MedicalForumWA 1017 Public Edition

y fl o t t fi Health Shapes Up Staying in the Game Musculoskeletal lowdown Wheels to Adventure

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1235-5/03-17/0811

EDITORIAL

Words! Words! Words!

So, another state budget has been delivered with the usual quota of infographs (a lot of red!) and analysis from the usual suspects. And doesn’t it sound like Groundhog Day?

talking to people on the ground and by all accounts consumer and clinical committees were swamped by interested people wanting to take part. In the spirit of constructive comment, we will push down the enemy C word – cynicism – at this point.

• “Broken Promises” Check

We know from many readers, the heightened levels of frustration within the profession about a system which has tied itself up so securely in quality and safety tape that the most important C word (albeit hyphenated) of all – common-sense – has been completely forgotten.

• “Missing money for health commitments” Check • “Fiscal black holes” Check • “No funds for ageing infrastructure” Check • “We will honour commitments” Check

A good start would be to do a common-sense audit of policies and procedures because unless some space for innovation can be made, we will be faced with a 200-page report that will be full of comforting words for politicians and cold comfort for the 40,000 people working in the system and the million-plus people paying $8.9b in bills.

We are at war … and it’s a war of words.

And just like the industrial military complex, an oversized industry has sprung up around the demand for words, which are minted in the workshops for select use, turned into wordy statements and then fired at us by the Talking Heads.

But be warned, the payload doesn’t explode until it appears in a headline on a media platform somewhere.

Bureaucrats need to fall in love with transparency and accountability because without these we will have no lasting reform or revitalisation.

The good news story will be a system that is sustainable and accountable – in fact that’s almost all the safety and quality tape you need.

On and on it goes.

In this edition we take a look at the very early days of the Sustainable Health Review, which has the potential like all government reviews to sink into the mire of words.

While it may not be apparent immediately, dare we hope that this review may be a different beast? That it might actually be a creative, collaborative, consultative and constructive process – the four Cs so beloved of bureaucrats everywhere, rather than a razor gang.

Well, the early signs are promising … for starters, it’s headed by an ‘out-of-towner’. Ms Robyn Kruk has vast health system experience – from SOMEWHERE ELSE! Fresh eyes, fresh ears and fresh mind. In short, a breath of fresh air who can take ‘without fear or favour’ to heights rarely experienced in Western Australia.

We’ve also been told there is no cost-savings target, which could mean that everything is fair game or the review panel has an open mind and a keen eye. We also hear the panel is

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MEDICAL FORUM

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

In return, those sitting on the sidelines – politicians, media, employee and employer representative bodies – need to change their tune. It’s easy to lob a few negatives to grab attention, much harder to be part of a constructive conversation. Surely this happens behind closed doors, so why the cheap shots for a public growing increasing tired of words from men (mostly) in high places.

Everyone has their work to do… so in the immortal words of Eliza Doolittle: Sing me no song!

Read me no rhyme!

Don't waste my time, Show me!

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

OCTOBER 2017 | 1

CONTENTS october 2017

22

10 FEATURES 10 Spotlight: Bobby Despotovski and

the W League 18 Cl Difficile in the Community 22 United People of Adventure 29 Keeping Players in the Game

NEWS & VIEWS 1 Editorial: Words! Words! Words!

Jan Hallam 4 Letters to the Editor

Looking for ED Solutions

Health Minister Roger Cook

Lack of Beds the Problem

Dr Yusif Nagree

Arts Offer Balance

Ms Claire Medhurst

WAMAS Too Precious to Lose

Mr Clinton Heal

Disability Sector Roadmap

Ms Julie Waylen 8 Have You Heard?

9 Beneath the Drapes 12 Rural Student Placements

18

29 14 21 24 33 35

Will This Review be Sustainable?

Autism Diagnostic Guideline Parent Coaching Exercise for Life Dealing with Data Breach

Lifestyle 47 Tour de Gracetown 48 Travel: Peller Estate, Canada

49

50 50 51 52 53

Dr Bruce McKay Wine Review: Fermoy Estate Dr Martin Buck Funny Side Wine Winner: Dr Nick Anastas Theatre: Let the Right One In Theatre: Masterclass Competitions

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MEDICAL FORUM

clinicals

5

Bone Remodelling Markers Dr Paul Glendinning

37

Too many Knee Arthroscopies?

Dr Sandra Mejak

38

44

Paediatric elbow injuries Dr Ryan Lisle

41

Treatments for Low Back Pain Dr Mark Hamlin

45

Injury prevention in AFL Dr Simon Jenkin

43

Four Problem Hand Injuries Dr Paul Jarrett

46

Managing Hyperparathyroidism

Dr Simon Ryan

Plantar fasciitis Dr Andrew Knox

guest columns

7

The Learning Continues Ms Gemma Slater

25

Research Dollars Where Needed Most Mr Terry Slevin

26

Learning for Today and Tomorrow Dr Simon Rosalie

27

Cannabis and Epilepsy – Why Not? Ms Joelle Neville

A Man of Vision Readers of the magazine will be well acquainted with the work of the John Fawcett Foundation in Bali. Over the past 20 years, the foundation, founded by Perth artist and humanitarian John Fawcett, has gathered together medical teams to help restore sight and repair cleft palates changing the lives of some of the world’s poorest people with relatively simple interventions.

Last month, John died in Perth after suffering a major stroke, leaving many people with heavy hearts but also a legacy that will live on through his initiatives. The JFF team in Bali, the board in Australia and the trustees in the UK have committed to continue John’s work.

After a cremation ceremony here in Perth, John’s ashes were flown to Bali. www.johnfawcett.org INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician) MEDICAL FORUM OCTOBER 2017 | 3

LETTERS To THE EDITOR Looking for ED solutions Dear Editor, Research as highlighted in Can GPs Sort Out EDs (September), makes a valuable contribution to the continuing debate on alternative pathways for patients who visit our Emergency Departments (EDs) in Western Australia.

To ensure future generations continue to enjoy the exceptional care our EDs provide, we need to find opportunities to reduce the pressure from increasing community demand. A sustainable health system for the WA community is a priority for the McGowan Government.

Putting patients first in all aspects of health care means ensuring patients receive the most appropriate care, where and when they need it most.

A significant number of ED visits could be appropriately managed in other health care settings. So far this year 152,784 visits to metropolitan EDs were identified as ‘GP type’ avoidable attendances, around 36% of all ED visits.

These type of visits for non-life threatening illnesses and injuries indicate there is an opportunity to implement alternative care pathways. I envisage GPs playing a crucial role in this.

The Government is committed to establishing alternative care pathways, such as Urgent Care Clinics, to improve choice and help relieve the increasing demand in EDs. An urgent care clinic could be linked to an ED or in the community where the resources of large primary care providers can be utilised as part of existing GP services, or in other health settings. There may be pathways available that accelerate access to care. Our minds should be open and one size will not fit all.

A $2m investment from the State Budget will allow us to develop the alternatives and implement a pilot scheme.

Of course, we do not want to stop people who have an urgent or life-threatening condition going to an ED. The community will want to be reassured that an urgent care clinic is enhanced primary care, not inferior emergency care for treatment of less serious issues.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

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

4 | OCTOBER 2017

By reducing unnecessary visits to EDs we will free up hospital beds and ensure those people who attend our EDs for emergency care receive the attention they need in a timely and appropriate manner.

Arts offer balance in life

It’s not an option for us to ignore the issue.

Thank you for sharing your recent article on Dr Robert Edeson and his new book, Bad to Worse (September).

As a Fremantle Press board member, I had the pleasure to hear Robert speak at a recent Fremantle Press Champions of Literature event.

Mr Roger Cook, WA Minister for Health ........................................................................

Lack of hospital beds is the problem Dear Editor, While the Australasian College for Emergency Medicine (ACEM) values all research undertaken to help reduce demand on emergency departments (EDs), the fact remains GP-type patients are a very small part of the emergency department workload (Can GPs Sort Out EDs?, September 2017).

A study of three major tertiary hospitals in Perth, released in 2013, found that GP-type patients accounted for less than 5% of the total length-of-stay of ED patients. Furthermore, various research has demonstrated that the vast majority of attendances at the ED are appropriate for the patients’ medical condition(s).

Dear Editor,

Robert suggested that inside every highly disciplined doctor there was another, more rebellious person, eager to come out and get creative. As a highly disciplined retired commercial lawyer, who is also passionate about books, I related.

An active interest in culture and the arts is a vital and healthy counterbalance to the economic, business and status obsessions that can distract us, both at a personal and societal level. Participating in culture means having an interest in the ‘public realm’ and the expression of ideas in society generally.

I believe this is consistent with the sense of inquiry that is such a strong part of scientific life. Thank you, Medical Forum, for recognising this in your culture pages.

Ms Clair Medhurst

Past approaches designed to ease the burden on EDs, such as standalone clinics, telephone triage lines and after-hours services and/or urgent care centres, have had little effect on emergency department attendances.

ED: Clair Medhurst is a Fremantle Press board member and Champion of Literature.

The Fremantle Press Champions of Literature is a philanthropic group supporting new and emerging Western Australian writers.

The greatest challenge faced by Australian and New Zealand’s EDs is access block.

That is, patients have to stay longer in the ED because there aren’t beds in wards of the hospital, which leads to ED overcrowding.

Disability sector needs roadmap

Evidence consistently demonstrates that overcrowding leads to increased patient mortality, morbidity and prolonged hospital stays.

The National Disability Insurance Scheme represents a fundamental shift in the way disability services are accessed and delivered, giving people with disability choice and control over the way they live their lives.

Increased resources, realistic targets and the implementation of evidence-based approaches for dealing with over-capacity are required in order to reduce the pressure on EDs and improve patient outcomes.

A/Prof Yusuf Nagree, Australasian College for Emergency Medicine

........................................................................

Dear Editor,

It also represents significant economic and employment opportunities for WA, triggering jobs growth and doubling the sector’s continued on Page 6

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

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

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Major Sponsor: Clinipath Pathology

Dr Paul Glendenning, Consultant Endocrinologist and Chemical Pathologist

back to contents

Bone Remodelling Markers: Value and Limitations Markers of bone turnover, measured in blood or urine, correlate with changes in the metabolic activity of bone. The rate of bone remodelling is important. With ageing, the quantum of bone removed/ resorbed and the amount replaced/ formed becomes increasingly imbalanced.

Consequently, the more bone remodelling units that are active at any one time, or the greater the activity of individual units, the greater the overall rate of bone loss.

Bone turnover markers are probably predictive of the rate of bone loss and could help determine the efficacy of treatment.

Bone turnover markers: • May predict fracture risk independently of bone mineral density, according to some studies.

• A drop in bone resorption is an early predictor of response to all anti-resorptive osteoporosis treatments initiated in general practice (bisphosphonates, denosumab or raloxifene), with these markers changing earlier than comparable markers of bone formation.

Consequently, at Clinipath Pathology, we will be transitioning from the measurement of urine NTX to the measurement of serum CTX and will commence reporting serum CTX assay results soon.

For example, denosumab suppresses bone resorption earlier and to a greater degree than a bisphosphonate.

Uses and Limitations

CTX can provide complementary information to bone mineral density in subpopulations but this measurement has not been currently adopted into fracture risk alogrithm calculators such as FRAX or the Garvan risk calculator for individuals.

Serum CTX is a potentially useful test when investigating the cause of increased alkaline phosphatase, verifying compliance with osteoporosis treatment, improving persistence with that treatment or identifying occult secondary causes of osteoporosis such as apathetic hyperthyroidism or other metabolic bone disorders such as Paget’s disease.

Samples collected fasting in the morning minimise intra-individual variation and requests ideally should include the reason for testing. Medicare currently provides a rebate for tests of bone resorption in patients with known bone disease taking treatment.

Which Bone Resorption Marker?

Markers measuring the rate of bone loss are degradation products of type 1 collagen cleaved during bone resorption.

• The assay can be performed manually or by automated methods and is only provided by one manufacturer (obviating the need for harmonisation) • The biological and analytical variability for CTX is well documented in the literature.

4. Measurement of bone formation and bone resorption do not provide additive information

key Points

The known limitations are: 1. Not all anti-resorptive treatments suppress bone resorption to the same degree.

Provision of the type of anti-resorptive agent used and the duration of treatment is not only helpful for billing but allows us to report more specifically - whether the rate of bone resorption is typical or higher than expected for a particular anti-resorptive agent.

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

This is because the baseline rate of bone remodelling is not predictive of the rate of change of bone remodelling or rate of change of bone density whilst on treatment.

Understanding these limitations and the potential value of measuring bone remodelling markers can be useful when making decisions regarding individual patient management in those taking treatment for osteoporosis.

Cross-linking telopeptides of collagen can be measured by immunoassays that are specific for the beginning (N terminal- called NTX) or end (C terminal- called CTX) of type 1 collagen. Whilst measuring urinary NTX and serum CTX provide comparable information there are some advantages of CTX over NTX. Consequently, serum CTX has been proposed as a reference method – see May edition of Medical Forum.

• Most serum CTX is from osteoclastic bone resorption (indicating high specificity).

3. The measurement of serum CTX cannot be used to select treatment

Whilst bone remodelling is a coupled process wherein bone formation and bone resorption are linked, the measurement of bone resorption or bone formation markers provide comparable information regarding the rate of bone remodelling. Measurements of both bone formation and bone resorption markers in individual patients do not help determine the degree of imbalance in bone remodelling and is therefore unnecessary.

• They may be predictive of later changes in bone mineral density (BMD), and can be measured before BMD changes can be evaluated.

• The measurand in the CTX assay is clearly defined, allowing this 8 amino acid oligopeptide to become the reference method.

2. Bone resorption is not predictive of future fracture risk in individuals

Patient Results: 9371 4340

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

www.clinipathpathology.com.au

1. Bone resorption markers can assess early response to anti-resorptive treatment.

2. Information about which antiresorptive treatment is being used and the duration of treatment is necessary if more specific advice is required.

3. Bone resorption markers results cannot be used to assess fracture risk or select treatment.

LETTERS To THE EDITOR continued from Page 4 economic contribution as we transition to fullscheme rollout over the next three years.

To realise the promise of the NDIS, a sustainable, vibrant and diverse WA disability sector will be crucial in supporting people with disability to achieve their goals through high-quality service delivery and measuring positive outcomes.

To ensure we are ready to meet those challenges, National Disability Services, representing more than 100 organisations which serve around 26,000 people, has developed a WA Disability Services Sector Industry Plan.

The plan outlines a coordinated, strategic approach to build capacity and capability of providers to ensure market and service availability, particularly for people in regional and remote communities.

By the time the scheme reaches full-out implementation in 2020, an estimated 39,100 West Australians with disability will be accessing services through the NDIS. According to our analysis, 10,000 jobs will be generated as demand for services grow, doubling the number generated by the sector to 20,144 direct and indirect full-time jobs in WA over the next three years.

Additionally, the disability sector’s annual contribution will double to $2.7b, up from $1.4b in 2014-15.

The State Government must invest in support strategies to ensure there is sufficient workforce capacity and scale to deliver the NDIS – that is, ensuring people with disability have access to a range of supports and services.

advocate on behalf of the community and join the WAMAS team negotiate with WA Health for continued funding so WAMAS could evolve from its current operation to a centre based at the Harry Perkins Institute of Medical Research.

We welcome the opportunity to find possible solutions to strengthen the workforce, particularly during the transition period, and look forward to working with Government and agencies to smooth the path ahead.

The community’s passion to protect this service has been overwhelming. It was a privilege to meet the Director-General of Health to relay those concerns from people who have experienced such quality care from WAMAS.

Ms Julie Waylen, National Disability Services WA State Manager ........................................................................

WAMAS too precious to lose Dear Editor, The Western Australian Melanoma Advisory Service (WAMAS) has been a pillar of exemplary clinical care for thousands of melanoma patients and their families since it was established in 2000.

The melanomaWA Support Coordinator Clare Moynihan and I speak widely throughout our network. By listening to those touched by melanoma in WA, we were well placed to

The WAMAS team devote countless hours to improve the diagnosis, treatment and access to clinical trials for melanoma patients in WA. We at melanomaWA believe that the WAMAS service, where clinicians from the range of specialties associated with melanoma treatment devote their time and resources, is unique.

This team approach is the best way to minimise the impact of melanoma on patients and we are excited to continue to provide support services to complement WAMAS’s great work and to ensure the transition to the soon-to be-announced centralised, statewide melanoma service is a positive one for all those touched by melanoma in WA. Clinton Heal, CEO, melanomaWA

Black Swan Health Counselling Services Black Swan Health provides high-quality, across the Perth Metropolitan area.

