Heart of Gold Raising an Olympian
• Child Health • Ears, Eyes and Rehabilitation
August 2012 www.mforum.com.au
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8 Michelle Scott: A
32 TM Regeneration
10 Raising an OIympian:
34 Down Syndrome
Dr Rob McEvoy
20 Nature Play: A
Passport to Childhood
26 A Doctor in the
House: A Child’s Perspective
NEWS & VIEWS
Mr Peter McClelland
12 Practice Management Telehealth
14 Have You Heard 16 Building Healthy Cities Mr Peter McClelland
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6 Juvenile Justice
Judge Denis Reynolds
24 Child Protection Prof Peter Winterton
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29 Culturally Competent
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Medical Forum readers expressed concerns over the process of selecting panellists. We ask the Medical Board for answers to some of those questions.
In the June issue of Medical Forum, the magazine’s publisher and editor Dr Rob McEvoy took up the issue of transparency and accountability particularly as they related to appointments by the Medical Board to complaints panels.
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He wrote: “While appointments to the Medical Board are posted on the AHPRA website, the names of the 30 or so doctor panellists appointed by the board to hear complaints were not.” While acknowledging that those called before a panel had the opportunity to raise any concerns about panellist selection and bring a lawyer, “no one in the profession is given the opportunity to inform the Medical Board about a panellist prior to their appointment.” This obviously hit a nerve with the majority of doctors who responded to the July E-poll who believed they should be given the opportunity to comment (in private) on panel selection. It took us some time to elicit a response from AHPRA but they obliged us with these responses to our questions in time for our August issue
What is the actual process for appointments – who currently has most influence?
Under the National Law, the appointment of panel members is the responsibility of the Medical Board of Australia. The members of the Medical Board of Australia are appointed by Australia’s state and territory health ministers. The Board consists of eight practitioner members (one from each state or territory) and four community members. When seeking new members for the list of panel members, the Medical Board of Australia seeks expressions of interest, including by liaising with the relevant specialist college if there are specialist skills or expertise required. Panel members appointed prior to 1 July 2010 (and 18 October 2010 for Western Australia) by the state or territory governments or by previous state and territory boards transitioned into the National Scheme.
Can anyone nominate? Yes, anyone can make an expression of interest.
If someone called before a panel reveals a probable conflict of interest with a panellist, what happens then?
The Medical Board of Australia has extensive provisions to manage a conflict of interest before appointing anyone to a specific panel. The Board is typically conservative on this issue – if there is any possible conflict of interest, or any reasonable perception of a conflict of interest, a different panel member would be appointed. The names of the panellists are made known to the practitioner who is to attend before a panel prior to the hearing in order that conflicts or other issues can be raised by the practitioner. The name of the practitioner who is to attend before a panel is also provided to the panellists so they can identify any potential conflicts of interest. The Board also undertakes an exhaustive due diligence process including criminal history checking and assessment of any conduct performance or health issues to ensure there is no impediment to the person meeting all their responsibilities as a panel member under the National Law. This due diligence process is similar to that in place when Board members are appointed. One of the benefits of the National Scheme is that appointments are made nationally, so there is a national pool of panel members available if for any reason a local panel member cannot be appropriately identified.
The Medical Board does not offer WA doctors the opportunity to comment on someone’s appointment as a panellist. Why?
The Board will publish the names of panel members in the AHPRA and National Boards Annual Report later this year. Doctors who are the subject of a panel hearing will continue to have the opportunity to comment on the panel, to identify any possible conflict of interest and to protect the integrity of the hearing process. • Visit www.medicalboard.gov.au - For more information about notifications, refer to the information sheets published under the Notifications tab • Lodge an online enquiry by following the Make an enquiry link at the bottom of the home page
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Management of Multi-Resistant Organisms in the Community T his article gives a brief overview of the more common antibioticresistant bacteria seen in general practice and potential management strategies.
Community-acquired MRSA Staphylococcus aureus is the most common bacterial cause of skin, soft tissue and bone infections. Community-acquired MRSA is now common in Western Australia. The MecA gene in MRSA codes for a new penicillin-binding protein which renders these bacteria resistant to flucloxacillin and all other beta lactam antibiotics (e.g. cephalexin, Augmentin etc). It is important to obtain swabs for culture and sensitivity to detect MRSA and therapy should be guided by laboratory susceptibilities. Strains which remain susceptible to erythromycin are also sensitive to clindamycin. Clindamycin is effective therapy for significant MRSA infections and it is available as an authority script in general practice. If the strain is resistant to erythromycin, it should be assumed to be resistant to clindamycin because although they are structurally different, they have the same target site and cross-resistance is very common. Alternative agents for MRSA such as fusidic acid, ciprofloxacin and rifampicin are suitable alternatives but should always be used in combination because resistance to these agents is common if they are used as monotherapy.
