “We did try to get an Australian boat but the timing for our departure was becoming increasingly tricky. My husband, who’s been sailing since the age of 12, put a lot of time into researching the boat that suited us best and we pretty much knew what we wanted in terms of sail configurations and internal layout.”

“In the end we went to the factory and chose a particular model with fibreglass hulls that was comfortable to sail with just the two of us on-board.”

it there because all the waterways freeze in winter. When the weather warmed up we headed further north to Norway, the Shetlands and the west-coast of Ireland.”

“We stepped back on-board Intrepid Elk last year in northern Spain, sailed to Portugal and Morocco before mooring it in the Canary Islands.”

Ocean passages in a sailing boat aren’t all about gently flapping mainsails to the tune of a gin and tonic. It’s no time for the fainthearted when the waves get higher than the mast.

Challenges of the sea “We’ve had some rough moments, more than a few actually. It can be very frightening and on every trip, about the third day out, we both suffer from seasickness. That’s as much about exhaustion as anything else because we’re both getting used to the cycle of going on and off watch every three hours. Until you get back into that cycle it’s a bit of a challenge.”

“But being on the boat is such a wonderful opportunity. It allows you into the lives of others, to experience different cultures and be a traveller rather than a tourist.”

“That can be tiring, too. We’re living with the locals and that means going out and doing things like shopping and having to speak a different language. It can be hard work, until we come back to Perth we’re rarely in a place where much English is spoken.”

Organising a trip takes time and effort, as does keeping the boat seaworthy.

“It’s surprising how little time there is between planning one voyage to the next.

You have to have a close look at intended

destinations, the route and potential weather conditions. Once you get on the boat there’s always plenty of domestic maintenance, everything from dragging out my funny old sewing machine to repairing electronic equipment.”

“There’s cultural ‘homework’ as well. We do a lot of research related to our various destinations because it’s important to have an understanding of the history of the places we’re heading to.”

All in the prep “And it’s also important to mention that, unlike my husband, I didn’t have an extensive sailing background. This entire venture was about six years in the planning and that included courses in radio navigation and meteorology combined with a couple of hands-on sailing courses in Bunbury.”

Medical Forum’s last correspondence with Intrepid Elk was an email sent from Curaçao in the ABC Islands. Next destination was Panama and then on to Perth.

“We were contemplating sailing around Australia when we get back but we’re feeling the pull of life back on dry land. So we’ll probably stop at that point, which will be very sad in some ways. But we’ve got two adult children and we’re missing out on a lot of family things.”

“I’ll take one very important thing away from my time on Intrepid Elk and that’s an appreciation of just what’s important in life.

I’ve got a much more finely honed sense of life’s priorities.”

By Peter McClelland

“We picked the boat up in the Mediterranean in March 2014 and spent the first six months sailing around there while we learnt how to handle it. We then headed to the Canary Islands, across the Atlantic to the eastern Caribbean and then on to Europe.”

“Then it was up into the northern latitudes, England’s south-coast, the Baltics, Germany, Denmark and Sweden. We had to take the boat out of the water and leave

After a storm

46 | MAY 2018

MEDICAL FORUM

It's all plain sailing

A puffin hitches a ride, mid-Atlantic

Departing London

Life on board

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Atlantic Crossing

MAY 2018 | 47

FOOD

MY LOCAL

Cambridge Corner Store 442 Cambridge St, Floreat Ph 9387 3949 The Cambridge Corner Store is about as ‘local’ as you can get. This little shop is a new kid on the block and it’s a real gem. In its former life, and that was only five months ago, it was somewhere you went to buy an emergency carton of milk or a newspaper. But that’s all changed under the ownership of Simone and David Stedman who have transformed both exterior and interior to create the very epitome of a ‘Corner Local’.

It’s just stunning inside, the shelves are full of interesting produce and the open-plan kitchen sings with the promise of great food. There’s pre-prepared sandwiches, salads and wraps plus some of the yummiest biscuits and cakes you’ve ever tasted.