We specialise in a wide range of adult and youth mental health conditions including but not limited to: • Anxiety Disorders • Stress Management • Eating Disorders • Depression • Personality Disorders • Addiction • Perinatal Depression • Grief & Bereavement • Trauma • Sexual Orientation & • Child Mental Health Gender Identity • Sleep Disorders

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MEDICAL FORUM

INCISIONS back to contents

The Learning Continues Education is an important part of a child’s life and that process shouldn’t grind to a halt during a stay in hospital, says teacher Ms Gemma Slater.

Hospital teaching probably isn’t a career that many people know much about. When I tell my friends that I’m an English teacher at the School of Special Educational Needs — Medical and Mental Health I usually get one of two reactions. The first is a long sigh, prompted by a romantic vision of me and a consumptive child in thrall to the power of Harper Lee’s prose.

Education is a rite of passage, an anchor of normality and, for medically compromised students, assists in the healing process..

The second response is far less poetic. ‘Why?’

procrastination and avoidance. It’s important for health teams to work with schools to develop care plans and support both funding initiatives and student re-engagement.

It’s a question I think about a lot, particularly in my current position as a liaison teacher with a Tier 4 Mental Health Service. The students I teach present with a myriad of behavioural and attitudinal issues. When they’re telling me ‘where I can stick my comprehension questions’ I often ask myself, why do I bother?

The easy answer is that there’s a legal obligation for these minors to access education until the end of Year 12, but there’s more to it than that. I’ve seen how education is a vital part of child and teenage health. It’s a rite of passage, an anchor of normality and, for medically compromised students, assists in the healing process.

I am an educator, mediator and coordinator.

Some students have successfully avoided school for weeks, months and years because it’s a place where they feel dislocated, embarrassed, angry and lonely.

My first task is to refamiliarise them with the classroom and build their confidence with accessible, achievable tasks. Some of these students return to their enrolled schools,

Ultimately, the goal is to make sure a young person is safe, functionally engaged in the community and getting an education.

others will require alternate educational pathways. But, thankfully, most students experience a shift in thinking towards education and its inherent benefits.

And then there’s mediation between agencies. A liaison teacher aims to create opportunities for Health and Education to come together and discuss the relationship between a student’s health and educational performance.

There’s little doubt that teachers and administrators benefit from gaining an insight into student health. That’s particularly the case when mental health problems manifest in oppositional behaviours, chronic

A big part of my work is with parents and carers. If a school enrolment has failed in some way, I help parents, carers and students to navigate a range of alternate pathways.

On discharge from hospital I try to have each student enrolled at a school where they feel comfortable and reasonably confident of success.

Regular school attendance is a normal part of life for most young people and the vast majority of my students want nothing more than to be ‘normal’. Health problems can be chronic, but they are often transient, so offering access to education throughout a hospital stay is vitally important.

And that’s why I do this job, and continue to love doing it.

CURIOUS CONVERSATIONS

A World of Possibilities Awaits Wembley GP Dr Leon Levitt would love to spend more time putting pen to paper.

If I could spend a year working overseas I’d go to… a remote village at the end of the line in Canada, Wales or Australia. It’d be great to use the broad skills I’ve learnt in a lifetime of general practice and obstetrics to care for a small community. I’d also have time to write the books that are itching to be written.

My worst moment in medicine was… when I discovered that the patient in front of me was a former member of the Nazi SS. I’d delivered his grandchildren, cared for his family, only to find out that he may well have been involved in the murder of my wife’s family in the concentration camps.

One of the greatest threats to the practice of good medicine is… the term BEST PRACTICE. The world is not black and white, nor is the practice of medicine. I’d like the term to disappear…it limits our thinking as doctors.

The book I’m reading now is… a trashy, popular romantic novel.

I’m trying to work out how sex scenes can be incorporated into a novel without being too explicit.

I wish I had more time to… write, get down on the floor and play with my grandchildren in their world and help my patients with personality disorders. The latter, in particular, need a trusted sounding board.

MEDICAL FORUM

OCTOBER 2017 | 7

HAVE YOU HEARD?

GPs and kids

We were interested to watch the WA Department of Health video describing the roles of the new Diabetics Complex Care Clinics, which aim to reduce patient wait times and fragmentation for those with complex type 2 diabetes. The DCCC shtick is that they provide timely care closer to home and reduce the need for care in a tertiary hospital outpatient clinic. We asked a DoH spokesman to fill in the gaps. The pilot clinics are being run at Kwinana Medical Centre and Cockburn Integrated Health by the Health Networks, South Metropolitan Health Service (providing endocrinology support and program evaluation) and 360 Health + Community, which is coordinating the clinics. Specialist care is being delivered by advanced skills GPs (ASGPs) with the support of an endocrinologist. Patients at the DCCC receive support from a diabetes educator for each session, and an exercise physiologist and dietitian if appropriate. DCCC GPs are required to complete the ‘Advanced Diabetes Care in General Practice’ course run by the University of Queensland. Once the course is completed, the ASGPs manage patient care under the supervision of an endocrinologist (from Fiona Stanley Hospital) for three months. The WA pilot has engaged and recruited GPs within the catchment areas, and services began in November 2015. The latest statistics for the 18 months to July 2017: a total of 503 referrals have been received and over 2100 occasions of service provided.

Former Geraldton, now Queensland, GP Dr Edwin Kruys blogged a timely response to an idiosyncratic piece of research published in the Journal of Paediatrics and Child Health last month. While it showed that around 90% of parents are mostly or completely confident in GPs to provide general care to their children and 93% reported they would take their child to see a GP in the event of a minor illness, instead of visiting an ED, the academic paediatric researchers concluded that “confidence with GPs is an issue for parents of many walks of life”. Edwin writes that the authors conveniently omitted the “mostly confident” category (45%) and only reported the “completely confident” category (44%) as their main result, stating that “fewer than half of parents were completely confident” in a GP. Of course it went viral. We have searched for a response from the journal and/ or the authors but found none. The AMA and the RACGP have hit back but Edwin smells a rat. He thinks the report is a softener for more training “similar to the certificate for GP provision of antenatal care”. As Edwin points out, GPs’ core business is child health. What a waste of time!

GPs take on hep C The WA Department of Health has released a report on hepatitis C treatment uptake, to September 2016, after new treatments were listed on the PBS in March of that year. In that time 1827 people initiated Direct Acting Antiviral (DAA) treatment for chronic HCV, representing 8.9% of West Australians living with the condition. About equal numbers were prescribed treatment by a GP (51%) or a specialist (49%) and the proportion of those treated by a GP increased from 43% to 54%.

Of the 201 DAA prescribers, 66% are GPs. Full report and information about free online training on hepatitis C management and clinical guidelines at www.health.wa.gov.au

Pocket costs rocket As reported last month, the Senate Community Affairs References Committee will be reporting their findings on the value and affordability of private health insurance and out-of-pocket medical costs, mainly from specialist care, on November 27. Peter Sivey, writing in The Conversation last year, said about 50% of Australians had private health insurance, and Australians pay too much to see a specialist. About 30% of specialist services are bulk billed (compared with 85% of GP services). For many, bulk billing is now so entrenched, many doctors know nothing else. Health consumers’ out-of-pocket costs are not going to go away and there have been mounting calls for greater transparency of charges before a patient signs the consent form. Websites comparing specialist costs are springing up like mushrooms, even one started by a frustrated Sydney GP who started his own price comparison website so he could inform his own patients. While his methodology by his own admission is crude and the results incomplete mostly due to receptionists being unforthcoming, it speaks volumes of just how difficult it is to get accurate pricing information. And even

when you do, how is a consumer to work out relative values without outcome data. While these types of websites are fraught with all sorts of inconsistences, are they better than nothing? For example, while 18% of urology surgeons charged no out-of-pocket fees, data released by Medibank and the RACS showed NSW surgeons charged $7049 in out-of-pocket fees on average, compared to $4110 among Victorian surgeons, and $1579 in Tasmania. The RACS is said to be fully committed to full disclosure and fee transparency for patients after it released data in 2015, showing that a small number of surgeons were charging extremely high fees and it was recognised that “patients may feel compelled to accept the procedure and attendant cost in the understandable hope for cure or relief of suffering” One in five cancer patients say finances impact their treatment decision-making. With 27% of initial bladder cancer resections requiring re-operation within six months, and out-of-pocket expenses varying by about 400%, urologists may wish to explain things.

Making hospitals happy places We’re not sure that the horse hasn’t bolted on this one in WA given that we may not see a new hospital built here for quite some time, but it was interesting nonetheless to take part in a sustainable healthcare architecture webinar organised by the Green Building Council of Australia. It was led by US architect Gail Vittori whose firm has done a lot of work around integrating health into design decisions, with the Austin health complex in Texas a standout example. There is no dispute that environment affects health outcomes, so the greener and cleaner the environment it stands to reason that patient outcomes will improve. Gail goes as far as to suggest that hospitals will become ‘wellness centres’ but that may be an activated almond too far. Perhaps the most interesting take home point is that health campuses can participate at any level – from a visual and physical connection to nature, energy conservation, renewables and even their own food production. If something needs replacing, consider a green alternative. It makes sense. Another message is that health practitioners should be chief design consultants. They are the experts in understanding how environment affects function as well as health.

Kindness and hard work show Radiation oncologist Prof David Johnson met artist Alan Green in 2010 under not so-happy circumstances when Alan was referred for treatment at Sir Charles Gairdner Hospital. While time has passed and both men have moved on with their lives, Alan has created an indelible reminder of the link they shared. He’s painted David’s portrait, which has been named among the 40 finalists in the Black Swan Prize for Portraiture. David told Medical Forum that the process of ‘sitting’ for his portrait included several sessions with Alan, who took numerous photos. “I have yet to see the portrait in the flesh but I have seen pictures. My wife thinks I need a shave but Alan would come after a long clinic and that’s how I look!” he said. Alan said of David in his submission: “I was especially impressed at how generous he was with his time to explain everything in detail and with kindness, as he was aware of where I was heading.” Alan’s work and that of other finalists will be on display at the Art Gallery of WA from November 1 for a month and portraits will go on tour around the St John of God Hospitals at Murdoch, Midland and Subiaco in December.

8 | OCTOBER 2017

MEDICAL FORUM

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Complex care, simpler?

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Overtaking trial in WA Cyclists were the only road users to increase (by 8% per year) the number of seriously injured and hospitalised road accidents from 2007 to 2015. MVA occupants, pedestrians, and motorcyclists had no change in incidence over that time. Moreover, disability-adjusted life-years (DALYs) – years of life lost and years lived with disability – increased by 56% over that period for cyclists, whereas it declined for the other road users. Most of those injured were male (87%) and average age was 46 years. While this increase was partially put down to increased cycling participation rates, also mentioned were speed, road rage, and congestion. Wearing helmets and dedicated cycle paths reduce the incidence and severity of injury according to European and Australian research. In April, the new WA Labor Government announced a two-year trial of the 1m rule, which means motorists must leave a 1m clearance between their car and a cyclist when overtaking at 60km/h – faster than that,

the distance is 1.5m. NSW, Queensland, ACT, South Australia and Tasmania have all introduced safe passing laws. In the Netherlands, we understand, the onus of proof is on the motorist should cycle and motorcar collide. Health costs in Victoria alone from cyclist injuries were about $1.4b during the nine-year period of one study. But it may need more than legislation. With the number of road users of all types, cycling and motoring peak bodies are calling for education of the road rules and more tolerance. Stephen Moir from the Motor Trade Association said "My fear is that motorists won't comply. We need to take a much stronger approach to people who deliberately set out to harm another person on the road, whether on a bicycle or in a car." There are indications from those states with the 1m rule is it is having an impact on cyclist injury numbers.

ED staff need space

difficult trade-offs to accommodate their work and their need for occasional refuge from a stressful environment. The most notable finding is that the current trend to de-institutionalise the hospital environment (by creating more hotel-like spaces and fewer barriers) is not necessarily what ED staff want or need, which was a sense of control over when and how they interacted and communicated with patients. “Staff preference for more enclosed and protected spaces that communicate hierarchy and separation from patients suggest that EDs needed to find a balance between a clinical aesthetic for staff and a calming environment for patients,” the report found.

Speaking of doctors being consulted on design issues, another report has been launched from the Melbourne, Monash and Deakin universities looking at the design of EDs to minimise error as a result of miscommunication between staff.

Government funds went into a survey of ED staff to determine what spaces they needed to have safe, ethical and effective conversations with patients and colleagues.

Researchers found staff talked briefly and frequently in all areas of the ED – central workstations, dedicated rooms, transit areas, communal and patient spaces – and made

• Dr Gervase Chaney resigned as the commissioning Executive Director of the Perth Children’s Hospital and has been appointed Dean of the Notre Dame medical school. He starts his new role in midOctober.

• Professor Andrew Whitehouse, from the Telethon Kids Institute, has won the 2017 Eureka Prize for Emerging Leader in Science.

• Wembley Downs GP and co-lead of the Doctors Health Advisory Service, Dr David Oldham, is the WA finalist in the 2017 RACGP General Practitioner of the Year Award. Dr Sarah Newman is the 2017 RACGP WA Registrar of the Year and Dr Harinder Paul is the GP Supervisor of the Year. As reported earlier, Canning Vale Medical Centre is in the running for national General Practice of the Year.

• Brad Potter from The Health Linc celebrated 20 years in the industry by winning the Australian Institute of Business Brokers Broker of the Year. This is the sixth time he has won the award the in part seven years.

• Albany’s Regional Palliative Care Coordinator, Lesley Forrester, (pictured left with Amanda Bolleter) was awarded the Palliative Care Australia (PCA) Rural and Remote National Award for Excellence.

• St John of God Health Care Maternity Reference Group Coordinator Zoe Islip has won Catholic Health Australia’s Emerging Leader Award.

• Ms Glenys Beauchamp is the new Secretary of the Department of Health in Canberra.

BY THE NUMBERS: Musculoskeletal Conditions

44.6%

is the proportion of burden attributed to overweight and obesity for those with osteoarthritis (For those with gout, the proportion of burden attributed to weight was 38.5%.

Occupational exposures and hazards were risk factors for 17.2% of back pain)

• Musculoskeletal conditions were the fourth leading contributor to total burden of disease

• Back pain, osteoarthritis and rheumatoid arthritis made the great contribution of musculoskeletal burden • 39.5% of those with osteoarthritis (n=33,606) were classified as severe; 34% (n=27,586) of those with rheumatoid arthritis were severe; 41.2% (n=66,925) of those with ‘back pain and problems’ were severe • 66% of those with osteoarthritis were female; 64% of those with rheumatoid arthritis were female; 84% of those with gout were male • Accounting for population increase and ageing there was a 15% reduction in the total burden due to musculoskeletal conditions between 2003 and 2011, from 26 to 22 disability-adjusted life years (DALY) per 1000 people • There was no change in the DALY rate for osteoarthritis (3.5 per 1000 people) • Total burden for rheumatoid arthritis decreased from 4.4 to 3.5 DALY per 1000 MEDICAL FORUM

OCTOBER 2017 | 9

spotlight

Bobby Despotovski has taken his knowledge and skills as a player and is sharing it with the exciting women wearing the Glory purple.

It’s been a colourful career for W-League Perth Glory coach Bobby Despotovski. As a young, talented teenager in Yugoslavia it was a choice between handball or football.

Bobby decided on the latter and then the Army, with the looming horror of war in the Balkans, decided they wanted him.

“I played a lot of sport when I was young and it came down to a choice between two different codes, both of which are incredibly popular in Europe. I was playing handball on Saturday and football on Sunday.”

“I was on the brink of a professional career with Dinamo Pan Evo and then I found myself in a military uniform. As an Australian citizen [Bobby was born in Perth] it wasn’t compulsory for me to fight in the war but I’d grown up there, all my friends were going and soon I was heading in the same direction.

I had a change of heart and, after a couple of strategically self-inflicted injuries, I came home to Perth.”

It turned out to be a good move. Bobby represented Australia, played more than 200 games for Perth Glory and scored more than 100 goals.

“When I look back on my playing career I realise how lucky I was. The team was just emerging in the late 1990s and we had the good fortune to play under the incredibly popular and successful German coach, Bernd Stange.”

“We won three titles in the old National Soccer League and two championships in the current A-League so it was a great time to be at the club. When I moved into a coaching role, the experience of playing under Bernd was invaluable. He had such a positive rapport with the players and I use a lot of his strategies in the way I shape a team.”