Penicillin and multi-resistant Streptococcus pneumoniae (PRSP) Streptococcus pneumoniae (pneumococcus) is the most common bacterial cause of otitis media, sinusitis and pneumonia in children and adults. Unlike MRSA, the resistance seen in PRSP is a relative resistance with small changes to multiple penicillin-binding proteins gradually raising the minimum inhibitory concentration (MIC) of the organism. Most strains in Western Australia fall into the intermediate resistance category (MIC of >0.06mg/L and <2mg/l). This is of clinical relevance in the community for the
treatment of otitis media and sinusitis. This level of resistance can usually be overcome by increasing the dose of oral amoxicillin to 100mg/kg/day in 4 divided doses (up to an adult dose of 1gram PO QID). Where the organismâ€™s MIC is 2mg/L or higher, a change of antibiotic to a different class may be required. Multi-resistance is very common in penicillin-resistant strains so it is important to obtain microbiological samples where possible. Other beta lactam antibiotics such as cefaclor offer no advantage over amoxicillin and are generally less effective.
"The Key hole effect of an Extended Spectrum Beta Lactamase producing gram negative (ESBL)â€?.
It is important to remember that resistance to other classes of antibiotic (eg tetracylines, erythromycin and cotrimoxazole) are usually absolute resistance and therapeutic failure will occur with these agents. A practical approach to treatment of uncomplicated otitis media in children is to start with oral amoxicillin in the usual dose of 50mg/kg/day in 3 divided doses. If there is a failure of clinical response after 48 hours and no cultures are available to guide therapy, then it is reasonable to continue the oral amoxicillin but at a dose of 25mg/kg/dose twice a day and then add in amoxicillin/clavulate combination twice a day (dose of amoxicillin component is 25mg/kg/dose) and alternate the two agents. This delivers a dose of 100mg/
By Dr Michael Watson
kg/day of amoxicillin without delivering excessive quantities of clavulanic acid, which may cause significant side-effects. This combination also provides cover for beta-lactamase producing bacteria such as Haemophilus influenzae, Moroxella catarrahalis and Staphylococcus aureus.
Multi-resistant gram negative organisms Enteric gram negative rods (e.g. Ecoli and Klebsiella sp) are the most common cause of urinary tract infection in children and adults. In the past these were predictably sensitive to agents such as cephalexin and invariably sensitive to intravenous agents such as ceftriaxone. Two new resistance mechanisms have emerged in the few years called extended spectrum beta lactamase (ESBL) and Inducible Chromosomal beta lactamase. These two types of beta lacatamse break down all penicillins and cephalosporinlike antibiotics (including third generation cephalosporins) with the exception of the new carbapenems (meropenem and ertapenem). They are now common in the community in WA and their plasmids (circular pieces of DNA) often also contain genes for resistance to aminoglycosides (gentamicin), fluoroquinolones (ciprofloxacin and norfloxacin) and cotrimoxazole rendering them virtually untreatable with any oral agent available in Australia. For those strains without an oral antibiotic choice, treatment with IV intravenous antibiotics is required and a good option for this is single daily Ertapenem as home IV therapy.
Summary Multiple antibiotic-resistant bacteria are now common in the community in Western Australia. Choice of therapy should now be guided by microbiological investigations in many situations as the ability to reliably predict antibiotic effectiveness is rapidly disappearing. Judicious use of antibiotics will be essential to help prevent the further spread of these organisms in the community.
Operating to stop the waste Last month, Dr Richard Yin raised the issue of the wasteful notion of paper linen, here Dr David Borshoff looks at the issue inside the operating room.
t an anaesthetic conference in Chicago last year, a session was devoted to ‘The Environmental Impact of Anaesthesia’. It included choosing an anaesthetic technique based not just on clinical need, but also on its greenhouse gas and landfill contribution. I have since received a directive from ‘Corporate Nursing Services’ in my public hospital, to only employ ‘Single Use Tourniquets’. Yes, that elasticated, plastic buckled item that for years we have used to extract blood or insert intravenous lines, has to be thrown out after each case in the name of infection control. This is in addition to single-use drapes, laryngoscope blades, bronchoscopes, masks, circuits, sucker bottles, instruments, gowns and procedure packs. Significantly, the procedure pack contains a stainless steel pair of scissors, forceps and needle holder – all to be discarded. Clearly, single-use items have established their place in patient care – needles, endotracheal tubes, urinary catheters and
scalpel blades to name a few. But to target the tourniquet, when ECG leads, automated blood pressure cuffs and pulse oximeters remain, seems excessive and could be viewed as environmental vandalism. The importance of a good infection control department cannot be overestimated. The work, highlighting a need for meticulous handwashing, urinary catheter management, central venous line care and health worker education, is all evidence based and beneficial. However, implementing single-use policies with its associated impact on the environment carries enormous responsibility and decisions should be based on sound scientific evidence. Cost restraint and convenience in the current climate are not adequate justification. Examining the ethical implications of this practice, the question is raised on where to draw the line. As one of the world’s highest carbon producers per capita, it seems arrogant to expect developing nations to sign agreements on emissions control, while
we enthusiastically adopt the single-use mentality for cost cutting and questionable clinical benefits. When do we, at all levels of society, take responsibility for our environment and say enough is enough? When do we accept the current standard of health care and cease to consume more resources and produce more landfill for potentially small gains? If policy makers and health-care workers all witnessed hospital waste at the end of each day, perhaps our thinking and behaviour would change in support of a more sustainable future. And if my public hospital is serious about reducing the risk of infection, then they should employ surgeons who use the best technique, take the shortest time, minimise tissue damage, give appropriate antibiotics and make sure everyone has clean hands. Let’s keep the tourniquet. l Declaration: David Borshoff is a private anaesthetist who maintains a sessional public hospital commitment.