The coffee’s great and their pies are the best in Perth!

GRILLED FISH WITH TANGY GREEN SALSA INGREDIENTS 8-10 oily fish fillets, pin bones removed (mackerel, barramundi, herring) Olive oil Coarse sea salt and black pepper SALSA 125g celery stalks, thinly sliced 60g marinated green olives, stoned and cut in half 3 tbsp salted capers, rinsed 70g raisins 1½ tbsp white wine vinegar 4 tbsp olive oil 3 tbsp maple syrup Handful of flat-leaf parsley, equal quantity of coriander, roughly chopped

METHOD Prepare salsa, which can be done several hours ahead except for the chopped herbs (add those when serving). Add celery, olives, capers, raisins and chopped herbs in a large bowl.

Prepare dressing mixing the vinegar, oil and maple syrup.

Rub fish fillets with oil and lay on an oiled alfoil-lined tray that fits under the griller or if cooking on the barbecue a wire mesh clamp. Grind salt and pepper over the fish and place under a preheated hot grill for 5 minutes. Check and if cooked turn and give 3-4 minutes the other side until fish is just cooked through.

Lay fish on a serving platter and spoon the salsa over the top.

A perfect dish a part of a larger share meal or as a starter.

Wine winner

Dr Murray Nixon has a self-proclaimed ‘tone-deaf wine palate’. Nonetheless, he’s come back to Chardonnay, loves a Sparkling Red and discovered the pleasures of New Zealand Pinot Noirs while living in the Central Otago region. Murray’s looking forward to tuning up his palate while enjoying his Brash Vineyards Doctor’s Dozen.

48 | MAY 2018

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WINE REVIEW

Oates End Oates End is located in the prime viticultural area of Wilyabrup with a vineyard planted in 1999 to cabernet sauvignon, sauvignon blanc and tempranillo. It is owned by the Oates family, Cath and Russ (pictured above), with Cath looking after the winemaking since her return to Margaret River after stints overseas. Their wine portfolio consists of three wines and all quite distinctive, with a lot of clever French techniques used to produce some unique wines. Margaret River needs producers that are not afraid to showcase different ways of making their classic varietal wines.

1

2

By Dr Martin Buck

1. Oates End 2017 Sauvignon Blanc Semillon This is a different take on the iconic Margaret River blend with a lot of French techniques used in the process. Hand-harvested fruit picked in small parcels is then crushed, pressed into oneyear-old French barriques and left on lees for 10 months. It is later blended with wine fermented in stainless steel tanks to give more freshness. The result is a crisp, clean wine with grassy Semillon aromas and a hint of passionfruit. The palate has great length, some complexity and a lovely softness. It is only recently bottled but should reach its peak next year.

2. Oates End 2016 Tempranillo It’s a masterful choice to select Tempranillo for planting in Margaret River and this Spanish variety is a wonderfully flexible grape. Whether the climate be hot or cool, the wines are distinctive and reflective of the area. The 2016 Tempranillo was harvested at night to protect the flavours, then into open fermenters with final fermentation in French barriques for nine months. In the glass there are aromas of dark berries, oak and savoury beef stock. A medium bodied style with good acidity, balance and palate length. As a huge Tempranillo fan I found this wine right up there with some of my favourites. Still young, this wine will be much better balanced with some short-term cellaring.

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Oates End 2014 Cabernet Sauvignon Finally, a classic Margaret River Cabernet Sauvignon – or so I thought! Picked in two passes, a long ferment with some whole bunches, a wild yeast ferment and ageing in large French oak puncheons for 20 months, then bottled without filtration. It’s a long way from traditional Australian cabernet sauvignon. The resultant wine has delicate berry aromas, some oak and a hint of menthol. An interesting, medium-bodied style, limey palate with beautiful integration of fruit and tannins.

A very enjoyable wine with great subtle fruit expression and soft tannins.

MAY 2018 | 49

SOCIAL PULSE

Celebrating Rural Doctors The annual Country Doctors Awards, hosted by WA Country Health Service and Rural Health West, saw more than 30 doctors recognised for their contributions to the health and welfare of people living rurally and remotely.