“Nonetheless, it’s very much my own brand of football that I bring to Perth Glory. Some things I’ve borrowed from Bernd, but most of it is me and it has to be that way.”

Monitoring knee loading

Managing retirement

“And, with the women’s game becoming more popular, these issues are really important. If you want to see attractive, fast and skilful football you have to have the world’s best players at peak fitness.”

When the final whistle blows on a player’s career, particularly at the elite level, it can be difficult stepping away from the spotlight.

“I didn’t find that aspect too difficult. For a player who doesn’t have anything to fall back on it can be incredibly difficult. All the training with your teammates, the thrill and excitement of big games combined with lifting a trophy now and then is pretty seductive.”

“I’d planned well ahead and had a sports shop in the latter stages of my career. I also had a young family to look after, so the impetus was there.”

And, according to Bobby, the move into coaching in the W-League was pretty seamless, too.

“It really helped that Perth Glory had been involved in the women’s game for some time. It’s important to have the right blend of players at the club because the psychological dynamics are directly related to success on the pitch.”

“You might have some of the best players in the world, and we do with Sam Kerr, but if they aren’t a good ‘fit’ for the team there’s no place for them at Perth Glory.”

“There are some important differences between the women and the men when it comes to football at the elite level. We see this, in a physiological sense, with knee injuries. They’re more prevalent in the female players and, as a result, the incidence of ACL problems is much more pronounced.”

“We try to minimise that with strengthening exercises and monitoring knee loadings but it’s something we have to watch closely.”

“The national team [the Matildas] is a crucially important component in lifting the profile of the women’s game. There’s no doubt the code needs to attract more sponsorship and that requires more coverage on both television and radio.”

“We’re beginning to attract more top-level internationals and that’s vital because of the finite pool of players in Australia. There are 10 teams in the competition, which spreads the talent pool pretty thinly.”

The current coach of the Socceroos, Ange Postecoglou is under pressure due to poor World Cup performances. So, is that a future role for Bobby?

“I have no desire to manage a team at the international level. The pressure is intense and relentless with too much time away from home. I’ve got a wonderful job here at Perth Glory and I’m very happy.”

By Peter McClelland ED: The Westfield W League season kicks off on October 27 with Perth Glory playing Melbourne City at NiB Stadium.

Bobby Despotovski coaching the Perth Glory W side and, inset, Glory and Matilda's star Sam Kerr

10 | OCTOBER 2017

MEDICAL FORUM

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BOQS001647 V1 04/17 | 11 OCTOBER 2017

close-up

Seeing is Understanding Exposure to life in rural and remote regions of the state during medical school is making more students consider work outside big cities.

A trip to the Kimberley with Patches Paediatrics was an eyeopener for second-year medical student, Nic Mattock.

“One of the best things to come out of the trip was the realisation that my way of looking at life, as a young, white, privileged male, was pretty narrow. I’d never been more than 100km north of Perth, so everything I experienced in the Kimberley was completely new.”

“I had a ‘cookie-cutter’ perspective, that’s for sure.”

“We do get some teaching at university around these issues but it’s pretty difficult to deliver it in a completely effective manner. Until you get out into Aboriginal communities you can’t really understand what’s appropriate and what isn’t. The Kimberley is an incredible place and I got so much out of the placement.”

Nic doesn’t come from a family of doctors and an interest in science led him down the medico path.

Finding the right spot “I loved science as a subject at school and felt that medicine was an ideal expression of that because it’s a really good marriage of theory and practice. I’m absolutely convinced it’s the career for me and I’m looking forward to spending more time in a hospital environment. My first placement was in a renal dialysis ward and, sadly, there are a lot of Aboriginal people with kidney disease.”

“It’s much easier to understand something of what Aboriginal people are going through with the benefit of the Kimberley experience.”

“The Patches Paediatric model and working with Dr James Fitzpatrick was inspiring. To be able to offer almost the full gamut of services in such a remote environment is a wonderful thing. It’s a completely different way of working compared with a doctor’s surgery or hospital ward, particularly when you’re dealing with something like Foetal Alcohol Spectrum Disorder (FASD).”

“It’s a terrible condition, and even more so because it’s entirely preventable.”

“But one thing that the Patches clinic showed me is that young people with FASD are able, with the right treatment, to live happy and engaged lives. It’s absolutely vital that they’re not ostracised.”

Changing perspectives For a young medical student with relatively little prior rural exposure, a placement such as this can be career-defining, says Nic. “I’m not from the country and probably wouldn’t have considered rural medicine. But to see how a small amount of money can make such a big difference in the lives of these kids was an eye-opener. Just to

12 | OCTOBER 2017

Medical Student Nic Mattock, left, with Dr James Fitzpatrick and other members of Patches’ Kimberley team.

Below, Dr Fitzpatrick at work

have one more teacher’s assistant with appropriate skills changes the entire dynamics of a classroom.”

“It’s pretty intoxicating stuff for a medical student!”

“My own career choices tend to change month by month. I’m leaning a bit towards critical retrieval care, something like RFDS but the problem there is that it appeals to about 90% of my peers as well. It’s important that all students, whatever the discipline, have the opportunity to experience professional placements that are challenging and rewarding.”

“One thing for sure is that I won’t be seeking a career that involves too much number-crunching. I did some work on a FASD database with a couple of other students before going to the Kimberley and I have to say I prefer the interpretative, writing-up side a lot more!”

“The internship at the McCusker Centre for Citizenship at UWA made the Patches trip possible and it’s been really helpful. Its broader purpose is to provide funding to enable young people to develop their skills and engage with the wider community.”

“They normally go to applicants in law or business so it was nice to see medicine getting in on the act as well.”

By Peter McClelland ED: In March, first year medical students from the University of Notre Dame and second year medical students from Curtin University will participate in a four-day Wheatbelt immersion program. Around 160 medical students will be billeted with local families in seven Wheatbelt communities where they will get involved in local activities and visit local health facilities and emergency services. Students will see up close the benefits and challenges of rural medicine early in their studies and improve their understanding of the challenges faced by rural communities in accessing primary health care. The three-year program is a joint initiative of Curtin University, Rural Health West, WAPHA, Wheatbelt East Regional Organisation of Councils and University of Notre Dame.

MEDICAL FORUM

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FEATURE

Will this Review Succeed?

The Sustainable Health Review is not the first in the history of WA Health but it certainly needs to find some solutions to age-old problems.

In May, the Health Minister, Roger Cook, made good an election promise to hold a review into the sustainability of the health system in WA. He announced that Ms Robyn Kruk, a former Director General of Health in NSW, would be the independent chair of the Sustainable Health Review (SHR) which would be informed by both a clinical and a consumer reference group.

The infograph here shows with broad brush strokes and big numbers why the WA Government is eager to find efficiencies.

However, its Terms of Reference also paints a more subtle yet not less concerning picture of patient care if the SS Health continues to steer in the direction it is heading:

WA public health system has grown (last 10 years)

Population

29%

ED attendances

49%

Terms of Reference “While a number of major infrastructure projects and other changes have been initiated since 2004 (when the Reid Report was released), WA’s health system continues to experience unsustainable budget growth and faces challenges associated with an ageing population, chronic disease and health inequity.”

“Health expenditure has grown faster than inflation and the economy as a whole, accounting for 52% of overall government expenditure growth between 2013-14 and 2016-17. The WA health system is the largest single expenditure in the WA State Budget representing 30% of expenditure in 2016-17 compared to 24.9% in 2008-09.”

“The growth in the cost of healthcare has not been accompanied by an equivalent increase in services to the community. This growth is unsustainable, especially in a constrained budgetary environment.”

An interim report is expected to be handed to Cabinet in December with a final report due March 2018. So the clock is ticking and the SHR has got busy with a series of forums being held across the state (last month and throughout October) asking clinicians and the public for their views on how health sustainability can be achieved.

Perhaps as testament of how hungry clinicians are for reform, there was a flood of interested health professionals prepared to work on this major review. The clinical reference group is large – with 30 people from both hospital and community medicine with geriatrician Dr Hannah Seymour the chair.

Dr Hannah Seymour

Hannah, who is also Medical Director and Clinical Lead for Information Technology

14 | OCTOBER 2017

Hospital admissions

39%

Births (public)

36%

$7 billion infrastructure investment

Health costs continue to rise 20% Health spending has more than doubled in 10 years

WA public hospitals cost 20% more than national average

WA State debt

$3.8B $8.8B The system is under pressure 2.4M

Ageing population (50% more people over 65 in 10 years)

Growing population (3.2M in 10 years)

Chronic disease cost ($1B in 10 years)

Fewest GPs per capita of all States

Key to a sustainable future for health

Patient first

Value for money

Healthy lifestyles

at the Fiona Stanley Fremantle Hospitals Group, among other positions, told Medical Forum that the health review panel was overwhelmed by the high number of high quality clinicians wanting to be involved.

Listen to the clinicians “That is a really positive starting point. We wanted a broad mix of people with different skills and experience to get a range of viewpoints. We’re not expecting these people to give us all the clinical ideas, we expect the forums to come up with those, but we do we

Partnerships across sectors

Technology and innovation

want their clinical engagement and opinions on those ideas put forward,” she said.

“We don’t want to improve one area to find that the ‘solution’ makes another area worse and you need clinicians’ experience to avoid that from happening.”

“We had our first meeting recently and used the same framework we’re using in the forums; basically asking people what were continued on Page 16

MEDICAL FORUM

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MEDICAL FORUM

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Feature continued from Page 14

Will this Review Succeed? their burning issues. The clinicians in the room came up with the big issues.”

They included: • Becoming more preventative and less reactive • Addressing waste and inefficiency • Adjudicating the tension between quality of care closer to home v high-end quality in locations that need volume to deliver them properly • Accountability of leadership • Health literacy • ICT system design • Inter and intra-government efficiencies.

It’s a well-thumbed wish-list familiar to everyone who has worked at any level of the health system. So how hopeful is Hannah that the review is going to affect real change?

“I think by having clinicians involved and having the hard conversations with all the pros and cons on the table, we have the best chance possible to implement changes that we have struggled with in the past,” she said.

Not all slash and burn “And it’s not about cost-cutting – we don’t have a savings target. It is about doing things

better. However, it is legitimate to ask that if we invest in certain things, we add value to ensure we get the best return on investment for improved patient outcomes.”

patients and their own devices. I don’t know the answers to digital disruption but we do need to be aware where the next innovation is coming from and how we can work with it.”

Over the last several issues of the magazine, we have had mostly hospital-based doctors involved in surgery carry on a sometimes desperately frustrated dialogue about the waste of unused and single-use surgical consumables. The system response to those concerns was typically system-heavy quality and safety speak, which can restrict opportunity for common sense and flexibility.

Whichever focus the review takes, change will be at the heart of any meaningful implementation.

For Hannah, her holy grail is improvement in the pathways of care.

“As a consultant geriatrician, I’m passionate about early discharge and rehab in the community because people do better. We as a system can do better with those links between the community and the hospitals and be clearer about what hospitals do well and what can be done better elsewhere.”

Hannah sees digital innovation as critical not only to her own area of concern but for those in the scope of the entire review.

“Interestingly, I had medical students just yesterday ask me what advice I’d give them.

I suggested to them that whatever path they took they would need to be really good at change. We all have to be able to adapt and change and if we can do that in a positive way we will all be happier and more productive.”

“If you told me 20 years ago that I’d be using my mobile phone so extensively in clinical practice, I’d laugh at you. Mobile phones represent a massive change and yet we have all adapted to that, so the medical profession is capable of great change, in fact, it is imperative.”

By Jan Hallam

“Knowing where we are going with digital innovation is vital and it’s not all about big IT systems. We have to start working with

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feature back to contents

Cl Difficile: Worrying Life Cycle

Prof Tom Riley MAppEpid, PhD, FASM, FAAM, FRCPath, FFSc(RCPA)

Why is Prof Thomas Riley frustrated that his message of community spread of Clostridium difficile goes unheeded? Certainly, vested interests stand in his way.

We know that travellers can bring antibiotic resistant bugs to Australia from overseas, such as resistant commensal gut E coli, and injudicious use of antibiotics in the parent country, or here, might make things worse. But what if the bug has characteristics that allow some human behaviours to select it out to cause illness?

and yet we have big piles of pig, horse and cow manure, full of Cl difficile, which we are spreading on vegetables and lawns,” he said.

That’s where Professor of Public Health at Murdoch University and ECU scientist Prof Tom Riley and Clostridium difficile come in.

Although Tom’s first paper was in 1980, this bacteria has been around for a lot longer as an opportunist that inhabits humans. The Cl difficile spores are a unique problem because they are transmitted easily in the community and are hard to kill.

This story is different in one main respect – how Clostridium spores are spread.

Everyone is familiar with the wide use of broad spectrum antibiotics, creating selective pressure that encourages the transfer of genes from one bug to another, mainly in the human gut. In that way we get more resistant E coli, Klebsiella, Campylobacter, Staph aureus, Shigella etc. People can become carriers, get sick and are hospitalised where they prove a problem, and we read about how hospital doctors struggle to find the right antibiotic to fix them or their contacts.

When those weakened by something such as inflammatory bowel disease become infected the results can be catastrophic. It can bring hospitals to a standstill while everything is cleaned thoroughly, mainly to get rid of spores. If it happens to be a more resistant strain, such as ribotype 027 in North America, there is even more concern about spread.

“About 40 years ago we discovered that Cl difficile caused problems in hospitals. But the community prevalence of Cl difficile infection has increased dramatically, not primarily because antibiotics are more used in the community but because there is more Cl difficile multiplying in food-production animals,” Tom said.

Community full of spores

“Wherever their manure goes, the potential to spread Cl difficile increases. Calves and piglets all get colonised because farmers use ceftiofur. We published a paper this year –

“The bug is different, so the story is different.

We are talking about the spread of one bug

18 | OCTOBER 2017

most of the lawn in Perth is full of Cl difficile because much of the turf is grown on pig manure.”

“We have to stop putting antibiotics into production animals. Cl difficile is intrinsically resistant to cephalosporins so why approve it in production animals. It’s stupid.”

Some explanations Ceftiofur is a third generation cepaholosporin approved only for veterinary medicine. Cl difficile is not normally a gut commensal except in young babies, whether human, piglet or calf, and is eliminated by the time babies are weaned, which in production animals (if the mother’s milk does not contain broad spectrum antibiotic), is at about three weeks. We arbitrarily say human babies are weaned by the age of two.

Some strains of Cl difficile are associated with explosive diarrhoea and conditions such as pseudomembranous colitis in humans, and colitis X in horses, perhaps because these Cl difficile bugs produce an enterotoxin and their presence is favoured by the use of broad spectrum antibiotics.

“I wrote in the MJA in 2006 about the ribotype 027 strain in hospitals. I said then, ‘be warned it is coming to kill us all’ but it didn’t. We didn’t

MEDICAL FORUM

feature get the nasty 027 strain that was the scourge of Europe and North America because we don’t use fluoroquinolones [e.g. levofloxacin and moxifloxacin] as much as they do in North America. The 027 strain’s resistance to fluoroquinolones was driving its spread there and it didn’t establish here because there wasn’t that selective pressure.”

In the US, fluoroquinolone use extended to acute bacterial sinusitis, acute on chronic bronchitis and uncomplicated urinary tract infections.

Those antibiotics again “Having said that, if you look at the mechanisms that allowed that strain to establish, we have all those features in Australia with our macrolide use. It’s because we are in love with macrolides [e.g. azithromycin] in the community and Cl difficile does mutate to macrolide resistance fairly easily.”

Antibiotic resistance of Cl difficile is one thing.

The prevalence of Cl difficile in the community is another. Some of Tom’s observations have come from new technology (mainly the more specific identification of strains through genome sequencing), and the benefit of some recent hindsight.

“Typing of Cl difficile allows us to distinguish strains of bacteria with far greater accuracy.

So we are sequencing more Cl difficile and inadvertently finding cases where there is contamination from contact with the most common source, food.”

“The reason the numbers of Cl difficile in Australia didn’t increase as expected was because, worldwide, Cl difficile in humans had been driven by the US use of cephalosporins [ceftiofur] in production animals.” This happened some 10 years before Australia.

“Australia only started using cephalosporins as a veterinary medicine from about 2000 and today most use occurs off label. A farmer might think that one of his piglets – one of 3000 in a farrowing shed – has an enteropathic Ecoli causing diarrhoea, and that all the piglets might die, even though they have been vaccinated, so he gives every mother pig in the shed a jab of ceftiofur.”