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Early Intervention is the Key
Vulnerable children in the juvenile justice system need prompt and specialist help â€“ not another court â€“ according to President of the Children's Court, Judge Denis Reynolds.
he Children's Court of Western Australia deals with all charges brought against children for criminal offences, including the most serious offences of personal violence, robberies, burglaries, car stealings and sexual offences to the less serious kinds for which no detention can be imposed such as disorderly conduct and simple traffic offences.
level. Entry into the youth justice system should not be regarded as the catalyst for assessment and service provision. Also, mental health funding should not be linked to crime reduction.
Often children appear before the Court for multiple offences.
Section 49 of the Young Offenders Act 1994 empowers the Court to send a child it believes is suffering from any mental or nervous disorder or handicap to a suitable place for observation, assessment and recommendation on future treatment. There is no place specifically for children that the Court can use for this purpose. The Bentley Adolescent Unit provides much-appreciated assistance to the Court for this purpose but it is not a secure facility.
The prevalence of mental health problems is greater for people in the justice system than it is in the general population. I have been President of the Court for the past eight years and it is my firm view, and that of experienced Magistrates of the Court, that many children appearing before the Court are more mentally damaged than ever before. In many cases seriously so and very young. Given this, the funding for the Mental Health Commission to provide psychiatric and psychological services to the Court is particularly relevant. The Court has long been in need of more mental health services and program for children to assist it to perform its functions. From my vantage point, service providers seem to be under pressure and there are long waiting lists of up to six months. In some locations there are no services to deal with children with complex needs and in others there are no services at all.
Mental health funding should not be linked to crime reduction.
Children do not appear before the Court until they have reached the age of criminal responsibility, which is 10-years-old. By then, nearly all of the children that I deal with for serious offences exhibit acute mental health problems. In some cases, expert reports obtained by the Court show that children are suffering from diagnosed disorders. Regrettably, hardly any of them have been previously identified nor provided with any mental health services. It is absolutely essential that more resources are invested in early identification and intervention at the local community 6
When children appear before the Court, it seeks written reports on their psychiatric and psychological health from Youth Justice of the Department of Corrective Services. Such reports are highly expert, but far from timely.
Section 5 of the Criminal Law (Mentally Impaired Accused) Act 1996 empowers the Court, if it suspects that a child has a mental illness requiring treatment, to send the child to an authorised hospital to be examined by a psychiatrist and potentially be made an involuntary patient. No hospital has been specifically authorised for children. The Frankland Centre at Graylands Hospital is a locked-ward facility used for the purpose of section 5 but it is really only for adults. As a result children are held at the Rangeview Remand Centre if bail is refused. Against that background the recent funding for increased mental health services for the Court is very welcome. The Court will be able to call on expert opinions from psychiatrists, psychologists and senior registered nurses in a more timely manner when a child appears before the Court. Of course, if the expert advises that the child needs to be remanded for further assessment, then the problem of a lack of a secure facility will still arise. Importantly, increased funding will provide more efficient links to existing services. The idea of a Mental Health Court has been discussed and, indeed, one is to be set up in the Magistrates Court. Clearly, the Court and the community need more resources for mental health services for children. The question is how can that best be achieved within the available funding?
In my view, the creation of a multiplicity of specialty courts within the Court is not desirable. We already have a Drug Court. Why have a separate Mental Health Court as well, when the cohort of children suitable for both would essentially be the same? Rather than a high proportion of the funding going to create and maintain another specialty court structure, it would be far better used to increase service capacity. The creation of a Mental Health Court would create expectations which the Court could not meet without timely access to adequate services. It could also unfairly criminalise and stigmatise some children, particularly those with psychiatric disorders who have committed relatively minor offences.
Rather than a high proportion of the funding going to create and maintain another specialty court structure, it would be far better used to increase service capacity.
Children who commit serious offences and those with mental health disorders have many factors in common. These include parental separation, exposure to domestic violence, unstable accommodation, neglect and abuse, grief, poor schooling and substance abuse. Their lives are characterised by layers of crises and they are constantly overwhelmed by stress and unable to cope. This results in behavioural problems. The responses to mental health problems need to be combined with programs which address all of those underlying causative factors. For Aboriginal children, it is essential for the coordinated response to include cultural programs and Aboriginal mentors. Establishing senses of identity, connection with community and hope provide a foundation for personal wellbeing, education and economic participation. Having a single prevention and diversion court within the Court, whatever its name, to manage each case in an holistic way with timely access to adequate mental health services is, in my view, the best approach. l
Mending a ‘Broken Heart’
Dr Mark Hands Clinical Associate Professor (UWA), Interventional Cardiologist
ecently, while travelling with my 19-year-old son Matthew, I took a hands-free call from a doctor at a peripheral metropolitan hospital. He wished to transfer a 69-year-old woman with "ischemic" chest pain associated with anterolateral ST segment elevation. Ten minutes before her chest pain she had been told the tragic news that her 39-year-old son had been in a motor vehicle accident overseas and was in a coma with severe head injuries. Matthew volunteered that it seemed she had a "broken heart". Indeed, that is exactly what she did have.