Doctors were recognised for 40, 30 and 20 years of service and with special awards recognising outstanding achievement in the rural medical sector.

“Rural doctors don’t just contribute to the health and wellbeing of their patients, but also the sustainability of rural communities,” said the CEO of Rural Health West Tim Shackleton.

Those who were awarded for 30 years’ service were unable to attend. They are: Dr Geoffrey Auguston, Albany, Dr Carol Fitzpatrick, Mt Barker, Dr Trenton Healy, Busselton, and Dr Leslie Jones, Busselton.

40 YEARS’ SERVICE AWARD Dr Yet Chee Low, Mandurah, Dr William Dewing, Bridgetown, Dr Hoon Loom Wu, Harvey, Dr John Rosser Davies, Manjimup, and Dr Malcolm Hodsdon, Kalgoorlie.

Dr Michael Hall, Bunbury, is not in the picture

to a funeral, you're better off in the casket than doing the eulogy."

"I will never understand why they cook on TV. I can't smell it, can't eat it, can't taste it. The end of the show they hold it up to the camera, 'Well, here it is. You can't have any. Thanks for watching. Goodbye'." – Jerry Seinfeld "The first coherent line ever spoken was: 'I have no idea what you're talking about’."

- Eddie Izzard "I was playing chess with my friend and he said, 'Let's make this interesting.' So we stopped playing chess." - Matt Kirshen That’s what she said

Throwing in the towel

The little things

"A woman without a man is like a fish without a bicycle" - Gloria Steinem

"There's an elderly man with a much younger girlfriend, who he can't satisfy sexually. So, he asks his wise counsellor.

'Next time you make love, employ a handsome, muscular young man to stand by your bed, vigorously swinging a towel above his head the entire time. That should do the trick.' So the elderly man hires a really fit male model for the night and then has sex with his girlfriend while the male model stands next to their bed, vigorously swinging a towel above his head. Nothing happens. The model politely suggests that the two men swap places, so that the model has sex with the girl and the elderly man swings the towel. They swap places and, within two minutes of having sex with the muscular male model, the girl has multiple orgasms. The elderly man looks at the model and says, 'See? That's how you swing a towel!'" – Adam Bloom

"I was walking along a road today and there I saw a small, dead baby ghost.

Although thinking about it, it might have been a handkerchief."

"I blame my mother for my poor sex life.

All she told me was, 'The man goes on top and the woman underneath'. For three years my husband and I slept in bunk beds" - Joan Rivers “Men don’t realise that if we’re sleeping with them on the first date, we’re probably not interested in seeing them again either” Chelsea Handler.

That’s what he said "The depressing thing about tennis is that no matter how much I play, I'll never be as good as a wall. I played a wall once.

They're relentless." – Mitch Hedberg "According to most studies, people's No.1 fear is public speaking. No.2 is death.

Death is No.2. Does that sound right? This means, to the average person, if you go

50 | MAY 2018

"I supplied Filofaxes to the Mafia – yeah, I was involved in very organised crime."

"I lost my job as a cricket commentator for saying, 'I don't want to bore you with the details.'" – Milton Jones Past, present, future "Look at the sea and think of your evolutionary past. Look at the sky and imagine the future. Look at the land and think of the present. And at the most profound place, where land, sea and sky meet, there ye shall play volleyball." – Simon Munnery "A hotel minibar allows you to see into the future and find out what a can of Pepsi will cost in 2020." – Rich Hall

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SOCIAL PULSE

20 YEARS’ SERVICE AWARD

20 YEARS’ SERVICE AWARD Dr Melanie Pountney, locum across the North West, Dr Gavin Osgarby, Northam, Dr Eleonora Brusasco, locum, Dr Hermann Meyer, Greenfields, Dr Keith Figueiredo, Geraldton, Dr Geoffrey Menezes, Geraldton, Dr Craig Hendry, Bunbury, and Dr Nicholas Newman, Bunbury