Colonised at first gulp “Left alone, piglets get colonised by Cl difficile, depending on their birthing order which dictates the piglet that gets the biggest gulp of colostrum from the mother.

Colonisation is highest by Day 7 and usually gone by Day 14, with other bowel flora replacing it. That’s what happens with human babies too but weaning is not regimented as in pig farming.”

Although Tom says Australian hospitals are better with their infection control and cleaning than US hospitals, he is worried that the spread of Cl difficile in our community will lead to its greater introduction into hospitals.

He says part of the problem in bringing what is happening to people’s attention is that we do not attribute cases to community infection as we should. He puts community infection rates at about 50%, and says many infections are in fact reinfections rather relapses after treatment.

MEDICAL FORUM

Cl difficile is prevalent in the food chain.

“We don’t count hospital-identified cases very well e.g. ED presentations are classified as hospital [and other examples are below]. In WA, infections are coming from lawns, a little from eating contaminated vegetables, and contaminated households. In a pilot study we found that 10% of kitchens in Perth were affected.”

“If you look at patients with IBS, their rates of Cl difficile infection have skyrocketed over the last 5-10 years. These people are coming into contact with Cl difficile more often in the community, and they have an abnormal gut flora so they are more likely to get Cl difficile, which doubles the chances of dying on top of your ulcerative colitis.”

He has problems getting those that hold the purse strings interested in preventive measures. He thinks interest in his ideas is stronger in the UK, where they have about half the rate of Cl difficile infection, due in part to their funding requirements.

“The other problem group is the haematology or oncology groups being treated at home.

They are more susceptible because they are often on antibiotics and have a poor immune system. The problem with those patients is if they get Cl difficile it is called ‘hospital acquired’ because they are in and out of hospital all the time but most present to ED with diarrhoea and an animal bug.”

“There is a financial penalty if they get more than their allotted cases,” Tom said.

Anecdotal evidence overwhelming For example, when they studied the of Cl difficile in the community in 2011-2013 they found two October-December seasonal peaks.

“That was due to imported onions. We were in an El Nino weather pattern in the summer of 2011-12, and the Australian onion crop in the eastern states failed because of drought, so we imported onions from California that were contaminated with Cl difficile. The epidemiological evidence was irrefutable.

The situation is in reverse now, so the problem has gone away.”

“We only import about 4% of our food in Australia, so we have a good handle on where it comes from. That’s why it was relatively easy to investigate,” he explained.

“There are case reports of two patients, a child and an elderly man, both infected with Cl difficile that came from an identical animal source. Because the patients lived in different locations the only way that could have happened was from a common source, I suspect salami or a poor quality meat where food preparation had not killed the spores.”

“Most of the Cl difficile infections are coming from the community. We need to educate GPs more about this and I don’t think there is enough testing of diarrhoea patients.

However, the guidelines say don’t test unless there is blood in the stool and they have had diarrhoea for three weeks. Generally, Cl difficile infections in the community are not as bad because people are inherently more healthy.”

By Dr Rob McEvoy OCTOBER 2017 | 19

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20 | SEPTEMBER 2017

MEDICAL FORUM

news & views

Autism Guideline Clears a Path National consistency in autism diagnosis is a step closer with the release of a draft guideline which will help individuals and families navigate the system.

The long-awaited guideline for autism diagnosis was released in draft form last month by the Cooperative Research Centre for Living with Autism (Autism CRC) after a 12-month consultation process.

Autism CRC’s chief research officer (and head of Telethon Kids autism research team) Prof Andrew Whitehouse said the guideline had been developed in partnership with the National Disability Insurance Agency (NDIA) after numerous requests over many years from the community for national and consistent diagnostic practices.

“Informed diagnosis is an important step to help families identify the nature and impact of autism on a person’s life, and importantly then identify the most appropriate types of supports best placed to assist – such as the education and health systems, and the National Disability Insurance Scheme (NDIS),” Andrew said.

Telethon Kids’ Dr Kiah Evans, who was coordinator for Autism CRC’s national guideline project, explained what the proposed guidelines would mean to medical practitioners.

“We anticipate that many referrers will come from a medical or allied health background.

In particular, primary health clinicians are well positioned to observe developmental differences and suggest a timely referral for an autism assessment,” she said.

“Medical and allied health professionals may be invited to conduct discipline-specific assessments to contribute to the autism assessment. A range of suitable professional disciplines include (but not limited to) dietetic, general practice, indigenous community health, nursing, occupational therapy, paediatrics, physiotherapy, psychiatry, psychology, social work, and speech pathology.”

The guideline recommends that assessors (diagnosticians or functional and support needs assessors) belong to specific professional disciplines and have specific expertise relevant to autism assessments such as paediatricians, psychiatrists, registered psychologists, speech pathologists, occupational therapists, and neurologists.

Kiah said when the final guideline was published in the new year, some education activities would be launched.

and allied health professionals about the autism diagnostic process through the WA Autism Diagnosticians Forum (WAADF).”

“We anticipate that integrating the guideline into the HealthPathways web portal would support GPs and other primary care clinicians to identify the need for an autism assessment and activate a referral.”

Kiah said GPs were expected to play a significant role in referring individuals for autism assessments (as a referrer) and providing assessors with information and impressions to contribute to the assessment outcomes (as a professional informant) “It is anticipated that the autism assessment report will be a valuable resource for GPs with their ongoing management of the individual, as it will contain detailed information of the core autism symptoms, co-occurring conditions, personal/environmental resources and recommended directions for support provision.,” she said.

ED: The comment period closes on October 19.

To participate go to www.autismcrc.com.au/ guideline-consultation

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MEDICAL FORUM

SEPTEMBER 2017 | 21

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United People of Adventure They didn’t hand out the keys to just anyone but if you love life on two-wheels as urologist Dr Rob Davies does, it was the trip of a lifetime!

A dozen people on motorbikes, the heat, rain and mud of north-eastern Madagascar and throw in a few million mosquitoes.

German motorcycle accessories company, Touratech, pulled the project together and, in April 2016, Dr Rob Davies went along for the ride.

“The selection process was surreal. A dozen of us from six different continents were flown to Touratech headquarters in Germany’s Black Forest. Our only instructions were to take carry-on luggage and that we’d be met at Frankfurt airport.”

“Over the next three days they sprung all sorts of surprises on us. We were interviewed on camera, scrutinised on team-building exercises and cooked group meals in one long psychological assessment. They gave us helmets and full riding suits, boots and a bag full of motorcycle gear. Then it was off to a motocross track to display our riding skills on large adventure bikes.”

“End result? One broken ankle, not mine!”

Injury fallout “The most serious injury was a broken fibula that ended the trip for the African rider, Omar Mansour. A rider from India ruptured his ACL but struggled on. Most of the medical issues were more mundane such as gastroenteritis, scrapes and sprains and immersion foot syndrome because our boots were constantly wet.”

“I was ably assisted by an occupational physician from Iceland and a trauma nurse from Australia. It all adds to the drama of the film.”

Rob’s pitch to the selection panel was unusual, to say the least.

22 | OCTOBER 2017

“My video application included footage of me extracting a loose tooth from our daughter, Annabella, using dental floss attached to my BMW 1200 GSA motorbike. It got me noticed!”

“Every person they picked was adventurous, adaptable and loved motorcycles. I’d have to say that I was probably selected as the trip doctor and photographer. We also had the Touratech CEO and his wife, a UK motorcycle journalist, a Hollywood actor and a documentary filmmaking team on the trip. And a small team of Malagasy riders on sensible, lightweight bikes.”

The documentary film, United People of Adventure (UPOA), is riveting stuff, stunning scenery and some wonderfully human moments where too much mud is never enough!

Adventure and good causes “We were based initially in the town of Antalaha and spent some time at the local orphanage where we distributed new mattresses to the children. Some of the proceeds from a book of the trip and the film flow back to the orphanage [see next page].”

“We were three days south of Antalaha as Cyclone Fantala bore down on the town, so it was pretty wet and muddy. And, sadly, the same area was hit by another cyclone earlier this year leaving half the population homeless.”

“A lot of close friendships were forged on the trip and that really was the highlight for me. The only way to get through the mud, the swollen rivers and dropped bikes was

Dr Rob Davies on a trip of a lifetime in Madagascar.

teamwork. You couldn’t have managed it on your own.”

Rob, who has recently returned from climbing in the Dolomites, seems to possess a twist or two of the ‘thrill-seeker’ gene. So, are his surgeon hands insured?

“I did worry about injury on the trip, both to myself and others. We were riding fully loaded, powerful 250kg bikes in challenging, off-road conditions in an isolated and developing country. What could possibly go wrong?”

MEDICAL FORUM

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Clockwise from top left: taking time out at the Antahala Orphanage: resting weary bodies: and serious bike action.

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“It’s true, I do seem to be pushing the limits more as I get older but it’s really all about managing risk. I reckon you’re a long time dead!”

“I asked my wife, Jenny, about all this. She said she didn’t mind as long as she can keep going to her art classes.”

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“One thing I do have increasing respect for is the practice of surgery.

Maybe that’s a reflection of the fact that I’ve been around long enough to see more ways that things can go wrong. The decision-making that goes into preliminary investigation and whether a patient will benefit from surgery can be stressful.”

“Again, it’s all about risk management. You have to weigh up comorbidities and surgical risk versus the natural history of the disease and the expected benefits of operating.”

One year after the ride, Rob shared in the glory, and a smaller amount of fame.

“They flew us all back to Germany for the release of the film. Thousands of people turned up and it was truly bizarre to be recognised by people who’d followed us online. Some asked for autographs and ‘groupselfies’, so I guess that was our 15 minutes of fame!”

“Jenny painted portraits of Touratech’s CEO and his wife in Touratech colours as a way of saying ‘thank you’. Everyone involved had been incredibly generous.”

Rob was brief and succinct when asked to reflect on the two-wheeled adventure.

“When can I sign up for the next one?”

By Peter McClelland ED: A special screening of United People of Adventure will be held at the Conference Centre Auditorium at St John of God Subiaco Hospital on Friday November 3 at 6pm. Funds raised go to the orphanage Orphelinat D’Antalaha and the town of Antalaha devastated by cyclone Fantala.

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MEDICAL FORUM

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news & views

ReachOut a hand for parents GPs are often among the first to know if a parent is going through a tough time with their teenager. It wouldn’t be ‘breaking news’ for any GP to hear that this generation of parents face some pretty serious challenges involving interactive technology, social media, bullying, drugs and alcohol.

And the fact that some form of mental illness impacts on one-in-four young people is alarming. Parents are working longer hours, and that can make it even harder to access support services and in some rural and

regional areas, this sort of support may not even exist.

The free ReachOut Parents Coaching program has just been launched providing individually tailored and confidential parenting advice. Its CEO, Jono Nicholas, said ReachOut delivered a mix of online and pre-booked telephone sessions, which gave parents the flexibility to access support from anywhere in the country.

“A GP with a patient who’s concerned about any aspect of parenting can suggest this service, no matter what the postcode. It

provides access to up to four phone sessions with a professional parenting coach as well as a range of digital resources,” he said.

“The phone sessions are delivered by social workers, psychologists and other health professionals from The Benevolent Society, an independent, non-religious, non-profit organisation that aims to help vulnerable people participate more fully in society. There’s a focus on building strong relationships and practical strategies that can be implemented from the initial call onwards,” www.reachout.com

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colliers.com.au/10163 24 | OCTOBER 2017

MEDICAL FORUM

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Research Where Needed Most The time is right for a considered approach to investing in research funding, suggests Terry Slevin from Cancer Council WA. It’s no surprise that cancer research is always in the news but the first-half of this year has seen something of a watershed.

A recent Senate inquiry, chaired by brain cancer survivor Senator Catryna Bilyk, focused on poor outcomes linked with this particular disease and the need for improved research. Cancer Council Australia CEO Prof Sanchia Aranda reinforced this message by asserting it was timely to focus on prioritising biomedical research and to make better use of existing technologies.

She said: “Much of the inquiry will focus, as it should, on laboratory research and discovery but we must not lose sight of lost opportunities within our current health system to reduce stark survival inequities between cancer types.”

This reality was highlighted by a recent WA Cancer Registry report on local cancer survival data, which reveals steady progress with a five-year relative survival for all cancers increasing from 52% in 1985-89 to 70% in 2010-2014. Survival (five-years) for people with melanoma, breast and prostate cancer

It's...crucial that we give serious thought to the most effective and efficient way to use...funds. exceeds 90%. But clearly, there are clear winners and losers.

The most common low-survival cancer is lung cancer with cancers of the pancreas, liver and brain not far behind. This is the sort of data that should be driving future research investment.

Research is underway in WA in some of these areas but the local research engagement – while critically important – is only a relatively modest component of the national and international research effort. Attracting sufficient funding for research has long been a major barrier but perhaps this tide might be turning.

The WA Future Health Research Innovation Fund was an election promise of the new State government. Budget woes

notwithstanding, we’re looking at a fund that should generate $35m a year to invest in medical research. A focus on cancer should utilise a sizable proportion of that investment.

There is also the generosity of philanthropist Andrew Forrest and his significant, one-off boost of $75m to cancer research.

The Cancer Research Trust, announced in early July, will see $13.5m committed to two cancer research programs in WA. And that’s timely because the amount of national research funding flowing to WA from the NHMRC has been steadily dwindling.

The new Medical Research Future Fund and Cancer Council WA continue to invest in research. The latter currently commits about $4m a year.

There’s no doubt that a boost in funding is a good thing. But it’s equally crucial that we give serious thought to the most effective and efficient way to use these funds. The real priority is to ensure that investment in cancer research generates real and tangible benefits to the people who need it most.

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guest column

The effective transfer of acquired learning is more complex than it looks, suggests Curtin University’s Dr Simon Rosalie.

The ability to adapt and transfer prior learning to new tasks is one of the oldest areas of learning research. In the early20th century, focus was on Identical Elements Theory (IET), which suggested that a ‘positive transfer’ of skills was more likely to occur when two tasks shared some identical elements.

But, predictably, there was a problem. The theory failed to define either what constituted an ‘element’ or its level of ‘identicality’ and that made falsifiability rather problematic.

Nonetheless, the influence of IET on modern medical education can’t be understated. A good example is the increasing use of highfidelity simulators but it’s a little more complex than it first appears.

It’s generally assumed that skills acquired on simulators readily transfer to actual patients because the simulation closely approximates real life. High-fidelity simulators focus on optimising contextual authenticity but is that the prime determinant of an ability to transfer those skills? Is the trainee merely a ‘passenger’ in the process?

Does the breadth and depth of their prior

If the Digital Age has taught us anything it is that the tasks of tomorrow will be very different from those of today. learning influence their ability to transfer skills?

The application of General Principle Theory to medical education is linked with the idea that a learning task does not necessarily need to occur in a completely authentic context. There is a much stronger imperative on functional, goal-directed knowledge and behaviours across the broad spectrum of learning tasks. It’s also generally accepted that when dealing with macro-changes, such as operating in different hospital environments, traditional theories of ‘skill transfer’ fail to fully encompass some of the finer details.

In other words, these theories struggle in their useful application to micro-changes such as day-to-day tasks across a range of patients with widely different needs.

Sir William Osler, a Canadian physician and a co-founding professor of the Johns Hopkins Hospital, put it well: ‘Variability is the law of life. And as no two faces are the same, so no two bodies are alike. No two individuals behave alike under the abnormal conditions that we know as disease.’

The transfer of learned skills between patients, and adapting treatment to suit, is critical for every medical practitioner.

But one of the ironies of any training program is that it applies today’s knowledge and practices to the requirements of tomorrow.

If the Digital Age has taught us anything it is that the tasks of tomorrow will be very different from those of today.

Perhaps learning to anticipate change, and how to adapt to it, is the key and exposing trainees to as many practice experiences in as many different contexts as feasibly possible.

It’s important to ‘learn’, obviously. But it’s equally important to be able to ‘transfer’ that learning.

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Learning for Today and Tomorrow

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Cannabis and Epilepsy – Why Not? Joelle Neville tells a highly personal story of her battle to ensure medicinal cannabis is made more easily available.

Never in my wildest dreams would I have imagined that I’d be writing for a medical magazine about cannabis. But when our daughter, Ava, was diagnosed with Tuberous Sclerosis in 2005 after suffering infantile spasms since birth, my life went in many different directions.