On arrival at our unit she still had some residual chest pain, was haemodynamically stable in sinus rhythm with blood pressure 130/80 and accompanying ST segment elevation leads V2-V6. After immediate transfer to the cardiac catheterisation laboratory, angiography demonstrated widely patent coronary arteries (minor plaque in the LAD). However, the distal two-thirds of the left ventricle demonstrated marked impairment of function (akinetic/ hypokinetic) in association with vigorous contraction of the proximal third of the ventricle (Figures 1 & 2). Her heart was "broken" and she had the classic Tako-tsubo cardiomyopathy. The troponin level peaked at 3.63ug/L (<0.1). Management consisted of ACE inhibition and beta blockade, and five days postevent echocardiography demonstrated already substantial improvement in left ventricular function. Tako-tsubo cardiomyopathy (TTC) can mimic anterior ST segment elevation myocardial infarction (STEMI). It is characterised by acute onset of chest pain, ST segment elevation in the chest leads and transient but usually significant wall motion abnormality of the distal half of the left ventricle. TTC is associated with the absence of significant obstructive coronary artery disease (CAD) or evidence of plaque rupture, and the left ventricular (LV) function usually recovers rapidly in association with an excellent prognosis. First reported in the Japanese population in the early 1990s, the term 'Tako-tsubo' refers to a Japanese octopus catching pot with a round bottom and narrow neck, which is the shape the left ventricle takes in systole. TTC is often referred to as 'stress cardiomyopathy' because
symptoms are frequently preceded by a major stress, either physical or psychological (e.g. unexpected death in the family, devastating medical diagnosis, car accidents, acute physical trauma, major surgical procedures). Interestingly, most patients are post-menopausal women. TTC is frequently clinically indistinguishable from acute left anterior descending coronary artery occlusion, with the diagnosis requiring differentiation with coronary angiography, which demonstrates no signficant CAD or plaque rupture and LV wall motion abnormality not explained by single vessel occlusion (i.e. multiple vascular territories are involved). With more patients undergoing angiography for acute STEMI, TTC is being more frequently recognised. Notably, serial troponin and creatine kinase MB levels are raised in TTC, but small in comparison with the wall motion abnormality (as in our case). However, the absence of a troponin rise does not exclude the diagnosis. It is unusual for serious haemodynamic compromise to persist beyond the time of initial diagnosis. While the ventricle is recovering it is reasonable to treat patients with beta-blockers and ACE inhibitors. Wall motion abnormality usually returns to normal within days and certainly within a month. Those who do not succumb to the initial haemodynamic compromise have an excellent prognosis and invariably no long-term sequelae (and importantly, coronary angiography avoids a diagnosis of anterior MI with its far worse prognosis). There appears to be no debate that the syndrome is due to a sudden surge in catecholamines. However, how this
About the author Dr Mark Hands graduated from UWA and trained in cardiology at Sir Charles Gairdner Hospital and Brigham Women’s Hospital, Harvard Medical School. He is an interventional cardiologist in private practice at Western Cardiology (chairman) and emeritus consultant cardiologist at SCGH. In addition to general cardiology and echocardiography his special interests include investigation and treatment of acute and chronic ischemic heart disease. Dr Hands’ interventional procedural skills include coronary angiography, angioplasty and stenting in stable angina and in acute unstable angina and acute myocardial infarction, cardiac pacing, percutaneous closure of atrial septal defects and patent foramen ovale.
results in acute reversible wall motion abnormality is unknown. Postulates include: microvascular spasm, acute LV outflow tract obstruction or perhaps neurally mediated localised microvascular ischemia.
Summary Tako-tsubo or stress cardiomyopathy is an important differential diagnosis in acute anterior MI. It may account for around 2%-3% of patients presenting with features of acute MI. Despite initial significant haemodynamic compromise in a significant proportion of patients, there is an excellent prognosis, which is important for ongoing counselling or perhaps insurance purposes.
n Thinker in residence Dr Stuart Shanker and Commissioner for Children and Young People Michelle Scott met some of the children of Roebourne.
A Healthy Future Begins Today Michelle Scott is giving voice and policy push for the 540,000 West Australians who are vulnerable and don’t vote. WA’s population surge has put many health services under pressure, but as the Commissoner for Children and Young People, Michelle Scott, says, it has meant the state has lagged behind other states in areas crucial to the wellbeing of children. “There are about 540,000 children and young people under the age of 18 in WA and almost half of those are 0-8 years. Over the past decade there has been an increase in births of almost 31% and services for those early years haven’t kept pace with the population growth.” “There have been three parliamentary inquiries and a general inquiry all saying there is a significant shortage of child health nurses and yet they are the most critical support to families in those very early years. They give important information to parents about child development, they are referral points to other parent groups to specialists, speech therapy, OT assessment, they help parents with sleep patterns/behaviours – these 8
are important areas in the wellbeing and development of a child.” While the State Budget committed $58 million over 4 years for 100 more child health nurses, it could be a fraction of the number needed to stop the slide. Commissioner Scott tabled a report to the WA Parliament earlier this year which delivered the sobering news that 1 in 4 children by the time they start school were developmentally vulnerable. That percentage was one of the highest in the country. “If you’re young and live in the rural regions, it’s a third and if you’re Aboriginal it’s 1 in 2,” she said. “This report identifies some of the problems and gaps and where we need to put our resources and investment.” An area that has garnered positive attention is mental health after the commissioner held an inquiry in 2011. “There were 141 public submissions and I met with parents, families, service providers, agencies and children,
themselves, across the state. Everyone felt it was an area of need. That report identified increasing reporting of anxiety and depression in children and young people.” “Many of these children have conduct disorders and behaviour difficulties. The data from that report told us that 4 out 5 children in WA who had a mental health disorder/problem could not access services. That report made 54 recommendations and we worked closely with the Mental Health Commissioner Eddie Bartnik and I’m please to say that in just over 12 months, there has been significant progress in redressing that issue.” “Previously 95% of funding in mental health went to adult acute hospital care, now it has been recognised that if we don’t do something about the mental health of children and young people, we not only don’t solve the problem, it will have enormous consequences as they grow to be adults.” Mental health and alcohol-related harm were the two emerging issues of concern medicalforum
“Parent and teachers are finding this issue of kids’ behaviour and anxiety and inattention real issues of concern,” Michelle said. “Dr Shanker’s message was that kids today were demonstrably under more stress. They sleep on average 2 hours less than 10 years ago. They watch TV 4 hours a day and spend 3 hours at a computer. And parents are under a lot of stress too.”