Dr Paul Salmon, Albany, Dr Ian Catto, Dunsborough, and Dr Charles Greenfield, Geraldton, were unable to attend

SPECIAL AWARDS People’s Choice Dr James Bowie, Manjimup

Medical Leadership Dr Kirsten Auret, Albany Dr Patrick Glackin, Esperance

Procedural GP/District Medical Officer of the Year Dr Alan Kerrigan, Narrogin

Rising Star (Emerging Doctor) Dr Khean Shang Wong, Broome

Peoples Choice Dr James Bowie, Manjimup

Medical Leadership Dr Kirsten Auret, Albany

Medical Leadership Dr Patrick Glackin, Esperance

Rising Star (Emerging Doctor) Dr Khean Shang Wong, Broome

Specialist of the Year (non-GP) Dr Sean George, Kalgoorlie

GP of the Year Dr Johannes Grobbelaar, Exmouth

Specialist of the Year (non-GP) Dr Sean George, Kalgoorlie

Metropolitan-based Specialist Bush Champions Dr Narelle Hadlow, Director, Regional and Support Services, PathWest Dr Andrew Wesseldine, Director, State Stroke Centre

Chairman’s Award Dr Johannes Grobbelaar, Exmouth and Dr James Bowie, Manjimup

Front row: WACHS Chief Mr Jeff Moffet, Lynnette Dias, A/Chief Medical Officer Dr James Williamson, Dr Shantha David, WACHS board member Dr Kim Isaacs.

Back row: Peta Fong, chair of WACHS Prof Neale Fong, Dr Felicity Jefferies, Kim Snowball and WACHS board member Meredith Waters

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Metropolitan-based Specialist Bush Champion Dr Narelle Hadlow, Director, Regional and Support Services, PathWest Dr Andrew Wesseldine, Director, State Stroke Centre

MAY 2018 | 51

BALLET

St Petersburg’s Winning Look The alluring dancers of the St Petersburg Ballet Theatre are schooled with care and precision and you can spot them from a mile off.

If you’re lucky enough to have St Petersburg Ballet Theatre’s Swan Lake on your ticket-stub you just know you’re in for a wonderful night!

Tchaikovsky’s sublime music, white tutus, pink ballet shoes and some of the world’s best dancers will be on stage at His Majesty’s Theatre in early June.

a brutally punishing career.

“Once they graduate and begin performing the Russian ‘body’ will usually maintain its shape due to the long, slow training of the muscles and torso without the need for harsh dieting.”

“As a dancer gets older there are inevitable issues with their feet and when they remove their pointe shoes it’s often not a pretty sight. The toes are often compressed and twisted, and bunions are a common problem. A dancer’s career can be as long, or as short, as a piece of string but many are still dancing as 40-somethings.”

“We love the Maj, it’s perfect for ballet!” said Andrew Guild, co-producer of the current tour. “There’s always a great atmosphere, the foyer is buzzing and the theatre’s internal space is absolutely gorgeous.”

Andrew points out that the company’s impeccable reputation for consistently world-class performances doesn’t spring out of thin air. There’s a Russian ‘look’ to all the dancers in the St Petersburg troupe and that process is both complex and ongoing throughout a performer’s entire career.

“The Russian system is different from anywhere else in the world. It’s heavily subsidised by the State and this goes right back to the Soviet era. The other aspect that’s unique is the way a dancer is selected.”

“A lot of time is spent choosing the ‘right’ body at a very young age. It’s certainly not just a matter of picking someone who’s enthusiastic and good at skipping around! They look closely at the bodies, the physical makeup of a potential dancer at around seven years of age.”

“Teachers and doctors will actually try and predict where these bodies will ‘go’ at the

52 | MAY 2018

onset of puberty and how they will react and develop during the training process and on throughout an entire career.”

“There’s a strong feeling within the Russian ballet sector that the bones, feet and muscles of children as young as four or five years-of-age are much too malleable to be subjected to intense pressure. Consequently, after much scrutiny they will enter a school around the age of eight and the same teacher will usually take the same group right through to graduation.”