Our journey began when we were told that she may never walk or talk, and that she may also be profoundly disabled. We were determined to prove that prediction wrong.

Nine long years of seizures, sleepless nights, medical appointments, pharmaceutical trials and surgery culminated in one last experiment. We’d tried everything to control Ava’s epilepsy and the final option seemed to point in the direction of medicinal cannabis.

My husband and I talked about which of us would go to jail if we were ‘sprung’ as we nervously awaited our first shipment to clear customs. It was something of an anticlimax when the postman dumped a parcel on our front doorstep.

We tried a small amount the same night, just to be sure we weren’t sending our daughter off into ‘psychosis’ land. It tasted pretty horrible and had no effect whatsoever.

This is a fight on two distinct fronts: one of education, doctors specifically, and the other a battle against endless bureaucracy.

We started Ava on a tiny amount the next morning and slowly built up to about 40mg of CBD a day. After 10 days the seizures stopped.

We were amazed because she’d been having about eight seizures a day, despite being on four anti-epilepsy medications. When she started sleeping through the night, our lives were utterly transformed.

attached to medicinal cannabis. I can’t tell you how many times a week I’m asked if my daughter gets ‘high’ on it. My answer is always the same, she is far less ‘stoned’ now than she was when we were shoving massive amounts of medication down her throat.

In fact, her general wellbeing and social interaction have vastly improved and she has been able to experience the normal childhood of a 12-year-old girl.

Now we’re fighting a different fight. We’re trying to obtain Ava’s medicial cannabis on prescription and, hopefully, have it subsidised.

It currently costs us about $10,000 a year.

This is a fight on two distinct fronts: one of education, doctors specifically, and the other a battle against the endless bureaucracy surrounding this issue.

We weaned Ava off three medications and settled on a dose of about 60mg CBD a day.

The actual product was the raw extract of a whole plant, low in THC and laboratory tested to ensure quality and consistency across different batches.

If I could leave readers with one message, it would be to consider the ethical implications of having a drug that could help patients suffering from a number of different conditions and electing not to use it. Surely no one is ignorant of the international and clinical evidence that supports the use of this substance?

For the past three years we have battled, both privately and publicly, against the stigma

A true understanding of cannabinoids is absolutely vital for everyone.

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MEDICAL FORUM

OCTOBER 2017 | 27

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Keeping Players in the Game The good news is more people are exercising but with it come injuries. We ask sports physicians how they are treating both the elite and the weekend warriors.

Sports physician and Eagles medico Dr Gerard Taylor suggests that there have been some positive changes in the area of sporting injuries, but that the real gains are being seen in the treatment of degenerative conditions.

Medical Forum caught up with Gerard while he waited in a hotel room in Adelaide for the elimination final against Port Adelaide. Yes, that Luke Shuey goal!

“I’d have to say that not much has changed in the area of ankles and knees, things like ligament tears, meniscal injuries and shoulder dislocations caused by contact sports.”

“There’s no doubt whatsoever that age is a factor. Kids are pretty rubbery and not particularly heavily framed up to the age of 13 or 14 so we don’t see a lot of trauma up to that point. But once they get a bit older they start hitting each other a lot harder and that’s when we start getting problems.”

“As far as treatments go, it’s pretty much the same. The standard ‘rest, ice, compress, elevate’ still does the job. Cam Walkers and Splints are used a lot more now, and that means we’re using plaster a lot less.

The combination of hand clinics and occupational therapists is making life much easier for all of us.”

Queues for surgery “One aspect that hasn’t changed is that professional sportspeople are highly likely to see the bright lights of an operating theatre, and probably more than once!”

“We have one Eagles player who has just notched up 30 operations and it is becoming pretty standard end-of-season practice that we’ll have 10 players out of a squad of 40 lined up to see a surgeon. Some players are definitely more injury prone and we also have meniscal problems requiring multiple operations.”

Gerard thinks the standard of orthopaedic surgery in Perth is particularly high and he has a comment or two regarding the increasingly common practice of spending money on return tickets to America.

there’s plenty of good news.

“We do see a lot of ageing warriors and one of the big challenges with them is tendon disease. It’s got poor healing capacity and it’s a bad condition Dr Gerard Taylor to have because it can be quite disabling. One approach that seems to be working well is Eccentric Exercise, and particularly so for strengthening the Achilles tendon.”

[Eccentric Resistance Exercise is muscle contractions involving the shortening and lengthening while the muscle is still producing force. The phase of contraction that occurs when the muscle shortens is concentric, whereas the phase of contraction that occurs as the muscle lengthens is eccentric.]

“We’re also getting good anecdotal reports on PRP [Platelet Rich Plasma] injections for partial tendon tears in the elbow and proximal patellar tendon tendinopathy.

The early results are positive.”

Gerard has a few more sharp points to make.

“We’ve seen good outcomes with Hyaluronic Acid and Durolane. They’re not cures admittedly, but we’re getting positive temporary improvements that would otherwise see people heading for joint replacement surgery. Ultrasound is another area showing a great deal of promise. We now use radiologists to deliver PRP in a highly targeted way, which is proving to be useful with hamstring tendons.”

“Hopefully, we’ll begin to get some good literature to back all this up and then we can go back to the government and get some Medicare funding!”

By Peter McClelland See P31 for more physicians' views.

“The West Coast Eagles are very well resourced so they’re happy to seek out the best treatment anywhere in the world. Bill Knowles is a physiotherapist in Philadelphia and he’s got an excellent reputation among elite athletes in the US system. Nic Naitanui’s much publicised treatment was very much in the final proprioceptive rehabilitation stage.

The club sent a physio over with Nic and he’s come back with some useful tips.”

Good news for tendons When it comes to the area of degenerative damage – not strictly ‘trauma’, as Gerard freely acknowledges –

MEDICAL FORUM

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30 | OCTOBER 2017

MEDICAL FORUM

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Treating Trends for Sport Injuries Medical Forum asked sports physicians for there views on treatment trends in their specialties.

Dr Peter Steele: For me, knees, shoulders and back pain are most common. I am seeing a number of teenagers with overload injuries because they are playing club, school and sometimes representative teams. No one monitors the overall load. And active older people are coming in with injuries, which is a good thing in a way – at least they are still being active Improved technology allows more specific diagnosis in most cases and being able to direct appropriate management quicker.

However, I think people in general are becoming happier to give conservative treatment a try before surgery.

Dr Peter Steele

In regards to joint replacement and revision, I’m not directly involved but I try to flag to patients with degenerative change the possibility of joint replacement in the future and then balance the load and their expectations to get the most out of the joint as long as possible.

In terms of elite sportsmen heading to the US for treatment, the size of their population and the number of elite sportspeople and programs would suggest they have dealt with difficult cases more often and have experience we do not. If athletes or clubs are happy to fund it then it is up to them, and they may well bring back new information.

Dr Arjun Rao: For me, overuse injuries especially soft tissue (tendon) and joint (arthropathy) are common and age is a factor.

In terms of new treatments, I have found biological therapy to be extremely beneficial.

Dr Arjun Rao

Regarding pressure to refer for surgery, in certain instances eg ACL injury there is, even though the Frobell study demonstrates that the recreational athlete can respond well to conservative management.

I am seeing an increasing number of joint revisions – it goes with the territory of an ageing population. I’m seeing increased frequency due to accelerated/Grade iV OA in a younger population.

Joint replacement still remains end-stage management. Even in the knee, 80% are satisfied with the result.

Regarding elite sportsman going to the US, I think a lot of it is down to slick marketing and the US does it better than most.

The technology is no different and in some instances inferior eg; treatment of chronic recalcitrant tendinopathy by autologous tenocytes – that’s available here but not in the US.

MEDICAL FORUM

OCTOBER 2017 | 31

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MEDICAL FORUM

news & views

Exercise physiologist Marianne Garvey who works with cancer patients.

Key Message? Keep Moving!

Exercise is the go-to treatment adjunct for a range of conditions.

Clinical research is firmly backing the benefits of exercise in a number of contexts, both physiologically and psychologically. It’s important to keep moving and the endorphins are an added bonus.

ones, who remain a little sceptical and some have actually refused permission for the patient to participate in the program. I guess they have a vision of a challenging gym environment with lots of shiny machines, but it’s not like that at all.”

Medical Forum spoke with several practitioners and academics about their work in the area.

“We have an individually tailored program underpinned by a thorough clinical assessment from a medical specialist. We have to remember that some of the people who walk in the door have never seen the inside of a gym in their entire lives. And, of course, all this can be pretty overwhelming for anyone dealing with a cancer diagnosis and that needs to be taken into account.”

Exercise physiologist Marianne Garvey is working with cancer patients to keep their muscles and spirits toned.

“There’s no doubt that a well-supervised exercise program can result in real benefits for cancer patients. We’ve done pilot trials on pancreatic, head and neck cancers and an extensive cancer survivor study that confirms just that,” she said.

“And we’ve seen positive spin-offs such as reduced fatigue and a lessening impact relating to treatment toxicity. I had one interesting comment from a radiologist who said she could usually tell the patients who were on the exercise program. They were then ones who were invariably positive throughout their treatment.”

“We do have patients who come in here and, initially, can barely get out of their chair. And, sadly, there are some who can’t continue with the program due to the progression of their disease. Nonetheless, we have many people who are so excited about the exercise program that we have to wait for their blood pressure to settle down before they can get onto the machines.”

Some doctors uncertain Most doctors are highly supportive but some have reservations, says Marianne, who works at GenesisCare’s Wembley clinic.

“There are a few GPs, particularly the older MEDICAL FORUM

Is there an emotional impact on health professionals working with cancer patients?

“There are some cases that are quite upsetting. I had one couple, a man and his wife, who had both been diagnosed with cancer and their children were about the same age as mine. It was all a bit close to home and I did get a bit teary after they’d gone.”

“But most of the time the exercise clinic is a pretty happy, upbeat place with plenty of banter and repartee. I had one patient, a retired doctor, who loved life and a glass or two of red wine and he embraced the program with gusto.”

“It’s so important to keep moving, particularly after a diagnosis such as this. And when it comes to fall prevention it’s all about glutes, glutes, glutes!”

Medical Forum also spoke with researchers Dr Rob Stanton and Dr Amanda Rebar, from Central Queensland University, Rockhampton. Their team’s focus is on the application of more finely tailored exercise programs for mental health disorders such as anxiety and depression.

Dr Rob Stanton

Finding the limits “The benefit of aerobic exercise is well established, there’s a lot to be said for raising the heart rate and generating pleasurable responses linked with the production of endorphins. Nonetheless, it’s well acknowledged that if you raise the intensity of the program beyond a certain point some people will inevitably feel worse,” he said.

“And, when you’re dealing with comorbidity such as anxiety and depression, it becomes quite complex if you’re trying to develop a program that takes into account the full suite of symptoms.”

“We need to understand this comorbidity to ensure that we respond in the best way to people suffering from linked disorders. We’re not trying to replace other therapies, just work alongside them to best help these patients.”

As Rob suggests, it’s absolutely crucial that the ‘consumer’ is an integral part of the process.

“One of the keys to success is to make sure that patients are involved in the design, implementation and evaluation of these programs. People’s symptoms can vary significantly from week to week, particularly with anxiety and depression.”

“We need to listen to them closely to ascertain just what makes them feel better.”

By Peter McClelland OCTOBER 2017 | 33

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Fertility, Gynaecology and Endometriosis Treatment Clinic 34 | OCTOBER 2017

MEDICAL FORUM

Practice Management

Financial Imperatives to Keep Data Safe

ORT HO C O M P WA

By Mr Jerome Chiew www.critical-it.com.au

In my previous article on the new data breach legislation (September), while the case regarding the Australian Red Cross Blood Service didn’t result in penalties, it would be prudent to note that the Australian Information Commissioner has the power to impose fines of up to $1.7m on top of remediation, compensation and identity/credit monitoring for affected individuals.

This can quickly add up to a lot of money and become a significant financial burden on your business.

It is highly recommended you review the guidelines on the OAIC website (www.oaic.gov.au/agencies-and-organisations/guides/) and develop an information-handling policy and a data breach response plan.

Also analyse the security aspects around the physical and electronic information in your business so you can map the flow of information and consequently identify areas that could be improved.

Some examples of considerations regarding the security of physical information include: • Ensuring that referral letters are not placed in public areas or open to prying eyes; leaving pathology results lying on the reception desk for anyone to see.

• Ensuring the physical destruction and disposal of sensitive documents is reasonably complete. Shredders differ in standard and performance. Strips of paper can be trivially reassembled, so invest in a good shredder.

• If using a secure document disposal service, check the provider’s current accreditations/certifications.

• Ensure all physical patient files/folders are stored securely.

• Physical access may need to be restricted to areas where sensitive documents are stored or processed.

• The transfer of documents to third parties should be done securely; consider a service with verified delivery only to the intended recipient.

Some examples of considerations regarding the security of electronic information include: • Using a secure messaging service such as Healthlink to send referrals and documents; email is not a secure method of transmission.

• Ensure that appropriate system permissions are set for each user so they have just the right level of security to perform their jobs efficiently, but not too much as to allow them to potentially gain access to restricted data.

• Using removable media such USB flash drives to store and transfer data to third parties may not be secure; flash drives may need to be securely wiped after each use or always encrypted. Also consider the potential for loss or theft of the flash drives.

• Removable back-up storage media should only contain encrypted data, mitigating any potential data breaches due to loss or theft of the media.

• When providing third parties with sensitive information, ensure they are aware of their obligations under the Privacy Act and Data Breach Legislation and verify the secure destruction and disposal of data once it is no longer require or their engagement has ended.

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CLINICAL OPINION back to contents

Too many knee arthroscopies?

By Dr Sandra Mejak Sport and Exercise Physician, Karrinyup

I was a member of the Australian Commission on Safety and Quality in Healthcare’s recent Knee Expert Advisory Group, looking at knee arthroscopy and OA. The group included members from orthopaedics, rheumatology, sports medicine, radiology, general practice, nursing, physiotherapy, and consumer representatives.

Over a year we examined the research regarding arthroscopies, other interventions for knee OA, lead body position statements and more.

Knee arthroscopies are commonly performed in Australia for knee pain in older patients. Most patients have degenerative knee disease (i.e. osteoarthritis). High quality RCT data has been emerging for many years suggesting that knee arthroscopies are no better than placebo in improving function and pain beyond six months.

It has been shown that knee arthroscopies are no better than placebo for: 1. OA, 2. OA with degenerative (the vast proportion of) meniscal tears, 3. Degenerative meniscal tears without OA, and more recently, 4. OA and meniscal tears with mechanical symptoms.

This fourth point was first examined just last year and came as quite a surprise, challenging the assumption that mechanical symptoms was a ‘no brainer’ indication for referral for arthroscopy, as catching or locking was believed to result from a mechanical blocking mechanism in the knee.

Trial evidence Looking at mechanical symptoms, Sihvonen (2016) and his Osteoarthritis Research Society International (OARSI) colleagues studied patients from one public hospital referral centre during 2007-2011 with nontraumatic onset of symptoms and having OA and a meniscal tear. 328 of 932 patients had mechanical symptoms pre-surgery. Mechanical symptoms were assessed using the self-reported Lysholm knee score: (1) no locking or catching, (2) catching sensations but no locking, (3) occasional locking, (4) frequent locking, or (5) locked at present. Those reporting no mechanical symptoms (response 1) were compared to those reporting mechanical symptoms (scores 2-5).

The proportion of patients satisfied with their knee 12 months after arthroscopy was significantly lower among those with preoperative mechanical symptoms (61%) than among those without (75%), and similarly improvement was also lower in the mechanical group.

There was no difference found in quality of life or pain. Of those with preoperative mechanical symptoms, 47% reported persistent symptoms at 12 months postoperatively.

So does anyone with a degenerative knee benefit from arthroscopy?

Maybe a smaller subset of more significant mechanical symptoms? Well, perhaps, but there has been no research studying only locking or severe catching, or some other subset of mechanical symptoms. And if there are indeed some patients who benefit from arthroscopic debridement, we have no way of knowing preoperatively who they are.

Therefore, don’t think of arthroscopy as first line management, and imaging is mostly not required.

So what instead?

There is good evidence for the efficacy of weight loss, aerobic exercise, strength exercises, and adjuncts such as NSAIDs, appropriate analgesics, cortisone injections for short term relief and hyaluronic acid injection for medium term relief. Knee replacement surgery is indicated when conservative measures fail. Patient-centred individualised care should be offered, acknowledging that comorbidities are often present.