for parents, young people and policymakers alike. Concern is growing about the persistent incidence of foetal alcohol syndrome but children themselves are drinking excessively in a culture that sends very mixed messages about the harm of alcohol. Commissioner Scott said that Australia had one of the highest rates of alcohol consumption in the OECD, second only to the UK and WA’s rates were higher than the national average. “We asked 300 young people their attitude to alcohol. They responded, ‘My parents drink; my parents give n Michelle Scott at the Commissioner for a Day Challenge with students. me alcohol’. That’s an issue for us. We can’t tackle young people’s thinker in residence. Canadian Dr Stuart consumption of alcohol without seeing it in Shanker has just completed his residency the broader community context.” sharing his thoughts and techniques on “These young people told us that they self-regulation – how children can firstly needed more education (and early at monitor their own behaviour and emotions primary school) and they urged an and then how can they can modify them. enforcement of the law. They told us they In Ontario he has been involved in rolling accessed alcohol two ways – their parents out a $1.5 billion program with teachers supplied it or they were able to get it readily, of early childhood, public health nurses, even though they were not 18, from licensed parents and physicians so they can teach premises. Secondary supply legislation those techniques to children. In WA he met needs serious consideration.” thousands of children, parents and allied One of the Commissioner’s creative health professionals for which the topic of initiatives was establishing an annual self regulation resonated.
“Teachers found Dr Shanker’s arguments compelling. An ECU report to the Education Department cited teacher evidence that on any one day 20% of their students were disengaged; they couldn’t focus or they were anxious. That’s quite a proportion
Michelle said that when it came down to what was most important in their lives, children and young people didn’t hesitate – it was their family and spending time with them that contributed most to their wellbeing. And an important part of the equation was GPs who were critical in their role supporting children and their families at all stages of their lives.”l
By Ms Jan Hallam
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The Heart of a Champion
The hearts of cardiologist Dr Luigi D’Orsogna and his wife Ann will stop for a few seconds this month as they watch their son live his Olympic dream. It’s a long, hard road to the London Olympics and Perth cardiologist Luigi D’Orsogna and wife Ann know every single step. Their 21-year-old son Tommaso is vying for a spot on one of the best 4x100m Freestyle Relay teams in the world. Tommaso is both dedicated and determined to reach the elite level of competitive sport, but as they all point out, it has been a team effort from the starting blocks to the finish line. “Juggling Tommaso’s swimming career with the demands of medicine hasn’t been too difficult. Fortunately, Ann is the swim Mum. She instilled in him the fun and competitiveness of swimming. I certainly can’t claim he’s inherited my ability! I’ve always tried to watch him compete, and not just for the successes, but also for the failures as well,” Luigi said. And Tommaso is the first to admit that there have been disappointments along the way. “The 200m freestyle trials didn’t go according to plan. I changed my coach six months beforehand and I just didn’t swim fast enough. I’d been on track to make the top two but ended up coming eighth. That was my worst performance for three years but I try not to dwell on those things.” Tommaso said. Olympic tensions won’t be eased until the final of the relay. There will be a few nailbiting moments for the entire family as the 6-member team gets whittled down to 4 for the final. “The pressure to swim fast is no different to any other race that I am in. I can’t concern myself on how others are swimming, whether they be competitors or teammates. I can only focus on what I need to do to get the best out of myself. If I am good enough, then I get to swim in the finals.” For his proud parents just making the Olympic team is an amazing achievement but they are especially proud of the way Tommaso has achieved his goal.
n Tommaso D'Orsogna 10
“To come back from the disappointment of missing out in the 200m Freestyle, and swim the next day to make the finals in the 100m Freestyle was testimony to his character. We were very proud of the way he was able to put disappointment behind him, to refocus and have the mental toughness and confidence in his ability to compete in such a competitive event,” Luigi said.