“That’s why you’ll often see the teacher’s name figuring prominently in a dancer’s biography. It’s a real accolade for a performer to have been taught by a famous teacher.”

It’s a training regime that obviously pays dividends. Russian dancers have a famously distinctive ‘look’ and they’re noted for their artistic longevity in what is

“Having said that, a dancer will peak in his or her early 30s and that’s as much about bringing an emotional maturity to a role as any physical component.”

“One of the stars of this show is prima ballerina, Irina Kolesnikova who is in her mid-30s and travelling with her young daughter. Irina will finish a performance at night, have a massage and be up early in the morning to look after her child.”

The dancers love performing to a full house and Andrew’s thinks he’s got the best job in the world.

“It’s such fun, a fantastic profession and I feel so privileged to be doing this. We’ve just had sell-out tours of South Africa and Asia with audiences having the time of their lives.”

“There’s such a love for the Russian ‘brand’ of dance and an insatiable demand for Swan Lake!”

By Peter McClelland

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THEATRE

Dark Side of American Dream Continuing its stunning series of chamber musicals, Black Swan State Theatre Company is bringing Stephen Sondheim’s biting satire Assassins to the Ledger Theatre in June with legendary Australian direct Roger Hodgman (pictured) at the helm.

I don’t think he meant it was his best but one that he thought was complete, which is interesting because it wasn’t hugely successful.”

Being Sondheim, you can expect the subject matter to be challenging and the music discombobulating and superb.

“The lyrics are so sharp and the music at times so achingly beautiful and yet there is this dark distortion of the American dream.

There is an edge throughout.”

Assassins looks into the uneasy heart of the American love affair with notoriety, fame and, of course, guns. It imagines the conversations of would-be assassins including Lynne “Squeaky” Fromme, who tried to kill the US President Gerald Ford in 1975 to prove her love to cult leader Charles Manson. Add John Hinckley to the list.

He attempted to kill US President Ronald Reagan in 1981 to impress actress Jodie Foster over whom he had obsessed since her role in Taxi Driver.

“On the eve of its Broadway season, the first Iraq war broke out and I think the show’s connections were a bit scared of its topicality. It had a fairly successful season in the early 2000s but even then I think the Americans found its subject matter tricky.”

Roger said this intriguing tale is treated with great wit and humour as well as seriousness.

What stirs Roger’s creative juices is Sondheim never says the same thing twice.

“Each one of his works is different to the other and yet there is a definitive Sondheim sound. I started directing Sondheim

musicals when he was the kiss of death but audiences have grown to love them.”

“He will never be as commercial as a Lloyd Webber but there’s always a Sondheim show playing somewhere in the world and the man, himself, is very good at encouraging performers to do different things with them. I think is he one of the most significant writers for theatre of the second half of the 20th century.”

“His work is intriguing – you discover new things all the time.”

Apparently, not unlike the puzzles Sondheim creates in is ‘spare time’. Roger said he is famous for having introduced cryptic crosswords to North America and loves inventing puzzles and board games.

“You find that in the music. Every time there is a beautiful melody he cuts it off before the end. He is a restless spirit that I find fascinating.”

By Jan Hallam

There doesn’t seem to be any shortage of examples and they reverberate through time.

Roger, who spoke to Medical Forum recently, admits to being a little obsessed himself with the excellence of Sondheim’s work. The theatre legend, whose intelligence and deep theatre knowledge transformed the Melbourne Theatre Company into the powerhouse it is today during the 15 years he was associated with it, has in more recent times become something of the go-to director for opera and musicals.

And Sondheim is a composer he has often returned to. He has met and spoken to the writer about his work on a number of occasions and Roger is always fascinated by the insights Sondheim has to offer.

“This is the third time I have reprised a Sondheim musical and he asked me which one was my favourite. Well I had to say that A Little Night Music was the most successful, while Sweeney Todd was the most amazing but I have an extraordinary soft spot for Assassins (which is probably wrong word!).”