Author competing interests: No relevant disclosures. Questions?

Contact the author on activesportsmedicine@gmail.com

MEDICAL FORUM

CLINICAL UPDATE

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

by Medical Director Prof John Yovich

ESHRE Conference Highlights 2017 … presented in Geneva, home to the WHO The two most advanced ideas in Reproductive Medicine were delivered in keynote presentations at the European Society of Human Reproduction and Embryology, now the most respected international forum: Carlos Simon (Valencia, Spain) described autologous cell therapy with CD133+ bone marrow-derived stem cells for refractory Asherman’s syndrome. This condition, relatively rare in my training days, has become increasingly common with intra-uterine adhesions and endometrial atrophy resulting in menstrual disorders along with infertility. The background is usually of repeated, possibly “over-zealous” D&C procedures and associated inflammatory conditions.

Hysteroscopic surgery can enable lysis of intra-uterine adhesions in some cases but persistent endometrial atrophy prevails in the majority. In the Valencia pilot study, CD133+ stem cells were isolated through peripheral blood apheresis with around 200 million cells injected into the uterine spiral arteries via femoral artery catheterisation.

All 11 cases Monument outside the WHO HQ in Geneva, showed improved dedicated to the Smallpox Eradication uterine cavity Program through vaccinations 1966-1980. and endometrial thickness at two months follow-up; three patients conceived spontaneously; and 7 achieved pregnancy by IVF and embryo transfer procedures. This novel autologous stem-cell therapy is a promising option with ethical challenges before consideration in Australia.

Denis Lo (Chinese University, Hong Kong), who introduced the world to non-invasive prenatal testing (NIPT), has been exploring the limits of this technology by sequencing the plasma of pregnant women to 270X haploid genome coverage. By using such a depth of sequencing and a custom-built bio-informatics pipeline, he has been able to detect fetal de-novo mutations on a genome wide level to a sensitivity of 85% and a positive predictive value of 74%. He also discovered “preferred DNA ends” to determine if the sample is of fetal vs maternal origin (without relying on the current DNA polymorphisms). Such second-generation fetal genomics from maternal blood enables a very exciting diagnostic future.

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OCTOBER 2017 | 37

CLINICAL UPDATE

Paediatric elbow injuries are relatively common and amongst the most challenging and difficult injuries to treat.

Prompt recognition and appropriate first aid management is essential which requires accurate clinical assessment and interpretation of plain films and where needed, paediatric orthopaedic referral.

No-one wants later deformity from childhood trauma to the elbow.

Timely intervention can be essential.

Figure 1

longitudinal traction of the arm with the elbow extended e.g. a parent grabbing the arm of their falling child or pulling the child by the hand. The annular ligament subluxes over the radial head and becomes entrapped within the radiocapitellar joint. There is pseudoparalysis of the affected limb, with the arm usually hanging in extension and pronation.

Functional anatomy A “simple” hinge joint, the elbow is kept stable by a complex combination of bony articulations and medial and lateral ligaments.

Various ossification centres around the elbow can create confusion and can be mistaken for fractures. Try the CRITOE mnemonic for their appearance: C - Capitellum (1-2 years of age) R - Radial epiphysis (3-5 years) I - Inner epicondyle (medial epicondyle; 5-7 years) T - Trochlea (7-9 years) O - Olecranon (9-11 years) E - External epicondyle (lateral epicondyle; 11-13 years)

ED

Ossification centres later fuse to their relative bones between the ages of 14-18 years (girls roughly two years prior to boys).

With X-rays, identification of anterior or posterior “sail sign” (Figure 1) is important.

If present, it represents a joint effusion or haemarthrosis. Why is this important? Children rarely “sprain” ligaments; they either avulse them or fracture bones. After trauma, a sail sign indicates an occult fracture, and appropriate immobilisation should be undertaken.

Pulled elbow (Nursemaid’s elbow) Usually before the age of 5, secondary to

Treatment of this injury is appropriate in the office: with a thumb over the radial head, reduce with forced supination and flexion of the elbow; often a palpable click is felt and pain relief is almost instantaneous.

Lateral condyle fracture Not complex to manage, this fracture is often difficult to identify. Failure to recognise and immobilise a non-displaced lateral condyle fracture can lead to non-union (with later cubitus valgus and ulnar nerve palsy). Unless completely undisplaced, these fractures are usually stabilised surgically and so should be referred appropriately.

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Paediatric elbow injuries

By Dr Ryan Lisle Orthopaedic Surgeon Perth

CLINICAL UPDATE Monteggia fracture/dislocation This injury combines a proximal ulna fracture with a radial head dislocation. Some are exceeding obvious, whilst some may be quite subtle with mild plastic deformation/bowing of the ulna shaft. The key to diagnosis is to ensure that the radial shaft/head aligns with the capitellum on all views (Figure 1).

Whereas most acute injuries can usually be managed with simple manipulation and immobilisation, late-presenting Monteggia fracture/dislocations are more of a challenge, requiring open reduction, osteotomy and/or ligament reconstruction.

Elbow dislocation (+/- medial epicondyle fracture) Elbow dislocations are not uncommon amongst sporting adolescents. Most are simple dislocations, managed in the ED with closed reduction under sedation.

However, in children, associated fractures of the medial epicondyle are not infrequent.

Initial management of this injury is still emergent reduction of the elbow, but care should be taken to ensure a congruent reduction post manipulation as there is a risk of incarcerating the medial epicondyle within the joint. If there is any doubt about the adequacy of reduction or the medial epicondyle fracture can no longer be seen, readily consider a post-reduction CT. Supracondylar humeral fractures This is the injury usually most common and potentially serious paediatric elbow injury

usually the result of significant trauma where a child has fallen on an outstretched arm.

Depending on the mechanism of trauma and fracture displacement, they are commonly associated with neurovascular compromise.

As such, careful assessment of distal neurological function and vascular perfusion is essential.

Other important clinical findings include clinical deformity, swelling, and anterior bruising or “puckering” of the skin (indicating the anteriorly displaced humeral shaft has impaled the brachialis to the skin). Rarely, these injuries can be open fractures. In addition, care must be taken to exclude a forearm or wrist fracture in the same arm.

Any of these signs indicate a high energy mechanism for which a high suspicion of possible neurovascular complications or compartment syndrome is warranted.

Radiologically, occult fractures can be diagnosed by the presence of a sail sign.

Minimally displaced fractures can be identified on the lateral x-ray, with the anterior humeral line running in front of the capitellum (Figure 1).

Unless undisplaced, most of these injuries require orthopaedic input. Initial first aid includes analgesia, accurate assessment of neurovascular status and splintage (not the usual 90 degrees of elbow flexion but in a position of comfort for the child, usually relative extension).

Any attempt at manipulation in the emergency department, regardless of the state of vascular perfusion, is not advised due to the

SCH fracture in 6 yr old; fell practising hurdling; required closed reduction and K-wire in theatre.

risk of further damage. A cold, pulseless hand is an orthopaedic emergency.

Key POINTs • Knowing the age relevance of various ossification centres around the elbow can minimise confusion.

• Accurate assessment is the key to appropriate management.

• If in doubt, immobilise and seek orthopaedic opinion.

Author competing interests: No relevant disclosures. Questions? Contact the author on lisleadmin@hogwa.com.au

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OCTOBER 2017 | 39

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CLINICAL UPDATE back to contents

Injury prevention in Australian Rules Football Australian rules football is played by well over half a million people of all ages, from weekend warriors to the elite semiprofessionals. The injury rate is higher than many other team sports, mostly involving the hamstring, groin/hip, thigh, knee, ankle and shoulder. Injuries occur more often in the first few weeks of the season, suggesting a lack of fitness and conditioning. Overuse injuries, such as stress fractures and tendinopathies, are more common in those training more and at a higher level, and in older footballers.

prescribed by a specialised multidisciplinary team. Everyone else is left to their own devices, poorly managing their injuries and jogging a few laps as a warm-up. While many AFL footballers consider IP, most do no more than purchase a mouth guard.

Putting prevention into action Whilst primary prevention is the holy grail, most players do not present for screening or advice beforehand. In winter, my Mondays are littered with the fallout from weekend sport - I doubt if any GP goes a week without seeing a football-related injury. This is an opportunity to not only treat the presenting injury but also advise on secondary prevention. A simple ankle sprain may seem relatively insignificant but an IP program can reduce the future risk of an ACL rupture, Achilles’ tendinopathy or osteitis pubis.

Proper sport-specific conditioning is very important. The focus is on reducing neuromuscular and biomechanical risk factors by improving strength, power, flexibility, endurance, agility and proprioception. IP exercise programs are incorporated into a preseason training as well as maintenance throughout the season.

The inaugural AFL Women’s season saw a high incidence of injury early on, probably in part due to a short preseason and many athletes coming from other sports. They simply did not have enough time to develop the specific physical conditioning required in elite football.

Numerous exercise programs are online for IP, however a good Physiotherapist or Accredited Exercise Physiologist is useful for more thorough individual programs. Many beneficial IP exercises, such as plyometrics, can result in injury if performed incorrectly, too frequently, or too early in a program, so encourage professional guidance. To improve compliance, emphasise the positive effect on performance and on-field success!

The impact of football injuries is significant: time off work, lack of exercise, cost, and impacts on mental health. Most of us know someone who quit sport and no longer exercise due to injury, contributing to the sedentary lifestyle that has become Australia’s leading cause of morbidity and mortality. For example, an ACL rupture in young people can lead to short-term reduced sporting ability and participation, impaired self-confidence, and even impaired learning.

Long term, ACL rupture is a major cause of knee osteoarthritis, which adversely impacts on quality of life and finances.

Responsibility for injury prevention (IP) lies with several stakeholders. The game’s administrators and officials are responsible for providing an environment and setting rules facilitating safe play. Professional AFL players are closely managed and IP exercises are MEDICAL FORUM

By Dr Simon Jenkin Sport & Exercise Medicine Registrar Cottesloe

Unfortunately, injuries amongst Australian Rules Footballers are relatively common and many are preventable.

ED

to reduce the risk of common lower limb injuries. It is easily transferable, can be applied to individuals or entire teams, and can be incorporated into a more traditional warmup. This is an invaluable resource, and I highly recommend it for any footballer, injured or not.

Author competing interests: nil relevant.

Questions? Contact the author on 9284 4511 ED. According to the 2015 AFL Injury Survey, since 1992, the incidence of new injuries has been about the same, as has the games lost to injuries but recurrent injuries have about halved.

At this elite level, hamstring and groin strains top the list, with knee injuries of various sorts largely unchanged, but calf and ankle strains or sprains more prevalent in line with the ‘running game’ spectators enjoy.

The author says, “The groin injuries have seen a downward trend in recent years due to improved screening and IP programs. There is evidence of an increase in ACL injuries with a higher friction between ground and foot. Footwear design and stud pattern can contribute to this but there is a definite link with the type of turf. Incidence increases as you go further north in Australia and earlier in the season, due to hotter and drier conditions increasing the traction. Turf type has an influence too, with higher thatch grass varieties such as bermuda worse than rye grass. The new Perth Stadium has a mix of wintergreen couch, with rye added in winter, and stabilised by 10% artificial turf fibres.”

Large-scale IP programs worldwide include the FIFA-11+ for soccer. In 2015, the AFL unveiled a major initiative aimed at reducing injury. It was largely funded by the NHMRC, AFL, and state governments. FootyFirst is a simple, easy to follow, progressive exercise training program specifically developed

Key messages • Football injuries burden patients and society, and many are highly preventable • Sport-specific conditioning and gradual increases in exercise load are vital • Direct patients to FootyFirst at www.aflcommunityclub.com.au

OCTOBER 2017 | 41

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CLINICAL UPDATE back to contents

Managing hyperparathyroidism Affecting 0.2-0.5% of the ambulatory population, primary hyperparathyroidism (PHPT) is the commonest cause of hypercalcaemia, commonly found while investigating non-specific constitutional symptoms (e.g. lethargy, diminished cognitive performance and fibromyalgia symptoms) or in the patient presenting with newly diagnosed osteoporosis or symptomatic urolithiasis. A parathyroid adenoma(s) is usually the cause, and parathyroid surgery is highly successful in curing hypercalcaemia in experienced hands, with most patients requiring one night in hospital, including those patients having a four gland exploration. Most recent surgical series from high volume centres report cure rates of over 90% with very low rates of surgical morbidity.

Primary hyperparathyroidism (PHPT) PHPT is always a biochemical diagnosis – parathyroid hormone (PTH) dependent hypercalcaemia, usually caused by a solitary benign adenoma, versus non PTH dependent (e.g. malignancy) – with PTH levels elevated or in the upper half of the reference range.

PHPT should be distinguished from secondary hyperparathyroidism where PTH is elevated with a low or normal serum total corrected and ionised calcium levels. This is not a surgical condition and commonly relates to vitamin D deficiency, renal impairment, malabsorption and anti-resorptive medications.

Familial hypocalciuric hypercalcaemia (FHH) This is a rare, autosomal-dominant disorder of calcium sensing receptors. The patient with FHH can have biochemistry similar to PHPT (i.e. concurrent elevation of serum calcium and PTH) however this condition is also not surgically curable and parathyroidectomy should be avoided.

A family history of hypercalcaemia should raise suspicion of an FHH diagnosis.

Patients characteristically have low urinary calcium excretion relative to the degree of hypercalcaemia. Urine calcium excretion assessment (measured as part of a fasting metabolic bone study) is important in working up the hypercalcaemic patient, and assists in distinguishing PHPT from FHH. Surgery and PHPT Parathyroidectomy is the only definitive treatment for PHPT. At diagnosis, a decision is made to either refer for parathyroidectomy or elect to pursue observational management, with any osteoporosis managed medically (i.e. anti-resorptives).

Some with PHPT have clear, noncontroversial indications for surgery such as symptomatic renal calculi, hypercalcaemic

MEDICAL FORUM

By Dr Simon Ryan Endocrine Surgeon Nedlands

crisis, or pathologic fracture or other forms of PHPT related bone disease.

In asymptomatic patients there is more controversy regarding surgery.

This specific issue has been addressed by guidelines by the National Institute of Health (NIH) for surgical referral for asymptomatic PHPT (commenced 1990; revised 2002, 2008 and 2013).

Sometimes difficult to demonstrate, a parathyroid adenoma can be removed surgically.

Removal often fixes the calcium metabolism problems picked up fortuitously when screening the presenting nondescript symptoms.

ED

Indications for parathyroidectomy in asymptomatic patients, according to the most current NIH guidelines, include a significant degree of hypercalcaemia (total adjusted calcium 0.25 mmol/L over upper normal limit), diagnosis of osteoporosis on DEXA, imaging demonstrated vertebral fracture, nephrolithiasis demonstrated on renal imaging, diminished renal function (creatinine clearance under 60cc/ min) and patients under age 50.

Younger patients are recommended for surgery because PHPT related complications are more likely to develop over time.

Ultrasound scan: Parathyroid adenoma indicated by yellow arrows beneath the larger thyroid gland.

Notably, the NIH criteria exclude constitutional and cognitive symptoms (fatigue, lassitude, memory disturbance etc.), which affect many PHPT patients and improve post-operatively but not in a predictable fashion.

Other considerations Patients not meeting surgical referral criteria require long term surveillance in case they develop them. Recommended surveillance (NIH guidelines) includes annual biochemical evaluation of renal function and calcium assays and annual to biannual bone densitometry.

incision. Negative parathyroid imaging should not preclude surgical referral for parathyroidectomy, because despite the improving sensitivity of imaging, there remains a degree of truth in the adage, ‘The only localisation necessary is to find an experienced parathyroid surgeon’.

Four gland parathyroid exploration in experienced hands remains a procedure with minimal morbidity and high cure rates.

Author competing interests : nil relevant disclosures. Questions? Contact the author 0408 280 276

For those patients wishing to avoid longterm surveillance, parathyroidectomy can be offered to them even though the patient may not have surgical referral criteria. Some literature suggests surgery is a cost-effective alternative to long term monitoring.

Parathyroid imaging (whether CT, ultrasound, or sestamibi scintigraphy) is indicated for surgical planning rather than diagnosis.

Parathyroid imaging can facilitate localisation of the enlarged parathyroid (adenoma), such that focused parathyroidectomy can be performed through smaller neck

OCTOBER 2017 | 43

CLINICAL UPDATE

The 2017 update from the National Institute of Health and Care Excellence (NICE) recommends an algorithm (see diagram) in the treatment of low back pain +/- sciatica.