n Commonwealth Games Gold Medal Relay Team: James Magnusson, Tommaso D'Orsogna, Eamon Sullivan and Kyle Richardson
The setbacks haven’t always been in the pool and it has been Mum to the rescue with a secret weapon. “I was diagnosed with coeliac disease when I was 13 years old, which was tough. I’m pretty experienced in managing my diet now and the main problems occur when I compete overseas. My favourite meal is Mum’s lasagne and I could eat it every day!” Luigi freely admits the swim gene is not on his side, but for Ann it has always been a ‘life aquatic’." “I grew up in Pinjarra and was a founding member of the Mandurah Swim Club. I have fond memories of competing at country meets and at State level. I was always keen for my children to be strong swimmers and to give them the opportunity to compete in the sport. All the children are good swimmers but Tommaso demonstrated a strong affinity for water from a very young age,” Ann said. “When he was six years old Tommaso told his aunt he’d go to the Olympics one day. But he was often in trouble with his coach for being under the n Ann, Tommaso and Luigi D'Orsogna water. He loved to swim under the other swimmers and wave to them. “Amelia and Gabby have always been very When reprimanded he’d just say he was supportive of Tommaso – they’re both having fun. He certainly embarrassed his very good swimmers and understand sisters who were training on the other side the demands of competing at an elite of the pool.” level. Amelia’s got degrees in Law & Arts However, there’s no sibling rivalry between Communication and now lives in London Tommaso and his two sisters, Amelia and where she’s the E-Commerce Content Gabby. They’re high achievers in their own Coordinator for the fashion house, Jimmy fields. Choo. Gabby’s a chartered accountant medicalforum
Juggling Tommaso’s swimming career with the demands of medicine hasn’t been too difficult. who works at Deloittes. We’ll all be together in London for the Olympics,” Anne said. For dad Luigi, the disciplines of sport and medicine have common ground. “Dedication, sacrifice and determination – there’s immense satisfaction in achieving goals as an elite sportsperson but you also need a degree of humility and selfbelief, qualities which are important as a doctor. The importance of teamwork and collaboration can’t be overemphasised either.” “Tommaso’s doing a degree in Medical Science at the ANU in Canberra. He’s talking about doing a graduate course in Medicine when he’s finished competitive swimming. Medicine’s a great career but there’s no rush for him to be a doctor. There’s a limited window of opportunity for his swimming and a medical degree can be completed later on. You’re a doctor for a long time.” While the family are all going to be in London to see Tommaso swim, it’s destined not to stop there. “I’m keen to go to Rio for the 2016 Olympics, but right now my Speedos are packed for London.”l
By Mr Peter McClelland 11
London will be Ken’s Olympic finale Dr Ken Fitch has been able to combine his medical vocation with his love of sport and it has taken him all over the world. Dr Ken Fitch, by his own admission, has had a fortunate life. He has been a physician at 17 Olympic Games and London will be his 18th and final outing but over the years he has seen a lot – from the horrific 1972 massacre of Israeli athletes in Munich to developments in the world of drug-testing. “Munich is certainly one of my strongest memories. It was such a shame because the Germans had done their best to put on a really enjoyable event and move away from the stigma of Hitler’s showcase, the 1936 Games in Berlin. Early one morning, I’d climbed over a two metre fence to go running around the perimeter of the Olympic village – a 6km run. It was probably the same fence that the Palestinians had used to enter the village an hour earlier. The Germans were completely unprepared for the hostage situation,” Ken said.
We’re pretty sure some people are still cheating because we’re not able to detect everything at the moment. While the horror of the Munich games still resonates, it’s the battle against drug cheats that has occupied so much of his time since. It was at the 1988 Seoul Olympics that Ken took a personal role in the doping case of Canadian sprinter Ben Johnson. “I actually took the message to Canada that Ben Johnson had tested positive to steroids. The ‘B sample’ was also positive and when we did a steroid profile on him we found that there was a marked suppression of
endogenous steroid production. This could only have resulted from previous chronic use of anabolic steroids, which completely conflicted with the excuse that someone had slipped a tablet into one of the 10 beers he drank after the race.” Drug-testing has advanced in leaps and bounds since then. “It’s all about chemical analysis. I’ve been a member of the Australian Anti-Doping Research Panel for the last 12 years and the panel funds the Australian Sports Drug Testing Laboratory in Sydney, which is one of the best in the world. It is a constant battle because so much of the stuff is made by clandestine laboratories overseas and purchased over the internet. Funding from the Research Panel has allowed the laboratory to identify several of these new drugs, which have been developed by slightly modifying the radicals. We’re pretty sure some people are still cheating because we’re not able to detect everything at the moment.” Anti-doping agencies share information with pharmaceutical companies, and have been for some time. But, as Ken points out, it’s not quite as simple as it seems. “We’re now liaising with some of the pharmaceutical companies to try and track third and fourth generation performanceenhancing Erythropoietins (EPO). Back in 1989 the IOC was about to ban the first EPO and the drug companies pleaded with us not to do that. So we asked them to put a ‘marker’ in it but they said it would cost millions to have it re-approved by the FDA. It’s complicated. You have to remember that they’re producing these drugs for people with chronic renal failure.” So now with the London Olympics off and running does he think it will be a ‘clean’ Games? “There will be athletes using performance enhancing drugs in London, there’s no
doubt about that. But I think there’ll be far fewer than there might have been now that the pressure has come on the African countries to test their own athletes. I think there’ll be five times as many athletes who’ll test positive pre-Olympics compared with the number failing a doping test during the Games.” From the heroics of the Olympics to the more prosaic issue of men looking after their own health, Ken has been preaching the same message for quite some time. “A lot of men don’t like to talk about this and, for too many of them it’s a case of ‘It won’t happen to me’ or ‘I’m just too busy’. I’ve been promoting exercise to prevent heart disease since the 1960s.” “Back then I used to say I spent half my working week providing patients with prescriptions for exercise and the other half treating the injuries they sustained heeding my exercise prescriptions!” “When you love medicine as I do, it was one of the best decisions of my life to become a doctor. When you’ve also got a passion for sport and can make a career out of both of them you’re very fortunate indeed.” l
By Mr Peter McClelland
Fact Box • There will be 10,500 athletes. 26 Sports and 39 Disciplines at the London Olympics. • There are 410 athletes in the Australian Olympic team. • There are 302 Medal events • 5000 doping samples will be taken • It will attract a global TV audience of 4 billion
Here’s some tips if you are not sure how to go about it • mbsonline.gov.au
• racgp.org.au booklet: ‘Implentation guidelines for video consultations in general practice’ • ruralhealthwest.com.au/go/telehealth
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Telehealth offers a much needed service to nursing home and country patients, without them having to go to the time and expense of travelling to major cities. The Government has offered very good incentives to the healthcare sector to take up Telehealth. We are still in phase 1, so signon payment is $6000 per service provider. When Phase 2 starts in July the sign on payment drops to $4800, which is still a very good incentive.