“Sondheim jumped in and said of all the musicals he’d done, it was the only one he wouldn’t change if he did it again.

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MAY 2018 | 53

COMPETITIONS

Entering Medical Forum's competitions is easy!

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

Movie: Hotel Transylvania 3, A Monster Vacation

Artist Nigel Hewitt creates wonder from the devastation of bushfires in his exhibition Recinder which is showing at Gallery Central in Perth. He collected ash from bushfires in WA and Tasmania – the two states in which he divides his time – to layer onto canvases creating a series of landscapes that explore concepts of destruction, rebirth and forgotten histories. Hewitt grinds, filters and separates the ash into five different tones, and then creates the artworks using two distinct techniques, unique to his practice. “Ash is a strange medium and it is loaded with inherent meaning,” he said. “For me there is something very exciting about taking a material that has be discarded and attempting to give it new life by returning it to a form that resembles what it once was.” Hewitt is a graduate of the Claremont School of Art, but grew up in Tasmania.

Recinder is Hewitt’s first solo show since 2011 and features 12 new works, created over a six-year period.

Gallery Central, North Metropolitan TAFE, April 30-May 19

The popular monster family is back but this time, they are taking a holiday on a luxury monster cruise ship taking in a spot of monster volleyball, working up their moon tans and stop-offs to exotic locations.

But it’s not all smooth sailing with shipboard romances and dangerous secrets blowing things off course.

In cinemas, June 28

Movie: Tea with the Dames Theatre and cinema lovers will take a degree of pleasure from Roger Mitchell’s documentary featuring the four great dames of British acting – Eileen Atkins, Judi Dench, Joan Plowright and Maggie Smith. The four get together over one weekend at the retreat once shared by Plowright and her husband, Laurence Olivier, talking about life and their amazing careers.

In cinemas, June 7

Movie: The Leisure Seeker Oscar winner Helen Mirren and Donald Sutherland star as an older couple looking for adventure on one boisterous and bittersweet final road trip. Based on the novel by Michael Zadoorian, Mirren scored a best actress nomination at the recent Golden Globes.

In cinemas, June 7

Winners from March Music - WASO Three Concert Package: Dr Min Chan

Dance: St Petersburg Ballet Theatre Swan Lake Rethinking Realities Pain Clinicals Mental Health Looking Ahead

MAJOR PARTNER

2018 Alliance Française French Film Festival: Dr Peter Smith, Dr Carolyn Bracken, Dr Paul Rodoreda, Dr Ioana Vlad, Dr Rachael Marpole

March 2018

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The renowned St Petersburg Ballet Theatre returns with the iconic Swan Lake with the heart-stopping music by Pyotr Ilyich Tchaikovsky. Starring prima ballerina Irina Kolesnikova and guests from the Bolshoi Ballet, it is a ballet everyone should see.

His Majesty’s Theatre, June 7-16

Comedy - Nick Cody – Loose Unit : (replacing cancelled James Valentine) – Dr Barry Vieira Movie - Peter Rabbit: Dr Hilary Clayton, Dr Richard O'Regan, Dr David Young, Dr Amy Gates, Dr Bonnie Chu, Dr Geoffrey Mullins, Dr Jim Gherardi, Dr Kamlesh Bhatt Movie - The Death of Stalin: Dr Andrew Christophers, Dr Stuart Paterson, Dr Derek Johns, Dr Alison Smith, Dr Heather Brand Movie - The Guernsey Literary and Potato Peel Pie Society: Dr Braad Sowman, Dr Liz Bussell, Dr Caroline Rhodes

54 | MAY 2018

Musical Theatre: Assassins Australian theatre doyen Roger Hodgman directs Stephen Sondheim’s seering satire of America’s cult of celebrity and the means by which some have attempted to obtain it. Bold, alarming and eerily relevant in these turbulent times.

Heath Ledger Theatre, June 16-July 1 MF performance, June 16, 7.30pm

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