The burden of low back pain can respond to judicious use of nonsurgical interventions.

RF cannulas positioned to treat the medial branches of L4-5 and L5-S1 facet joints simultaneously under local anaesthetic.

RF Denervation (or rhizotomy) RF denervation for low back pain specifically relates to the facet joints, supplied by the medial branch of the dorsal ramus at each spinal level. Multiple facet joint levels need to be targeted as there is cross innervation of facet joints.

The guidelines do not describe nerve root sleeve injections which may reduce pain in the short-term only and therefore are not considered to be cost-effective.

Spinal claudication

Transforaminal epidural: 23 g spinal needle placed in the safe zone of the neural foramen (right lateral approach); contrast media is perineural and extends via the neural foramen to reach the epidural space where it is envisaged injected corticosteroid and local anaesthetic will reduce inflammation in relation to the nerve root, dorsal root ganglion and the ventral dura.

Central spinal canal stenosis (SCS) can present with neurogenic claudication.

Similarly, some patients present with vascular claudication secondary to severe peripheral vascular disease. It is the history, physical examination, arterial Doppler and spinal imaging that differentiates the two aetiologies.

The recommended treatment for spinal stenosis is decompressive surgery. There is continued on Page 46

Key messages

conservative management. Epidural injections are performed to treat unilateral or bilateral radicular pain. Another indication for an epidural injection is discogenic LBP, however this has not been specified in the guidelines which are only written to provide a structure to help guide management but are not all encompassing.

• LBP and sciatica – try conservative management and MRI (or CT) scan only if not improving.

• If LBP due to facet joints – consider RF denervation after a positive facet joint trial block.

• Radicular pain / Sciatica – transforaminal epidural injection (TFESI) may reduce pain for shortmedium term. NRSI not routinely recommended.

The procedure can use interlaminar or transforaminal (TFESI) approaches depending upon the clinical presentation and the anatomy evident on CT or MRI scan. There is likely to be a better response from TFESI and

Managing low back and sciatica NICE Pathways

A trial medial branch block (MBB) or FJI is needed first to prove the facet joint is the pain source. The trial block should result in at least near-complete pain reduction with later recurrence of moderate to severe pain.

The RF procedure requires positioning of an electrode on the medial branch using CT or fluoroscopy. Nerve stimulation is confirms accurate needle localisation and then the RF electrode heats the medial branch, causing a small section of coagulative necrosis of the nerve. The lesion the procedure creates will gradually heal over time. It can be performed as an outpatient (in under 30 minutes, usually without sedation). There is frequently a period of pain flare-up (about 2 to 3 days), often followed by 12-24 months of reduced pain.

ED

therefore you should consider requesting this method of epidural injection on a referral form.

Radiologists may help diagnose and treat patients with LBP with or without sciatica (see June edition). Interventional options include facet joint injection (FJI), nerve root sleeve injection (NRSI), epidural injection, sacroiliac joint injection and radiofrequency (RF) denervation.

However, the NICE guidelines say “Do not offer” spinal injections. The authors have found FJI and NRSI to be ineffective.

Nonetheless, RF denervation is a recommended treatment for LBP when there is inadequate improvement from conservative methods (e.g. physiotherapy, psychological therapy, medications and exercise).

By Dr Mark Hamlin Radiologist Claremont

Person aged 16 and over with low back pain with or without sciatica

Information and advice to support self-management

Exercise

Manual therapy treatment package

Pharmacological treatments

Psycholigical therapies treatment package

Additional specific treatments for sciatica

Combined physical and psychological programs

Radiofrequency denervation

Other surgical procedures

Do not offer

Epidural injections For the treatment of sciatica, the NICE guidelines suggest an epidural injection be considered if there is failure to improve with

44 | OCTOBER 2017

Acupuncture and electrotherapy

Traction, orthotics, belts and corsets

Spinal injections and disc replacement

Spinal fusion (unless part of a randomised controlled trial)

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Treatment of low back pain by injection & RF ablation

CLINICAL UPDATE back to contents

Four problem hand injuries This article discusses two hand injuries that can be missed and two common hand injuries for which referral directly to a hand therapist may be warranted.

Fears about fractures include ED leaving something too long (for whatever reason) or over-reacting – these practical notes will help those fears.

Scaphoid fractures

neck (see X-ray) fair less well and are best referred to a hand surgeon.

Many practitioners are concerned about scaphoid fractures but they are relatively simple to diagnose or exclude given a systematic approach.

Many hand therapy practises have a close working relationship with a hand surgeon and will discuss with the surgeon if they are concerned surgery should be contemplated.

If you suspect a patient has a scaphoid fracture your first investigation is usually a plain scaphoid radiograph. However, a portion of patients have normal radiographs, so if you still suspect a scaphoid fracture, splint with a forearm-based wrist backslab or splint (there is no requirement to include the thumb in the splint) and organise either a CT (confirms 99% of scaphoid fractures) or an MRI (confirms 100% of scaphoid fractures and can also diagnose soft tissue injuries in the vicinity).

If the CT or MRI is normal you can manage the patient according to their clinical symptoms but if the patient’s recovery is slower than expected it would be worth asking a hand surgeon for their opinion. Any fracture revealed on imaging is managed accordingly.

Jersey finger Sudden resisted finger flexion can result in an avulsed flexor profundus tendon causing no active flexion of the distal interphalangeal joint but active flexion of the proximal interphalangeal joint usually persists.

A high proportion of these patients present late, which significantly compromises treatment outcome. They should be referred urgently to a hand surgeon.

Proximal interphalangeal joint sprain / volar plate injury

By Dr Paul Jarrett Orthopaedic Surgeon Murdoch

Saggital CT of scaphoid waist fracture (arrowed).

Sprains to finger proximal interphalangeal joints are common. Patients will present to you with a stiff and uncomfortable joint which has a fusiform swelling often after a forced extension or staving type injury. X-rays sometime demonstrate a small avulsion fracture at the attachment of the volar plate which is effectively a ligament sprain with a flake of bone attached; this does not represent a problem unless the fragment is large or the joint is subluxed (as in the x-ray beneath).

These injuries are best treated by the hand therapists with initial protection of the finger and subsequent exercises to prevent or treat a late fixed flexion contracture which common occurs without treatment.

Boxer’s fracture Little finger metacarpal neck fractures are common and frequently angulate although it is very uncommon for the finger to be rotated. As long as the angulation is under 45 degrees a “less is more” approach is best. Let patients know the end result of non-operative treatment is excellent but that there will be a long-term prominence at the fracture site and their knuckle will be somewhat less prominent compared to pre-injury.

Volar plate fracture but with joint subluxation (thus surgery required) Author competing interests: nil relevant Questions?

Contact the author on admin@pauljarrett.info

I normally ‘neighbour strap’ two adjoining digits for up to four weeks, allow use of the hand in that time within the limits of comfort.

Distal metacarpal shaft fracture – red line is where a neck fracture would be.

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The hand therapists can provide a Lycra neighbour sleeve, which is more convenient than tape, and if at risk of banging the hand a thermoplastic splint can be used for when the hand requires protection.

However, fractures that are proximal to the

OCTOBER 2017 | 45

CLINICAL UPDATE

Heel pain makes up about 25% of complaints treated by podiatrists.

Plantar fasciitis explained The most common cause of heel pain, this condition typically presents as an aching or stabbing sensation and tenderness maximal at the calcaneal tubercle at the origin of the medial fascia band (see image).

The condition is believed develop usually from chronic traction on the fascia - degenerative changes are often visible on ultrasound and MRI as localised fascial thickening. Acute presentations are far less likely.

A clinical diagnosis can often be made initially through palpation of the heel and a careful history.

Differential diagnosis Heel pain that is directed more centrally over the plantar calcaneal surface may raise suspicion of an alternate diagnosis such as heel spur syndrome. An x-ray can visualise a calcaneal spur, and MRI may demonstrate bone marrow oedema within the spur itself when symptomatic.

Patients who present with additional complaints of paraesthesia or numbness of the medial heel area may be experiencing a compression neuropathy of the tibial nerve or one of its divisions. This is not uncommon, and often presents in conjunction with signs of plantar fasciitis or heel spur syndrome.

Treatment The key to success in treating heel pain involves early and aggressive management as symptoms tend to become chronic when undertreated, causing altered weight-bearing on the foot and gait changes.

Most patients benefit initially from a combination of footwear changes, fascial stretches, orthotics, oral NSAIDs and/ or corticosteroid injection. Any underlying mechanical reasons for the condition can be addressed concurrently by a treating podiatrist.

Contemplating surgery

MRI of rearfoot showing thickening of proximal plantar fascia at calcaneal insertion.

Referral to a podiatric surgeon for recalcitrant heel pain, unresponsive to the usual treatments over six months, can lead to a beneficial surgical release of the medial

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46 | OCTOBER 2017

Heel pain can cause loss of mobility ED - this assumes greater importance as the dog gets fat, the spouse gets grumpy, and the tennis scores plummet!

Key points 1. Clinical diagnosis can be made through palpation and symptoms.

2. Imaging helps to support diagnosis and guide management.

3. Early and aggressive management leads to a better prognosis.

4. Referral to a podiatrist or podiatric surgeon should be considered for all cases. band of fascia. This is done via an open or endoscopic approach, usually as day surgery with minimal downtime post-operatively.

Chronic cases of heel spur syndrome may require resection of the calcaneal spur and release of the fascia if there are degenerative changes also present.

Neuritic heel pain resulting from compression of the tibial nerve requires confirmative MRI imaging prior to consideration of tarsal tunnel decompression.

Author competing interests: nil relevant.

continued from Page 44

...low back pain by ... no recommendation for epidural injection in these patients.

The pain associated with canal stenosis is due to mechanical and ischaemic factors rather than the inflammatory cascade associated with a disc herniation and radiculitis. This explains why there is only short term effect, if any, from an epidural in the setting of SCS or lateral recess stenosis.

What of anticoagulated (AC) patients?

Interventional services will have certain criteria that guide decision making in relation to AC. Cessation for some procedures can be far riskier than the risk of bleeding. It is important for the referrer to flag any AC, as well as a history of contrast allergy.

Author competing interests: nil relevant disclosures.

Questions? Contact the author on 0416 163 615

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Plantar fasciitis - heel pain

By Dr Andrew Knox Podiatric Surgeon Perth

CHARITY

Two-Wheeling to Gracetown Cycling with friends in some of the state’s most picturesque surroundings for a good cause … what’s not to love?

There’s no better place to be than stunning South-West WA in spring. The Tour de Gracetown gets under way in late October and The Ladybird Foundation will benefit from the two-wheel classic.

We know of at least three Perth doctors, Dr Sarah Pickstock, Dr Paul Langton and Dr Annabelle Shannon will be joining the peloton.

medicos who do the Gracetown ride although it’s often difficult to recognise people when they’re wearing their riding gear – and many of us don’t want to be recognised!”

In it to finish

“It’s a relaxed and cheerful day out with the lure of a swim and a nice lunch at the end of it all. Riding a bike around Margaret River is pretty special.”

“I really enjoyed the previous two rides.

On both occasions I rode with some of my Saturday morning group, which has been going for 15 years. It’s all about participation.

We’re definitely not there to race!”

“It’s a really nice way to ride through an area that you might think twice before jumping on your bike. The scenery is beautiful, but they’re not the sort of roads that you’d venture out on without some sort of safety procedures in place,” says Dr Sarah Pickstock.

Cardiologist Dr Paul Langton is a serialdevotee of the Tour de Gracetown and loves the opportunity to both conquer the hills while enjoying the scenery.

“There are signs and traffic marshals everywhere, plus safety cars and the security of being among a group of cyclists. We raise money for a really worthwhile charity so it’s a great way to feel good about having a day out in the Lycra! It’s a wonderful way to be part of a community of cyclists.”

Sarah is an experienced cyclist with lots of road miles clocked up in WA and overseas.

“I’ve ridden in Falls Creek and through the Pyrenees, once a tragic always a tragic!

I ride a seven year-old Scott bike with a few dents and scratches but if I wanted to go any faster I’d just pedal harder rather than buy a new bike.”

“I’m aware of my limitations!”

All in the legs “Many people, and some of them are doctors, throw a lot of money at high-end road bikes but they don’t necessarily go any faster. They do look good, though. There are quite a few

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“There’s no doubt that the TdG is one of the iconic social rides in WA and no one would be disappointed if they chose to give it a go.

There’s also the added benefit of supporting the Ladybird Foundation as well.”

A ride for everyone “I’ve done this ride 11 times now and the scenery along Caves Road is absolutely beautiful. I’d recommend it for any level of cyclist.”

“The ride crosses the Bussell Highway, winds eastwards to Rosa Glen before finishing in Gracetown. Most people do the full 110km but there is an option to do the half-distance.

If you’re doing a few rides a week in Perth, as I do, you’ll have no problems managing the TdG, although it might be a good idea to do some hill rides beforehand if you usually ride on flat courses.”

“We usually have a group of around 10 riders and it makes for a great weekend getaway.

There are lots of things to do in Margaret River!”

Dr Annabelle Shannon will be lining up for her third TdG later this month.

“Having the safety escort is great, particularly on the Caves Road section. A lot of the boys go hell for leather once that’s over while we cruise along enjoying the cows, paddocks and vines. It’s a nice stop at Rosa Brook for drinks, lollies and fruit. At the end of the ride they provide food but our group prefers to have ‘bubbles’ and lunch on the beach.”

‘There are usually a few doctors in the peloton but we’re rarely called on to do anything official. An ambulance crew is on standby and there’s a local police presence as well.”

“My road bike is a lovely, red and white Trek Domane. I also have a Trek town bike with a brown leather seat and a stainless-steel basket for riding to yoga or the shops.”

“The ride is an important fundraising event for the ROLLIS trial that will, hopefully, result in improvements to breast cancer surgery. They need a bit more money to finish the research so this is a good cause and a fun event all rolled into one!”

By Peter McClelland ED: 2017 Rotary Club of Belmont Tour de Gracetown. www.tourdegracetown.com.au

OCTOBER 2017 | 47

Travel

The Taste of Canada Niagara-on-the-Lake is one place that ‘comfortable’ Canadians live, often in retirement. The town, which features 19thcentury buildings, sits on the shores of Lake Ontario, at the mouth of the Niagara River that forms the current border with the US. Back in the good old days, it was a busy steamboat port for Toronto. Near the river, 19th-century Fort George was built by the British to defend against American attacks.

The townsite took on its current name in 1880 (it was called Niagara, and Newark before that when it was also the first capital of Upper Canada, now the province of Ontario). The renaming helped distinguish the townsite from Niagara Falls, which is not far away (but that’s another story!).

Niagara-on-the-Lake is currently known for its wineries and summer festival and, with a population of just over 17,500 people, its cosy exclusivity. One winery is Peller Estates, which at first glance doesn’t offer much more than many of the Swan Valley or Margaret River Wineries.

However, their signature wine is their dessert Icewine, which you can taste on a tour of the winery, complete with gloves etc. in the 10-below ice-room. Icewine is so named because grapes are hand-picked at night

48 | OCTOBER 2017

while at least at -10ºC, with the grapes frozen on the vine.

The picked grapes are pressed immediately and each frozen grape is said to yield just one drop of juice.

(Interestingly, the vineyard is on the same latitude as the south of France but local conditions give them freezing winters each year).

Looking at the Peller Estate website, their chef Jason Parsons (who has been at Peller Estates for over 20 years) is big on how food and wine are combined to complement each other.

At a sit-down tasting, we chose their fivecourse degustation. Ashley Hughes, our waiter on this occasion, first gave us a choice of fennel, raisin or semolina breads.

Then followed: 1. Ice Cuvee Rose (RRP CAN$36.95) was coupled with Duck Rillette (with garlic, house pickles, swiss chard, and cherry compote).

2. Riesling 2015 ($17.95) was accompanied

by Eggplant and Tomato Cheddar Scone, with oven dried tomato and olive oil.

3. Chardonnay 2015 ($19.95) was served with Diver Scallop (featuring warm pea salad, chilli tomato relish, pommes pailles and mint balsamic)

4. Carbernet Sauvignon 2014 ($22.95) came with either:

Rabbit Saddle stuffed with cabbage, cherries, panko navy beans, swiss chard and cherry jus, or

Beef Rib Eye with smoked potato mousseline, tri carrots, leek and bone marrow jus, or

St Honore pastry base with goat’s cheese, red onion and warm toasted almonds and poppy seed.