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Have You Heard? Health Service Governing Councils
SIDS and Co-Sleeping The University of Queensland’s Centre for Mothers and Babies (UQCMB) is keen to dampen suggestions that all co-sleeping arrangements are inherently dangerous. “Such a blanket statement is misleading,” said Jeanine Young, the Chair of SIDS and Kids National Advisory Council and UQCMB spokesperson. “Parents need to be made aware of all the factors relating to SIDS such as medication use, smoking, alcohol, pets and other children in the bed,” she added. Cultural factors play an important role, too. Prof Sue Kruske from UQCMB stated that “around 95% of indigenous families have co-sleeping arrangements and it’s also very common among our refugee population. It’s naive to suggest that there’s a direct link between bed-sharing and the deaths of these infants. Furthermore, you run a very real risk of alienating these groups from other health services if you don’t provide a more balanced appraisal.” It would seem, in this instance, that ‘moderation in all things’ is timely advice.
Five new councils were launched by Health Minister Kim Hames in mid-July with some experienced heavy-hitters sitting at the top. Prof Bryant Stokes leads South Metropolitan, Dr Rosanna Capolingua heads the Child and Adolescent Health Council and former Kalgoorlie Mayor Ms Nola Wolski is in charge of the Northern and Remote Country Health Service. In a press release Dr Hames stated that the “calibre of applicants was very high.” The aim is to make WA’s public health system more responsive and flexible plus increasing its accountability to the wider community. Each council will have four clinicians (one from allied health), three corporate representatives and one community member. In a linked reform, five new Health Services (including two for rural WA) also opened shop.
Target Mr Average If you’re concerned about poor investment returns thanks to the GFC and you’re tempted to suspend your disbelief, then here’s something not to try at home. The website, SmartCompany reports that about 2600 victims have lost $113 million through investment frauds during the past five years. A report compiled by a joint taskforce from the Australian Crime Commission (ACC) and the Australian Institute of Criminology paints a picture of the typical target of investor fraud: male, around 50 years-old with a self-funded retirement account. Add to the mix highly educated, well-read and confident in managing their own finances. The targets can be broken down into two categories – trusting investors and entrepreneurial investors. “Put in due diligence,” said an ACC spokesperson. “And, when it comes to long-term investment, what’s the hurry?”
Numbers swell for GP Training The federal government has announced that a record 1100 junior doctors will take up GP training places in 2013. In WA the number of places will increased to 101 from 92 places this year. By 2014, the government expects to have doubled the number of GPs in training with more being trained in each State and Territory and by 2020 the target is for an extra 5500 GPs and 680 specialist doctors nationwide.
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Med Schools’ Numbers Game With the debate set to hot up over Curtin University’s bid for a medical school, news from NSW where the regionally based Charles Sturt University is lobbying for a medical training course is sobering. The CSU bid for an 80-student course seems to have hit a snag because of a shortage of hospital training places in the state. What places are available are in high demand from full-fee paying overseas students. “There is a big challenge there to create the space for rural students to get access to rural and regional-based hospitals to undertake medical training,” CSU’s Mark Burdack said. It’s interesting times ahead for the education and training of our future doctors and campuses across Australia who will no doubt be burning the midnight oil trying to work through the conundrum. Watch this space.
The Australian Centre of Philanthropy ranked doctors as some of the most generous givers to charity in Australia with four medical specialties ranked in the top 10 occupations who love to give. Anaesthetists were ranked second on the list claiming an average of $2181 in charitable tax deductions, internal medicine specialists were third ($2133), GPs eighth ($1719) and surgeons were ninth, ($1706). Overall 8200 GPs, or almost 46% of the profession, claimed more than $14 million in donations and gave an average of 0.58% of their annual income to charity. CEOs and managing directors were on top of the list claiming on average $3923 each with an impressive total of $162 million claimed.