5. Icewine Cabernet Franc 2014 ($95.85) served with our choice of a smooth almond Pannacotta, or two delicious combinations of chocolate and gourmet cherries.

By Dr Bruce McKay

MEDICAL FORUM

WINE review

Fermoy Estate Hits New Heights Fermoy Estate is located in the ‘Golden Triangle’ of the Margaret River wine region in Wilyabrup. With some very prestigious neighbours, the quality of the grapes produced reflects the perfect soil and climate combination of the region.

Established in 1985, it has had a few changes of hands and now resides with Perth brothers Aaron and John Young. Much of the recent winemaking was done by the duo of Liz Dawson and Coralie Garnier-Lewis with the recent appointment of Jeremy Hodgson as senior winemaker giving more local experience. Fermoy Estate is a five-star winery in the James Halliday Australian Wine Companion.

Fermoy Estate has taken Margaret River winemaking to a new level. The wines tasted show great originality and are recommended.

By Dr Martin Buck

REVIEWER'S

PICK 1

2

3

2014 Fermoy Estate Reserve Cabernet Sauvignon

The last wine is one to keep in the cellar. Deep garnet red in colour with restrained berries and cassis aromas.

Made with predominately new French oak the balance of tannins is perfect and gives some cedar characters to the palate. This is wine that would sit well with some great Bordeaux classics. Drinking nicely now but will be one to keep if you like your cabernet matured.

4

1. 2016 Fermoy Estate Sauvignon Blanc This is a great reflection of the kind of quality winemaking at Fermoy Estate.

The nose is typical of the variety with lifted aromatics of kiwifruit and guava, a full palate of limey fruit combined with a little oak influence. The wine was partially fermented in French oak and it adds to the complexity and palate length. This is a wine with class and will be perfect for the summer months.

3. 2014 Fermoy Estate Chardonnay No surprises with this chardonnay as the winemaking techniques are make the fruit dance in the glass. Subtle oak combine with stone fruit aromas and the palate is soft, nutty and with some funky flavours. It reminds me of some of the wines of Meursault and I think it will get better with some medium cellaring.

2. 2016 Fermoy Estate Rosé Rosé is an often misunderstood wine and Fermoy’s example makes a clear statement on what makes a great wine. Salmon pink in colour with shades of Provence and a soft, subtle fruit nose. The palate is complex for a rosé and, again, some wild fermentation in French oak has delivered wonderful complexity. A tingle of late sweetness on the palate adds to the complexity.

This is a really well-made rosé and shows what great techniques can be used for this style.

4. 2013 Fermoy Estate Shiraz This wine is more hermitage than shiraz. Deep ruby red in the glass with aromas of aged plums and some peppery spice. A fabulous palate of soft tannins, pepper and brilliant fruit with some subtle barnyard flavours. This is another quality wine with unexpected complexity – a great wine for a blind tasting with friends! Who would have thought that such a wine would have come from the cool-climate of Margaret River.

WIN a Doctor’s Dozen!

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Enter here!

.. or online at

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Email P lease send more information on Fermoy Estate offers for Medical Forum readers.

Wine Question: Which Fermoy Estate wines had some wild fermentation in oak?

Answer: ....................................................

Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, October 31, 2017. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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OCTOBER 2017 | 49

According to Phyllis

Phyllis Diller

Whatever you may look like, marry a man your own age. As your beauty fades, so will his eyesight.

Housework can't kill you, but why take a chance?

Cleaning your house while your kids are still growing up is like shoveling the sidewalk before it stops snowing.

The reason women don't play football is because 11 of them would never wear the same outfit in public.

Best way to get rid of kitchen odours: Eat out.

I want my children to have all the things I couldn't afford. Then I want to move in with them.

Any time three New Yorkers get into a cab without an argument, a bank has just been robbed.

Burt Reynolds once asked me out. I was in his room.

What I don't like about office Christmas parties is looking for a job the next day.

The only time I ever enjoyed ironing was the day I accidentally got gin in the steam iron.

Wine

Winner

50 | OCTOBER 2017

His finest hour lasted a minute and a half.

Q: What is the right age to get married?

I admit, I have a tremendous sex drive.

My boyfriend lives forty miles away.

Twenty-three is the best age because you know the person FOREVER by then.

Tranquillisers work only if you follow the advice on the bottle - keep away from children.

– Camille, age 10

I asked the waiter, 'Is this milk fresh?' He said, 'Lady, three hours ago it was grass.'

You might have to guess, based on whether they seem to be yelling at the same kids.

The reason the golf pro tells you to keep your head down is so you can't see him laughing.

– Derrick, age 8

You know you're old if they have discontinued your blood type.

Love and Marriage (written by kids) Q: How do you decide who to marry?

You got to find somebody who likes the same stuff. Like, if you like sports, she should like it that you like sports, and she should keep the chips and dip coming.

– Alan, age 10

Q: How can a stranger tell if two people are married?

Q: What do you think your mum and dad have in common?

Both don't want any more kids.

– Lori, age 8 Q: What do most people do on a date?

Dates are for having fun, and people should use them to get to know each other. Even boys have something to say if you listen long enough.

– Lynnette, age 8 On the first date, they just tell each other lies and that usually gets them interested enough to go for a second date.

– Martin, age 10

It’s been a long time between drinks for red wine aficionado and orthopaedic surgeon Dr Nick Anastas. He last won a Medical Forum Doctor’s Dozen in 2009 but Nick’s coupon is always one of the first to arrive. He struck gold with some very nice wines from 3Drops Wines including a shiraz of memorable quality.

MEDICAL FORUM

theatre

Fangs for the Memories We, as a species, have always had fascination for vampires … they’re mysterious, sexy, murderous and above all immortal. Perhaps it’s envy! One of the more sophisticated renderings of the genre is the Swedish book and film, Let the Right One In, which explores the lives of teens living on the outskirts – marginalised both socially and financially.

One just happens to be a centuries-old vampire.

Let the Right One In is now headed for the stage at the State Theatre Centre from November 11 and will be directed by the new Black Swan State Theatre Company artistic director, Clare Watson – her first on the Health Ledger Theatre stage since heading west from Melbourne late last year. And, not surprisingly, she is excited by the prospect.

“I am a huge fan of the film. I think I have watched it half a dozen times, alone at night, which is the best way to watch a scary movie.

I’ve always believed it would be a great stage work and even applied for the rights when I was working for a youth theatre company but sadly they weren’t available,” she said.

The reason why was made clear four years ago when the National Theatre of Scotland produced a stage adaptation to critical acclaim. Clare will be using that adaptation but has her own ideas and also promises some special magic from the BSSTC designer Bruce McKinven.

Fright night “The set is ambitious and bold … and scary.

If you can scare people in the theatre, it’s as satisfying as making them laugh.”

The production has a 15+ age warning but with the popularity of fangs among the younger demographic, Let the Right One In will have broad appeal.

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WAAPA graduates feature prominently in the production. Sophia Forrest, who is daughter of FMG’s Andrew and Nicola Forrest, and most recently seen on Channel 9’s series, Love Child, is the female lead, Eli, and Ian Michael, who graduated from WAAPA’s indigenous theatre course, plays Oskar.

While Clare’s theatre work has been based in Victoria, she said she has been working with WAAPA grads her entire directing career.

“They’re brilliantly talented but, more than that, they are resilient and resourceful and for an arts school to be graduating artists who have that strength of character is an extraordinary thing.

When Medical Forum spoke to Clare, she had just released her first season as artistic director and there are some interesting times to come in our state theatre.

There is a Perth festival offering with You Know We Belong Together written and performed by Julia Hales, who, as an artist with Down syndrome, has some salient points about the presentation of disability in our society.

the chance to see Broadway gold in Stephen Sondheim’s Assassins with Roger Hodgman at the helm.

The final shows upstairs and down will have the town talking. Health Ledger Theatre hosts In the Next Room, Or The Vibrator Play by Sarah Ruhl, which speaks for itself, while Studio Underground looks into the complex life of Adriana Xenides – the instantly recognisable glamour girl on the TV gameshow, Wheel of Fortune.

Clare is hoping the season will start conversations at dinner parties and gatherings and wherever people ask, ‘what did you do last night?’.

“I believe as a theatre company, it’s our job to engage an audience and ignite empathy and always strive towards a more tolerant and more engaged society. Theatre can make people better humans.”

Working partnerships

“So what should we as a society, in this city, in the world, be talking about right now? What conversations should we be having? When the creative team started talking, it wasn’t about plays and actors but about issues that dominated our world such as extremism, climate change, misogyny, and from that conversation we started to gather plays and ideas around those things.”

There are collaborations with Yirra Yaakin Theatre Company and DAADA and with the main stage and Studio Underground working in concert, when it’s showtime, the theatre centre will be pumping with people and energy.

“A theatre season tells its own story and each play has to be there for its own reason and that’s the bit that I really love.

When we started thinking about themes of conversations, it became clear what should be part of the conversation.”

A classic makes a return in 2018 – Ray Lawler’s Summer of the Seventeenth Doll kicks off the mainstage season and following BSSTC’s hugely successful foray into the musical theatre genre with Next to Normal and Clinton: The Musical, audiences will get

By Jan Hallam

“It’s a gentle playful way of making a big political point,” Clare said.

ED: Black Swan’s 2018 season details at www.bsstc.com.au/seasons/2018

OCTOBER 2017 | 51

theatre

Amanda Gives a Masterclass Opinions range over the impact soprano Maria Callas had on the opera world.

Everyone agrees it was dramatic.

There’s no surprise that Amanda Muggleton is attracted to strong female characters. This doyenne of Australian stage and screen is no wilting violet herself. Over her four-decade career she has played jailed prostitute-murderer Chrissie Latham in the TV series Prisoner, the indomitable matchmaker Dolly Levi in Hello Dolly! and then there’s Chekov and scores of musicals. But most beloved by audiences is her worldbeating portrayal of Shirley Valentine.

She’s cranked up the character dial recently. When Medical Forum caught up with her, she was appearing nightly on the Sydney stage as cosmetics pioneer Helena Rubenstein in Lip Service. From November 16, she will be in Perth at the Subiaco Theatre Centre as opera diva Maria Callas in Terence McNally’s masterful play, Masterclass.

Both Rubenstein and Callas were forces to be reckoned with. Rubenstein, who began her cosmetics empire here in Australia, took on Revlon’s Charles Revson. He worked tirelessly to crush both Rubenstein and Elizabeth Arden’s businesses. He eventually won, but not without a fight.

Callas had to stare down the formidable opera establishment to have her talents taken seriously but like so many of the characters she played, her life took a tragic turn.

“Playing these two women does wring me out. They are very emotional plays – they are both funny and tragic but I adore them both,” Amanda said.

“Both women had to struggle against strong men – I call them bastards!”

Amanda brought Masterclass to Perth 16 years ago and it was a thrilling production then and expectations for its return are high.

The setting, as the title suggests, is a masterclass delivered by Callas to students of New York’s Juilliard school. Appearing alongside Amanda are opera singers taking ‘instruction’ and occasionally vocalising Callas’s famous arias – from Verdi’s Macbeth and Donizetti’s La Sonnambula.

“Getting up close to an opera singer in full flight is unbelievably powerful and at the Subiaco Theatre Centre, the audience is so very close. They will feel they are in a proper masterclass in a conservatorium, which will be a journey and a half.”

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The production will be helmed by UK director Adam Spreadbury-Maher, with whom Amanda worked in a London production of another of her famous set pieces, The Book Club. That performance won her a best actress award.

“Adam is an Australian who started off his career as a singer. He is still involved in opera but now as director. He produces the pocket operas which are so popular in London. When he heard that I was to play Callas again, he was very keen to be involved.”

Maria Callas’s legacy divides audiences.

Her big dramatic soprano voice was loved or loathed but few have a neutral stance.

And then there’s her offstage life that is stuff of legend.

A poor Greek girl thrust into the opera spotlight with a husband, 25 years her senior, shaping her and largely protecting her from the opera bullies.

There were the La Scala scandals in Milan where she refused to return to the stage after the first act because she was unhappy with her voice. It was a decision which sparked outrage inside the theatre and the wrath of the Italian nation.

There was the decision to drop more than 30kg of weight to improve her voice – and to look like her idol Audrey Hepburn. It is uncertain if her voice improved but the woman who emerged from the plus-size clothing was glamorous, confident and ready to party. One of the first to notice her outside the chrysalis was Greek shipping billionaire Aristotle Onassis and so began a life of extreme luxury and extreme pain.

All this tumbles out in Masterclass to the strains of some of Callas’s most triumphant opera moments. It makes tremendous theatre.

“The words she says in the play is ‘I was beautiful at last’ but her story is so tragic and the Callas haters loved every minute. It is a cruel world,” Amanda said.

By Jan Hallam

Competitions

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Movie: The Killing of the Sacred Deer Steven is a surgeon whose life becomes seriously complicated when he fosters a troubled teenage boy. Colin Farrell and Nicole Kidman star is the psychological thriller, which won the best screenplay at this year’s Cannes. Festival.

In cinemas, November 16

Movie: Loving Vincent Each of this film's 65,000 frames is an oil painting on canvas, using the same technique as Van Gogh. It was created by a team of 115 painters and is a biographical animated film on the life of Vincent van Gogh – the first feature-length painted animation. The story is inspired by a letter van Gogh wrote in the week before he died, in which he noted that "we cannot speak other than by our paintings".

Movie: Detroit Director Kathryn Bigelow tackles the Detroit riots that took place over five days in 1967 leaving 43 people dead, hundreds injured and a destroyed city. It was sparked by a police raid of an unlicenced bar in the poor Near West Side.

In cinemas, November 9

Oscar-winning filmmaker Hugh Welchman (Peter and the Wolf) and Polish painter Dorota Kobiela decided to make a movie doing exactly that. Hiring an army of painters from across Europe, each trained in the Dutch master's style, they set out to tell his story the way he himself would.

Movie: Molly’s Game

Consequently, every single frame of the resulting film, Loving Vincent, is an oil painting (12 per second); the noirlike detective plot is drawn from the artist's many letters; and the cast – Chris O'Dowd and Saoirse Ronan alongside Douglas Booth, Helen McCrory, Aidan Turner and more, with music by Clint Mansell – were chosen based on their likeness to real-life characters in Van Gogh's works.

From all reports, it’s stunning.

In cinemas, November 23

Based on the memoir of Molly Bloom it opens the lid on the high stakes of international poker. The former Olympic ski hopeful becomes FBI target when she starts an underground poker empire for celebrities, athletes, tycoons and the Russian mob.

Theatre: Masterclass Amanda Muggleton reprises her award-winning role as Maria Callas in a Terrence McNally’s masterpiece Masterclass. Maria Callas as her brilliant stage career begins to wind down, she delivers a masterclass to a group of young vocal students at the Juilliard School in New York.

In cinemas, November 2

M E DIC AL FO RU M $12 .50

Subiaco Theatre Centre, November 16-December 2

Winners from August

Theatre: Let the Right One In

Movie – Lavazza Italian Film Festival: Dr Laura Dotto, Dr Sue Bant, Dr Barry Leonard, Dr Jeff Veling, Dr Suzanne McEvoy

Origins of Disease Clinicals: Kids’ Zone Lifestyle: On Two Wheels

AUGUST 2017

Movie – Maudie: Dr Wen Loong Yeow, Dr Norman Juengling, Dr Jennifer Ha, Dr Catherine Keating, Dr William Thong, Dr Astrid Valentine, Dr Yohana Kurniawan, Dr James Flynn, Dr Jan Parker, Dr Tammy Barrett-Izzard Major Sponsors

Movie – Emoji: Dr Lawrence Chin, Dr Narelle Keally, Dr Nai Lai, Dr Paul Kwei, Dr Helen Slattery, Dr Ines Chin, Dr Andrew Toffoli, Dr Trixie Dutton Music – Brahms' German Requiem: Dr Trenna Bridge Music: Lux Aeterna: Dr Henrietta Bryan Theatre: Switzerland: Dr Raphael Beilin

MEDICAL FORUM

The Australian premiere of this stage adaptation of the acclaimed Swedish novel and film is also artistic director Clare Watson’s Black Swan directorial debut. The play tells the story of a friendship between a boy and a centuries-old vampire.

The Value of Values

August 2017 www.mforum.com.au

Heath Ledger Theatre, November 11-December 3

Clarification In our story on Dr Rob Edeson’s new book, Bad to Worse (September), we indicated that UK publication and US distribution Rights had been secured.

In fact, these Rights apply to his first book, The Weaver Fish.

OCTOBER 2017 | 53