Plugged in, Tuned In You see them on the train, at the bus stop, even sitting on your couch – people of a certain age, plugged into their phone or iPod tuned out and not listening to a word that’s being said. Peter Riggs of the Ear Science Institute Australia was not so much frustrated as concerned that permanent damage was being done to hearing. So the ESIA computer programmer devised the Safe and Sound app, which measures the decibel level of the sound emitted from a mobile device and tells the user how loud their music really is, and alerts them when they are nearing their daily recommended
noise exposure limits. The free app can be downloaded to any Android device and is suitable for all ears. An Apple app is in development.
Stethoscope rules, OK? It’s a cliche, but apparently a distinctly trustworthy one. A Curtin University study published in the Journal of Internet Research showed a number of ‘iconic’ medical images to a range of willing participants. The trustworthy stethoscope had twice the positive impact of any other medical symbol. The other items ranged from a reflex hammer, an otoscope and, in a nod to television, wearing scrubs. The results revealed a 95% odds-on rating that an artfully draped stethoscope suggested its owner was ‘honest, trustworthy, ethical and genuine’. Trust me, I've got a stethoscope.
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Cities Go with the Flow It's a time of great change in our city and Prof Peter Newman says it needs people of vision to speak up for its sustainable future. A recent State of Australian Cities Report received 150,000 hits in 24 hours. It’s a popular topic given that the vast majority of us live in cities clinging to the coast. Curtin University’s Peter Newman has some strong messages regarding social interaction, sustainable transport and making Perth a better place to live. He says that doctors and academics have an important role to play. “It’s very important for academics to speak out on these issues. Sadly, it’s quite rare for them to do so because most prefer to just sit back and observe. Right now is a very important time to help set the vision because it’s a time of significant change in our cities. And that change cuts both ways – it’s too slow for people who are concerned about climate change issues and too fast for some who are out in the suburbs seeing rapid changes they don’t like. It’s time for more people to speak out and provide a wider perspective.” There are distinct overlaps between critically important issues such as peak oil, the environment and health. Perth’s medical fraternity is a voice that Peter Newman would love to hear loudly and clearly. “I went to a recent Doctors for the Environment meeting and it was clear that the health agenda is a major part of the sustainability issue. We must have more liveable cities, we have to be able to walk rather than drive and we have to consume fewer resources. These are complex agendas and many of them will shape our time in history. If doctors aren’t part of this process, they’ll be missing an opportunity as respected members of the community to lead the discussion.” Sometimes it takes a significant life event to shape a career and that’s certainly the case with Peter Newman. He was living in California when the oil crisis struck and watched a city fall apart. “I realised that we had to overcome our car dependence. And when I was elected to Fremantle City Council I became aware that I could help set the agenda. I’ve been an engaged and eternally hopeful academic ever since.” So what would he see if he were to gaze down at the city of Perth from a hot-air balloon? “Traffic is at a complete standstill and people sitting in cars moving along in tiny little steps. You can walk faster than that! 16
fondly of his childhood in Perth. He was adamant about the importance of ‘taking back the streets’ for the people who live in them. Some European cities are leading by example, particularly in Germany and the USA. “There’s an eco-village in Freiburg, Germany, called Vauban. There are about 1000 homes with kids playing in the streets because vehicles are left outside the city in a car park. The inner city is set aside for pedestrians and cyclists and they’ve instituted a program called ‘biophilic urbanism’ which is about bringing nature back to the city. Most of us suffer from some sort of ‘nature deficit’ disorder – we all need a daily dose of nature.”
n Prof Peter Newman
You can also see a very fast train zooming past, the cars packed to the gunwales, the same train that all the experts said wouldn’t work because Perth was too scattered and car-oriented. And it works brilliantly! So, what we have here is a model to rebuild our car-based suburbs and transform areas around train stations into walkable centres where people can live and work and access other areas using a bicycle. One day I hope I’ll be able to look down and see that.”
It was clear that the health agenda is a major part of the sustainability issue. The remodelling of a city is a complex agenda, particularly with Perth’s rapidly increasing population linked with the mining boom. Overlaying that with attempts to build a sustainable future is paradoxically fraught with difficulties yet ripe with opportunity. “Sometimes I’m outrageously optimistic when I see the investment in renewables compared with fossil fuels. Peak car use is dropping dramatically, especially among young people, and the increase in sustainable modes of transport is off the scale in ways that we couldn’t have predicted. I see change happening at a rate I didn’t anticipate.” Medical Forum spoke with ABC Radio’s, Russell Woolf earlier this year and he spoke
By 2050, about 70% of the world’s population will live in cities and 75% of those cities exist now. Some of them are already ‘star performers’ when it comes to a comfortable and sustainable urban environment. “Singapore has shown what can be done with a high-density option and it’s very attractive, well integrated and liveable. Vancouver is a terrific place as are Portland and Seattle. In fact, that north-east corner of America is probably leading the sustainable city agenda. And how could you not love the traditional cities of Paris and London?” Perth, according to Peter Newman, scores reasonably well too. “I think we’ve done things that the rest of the world can learn from – take trains and water supply. Our train service has succeeded when all the experts said it wouldn’t and wind-powered desalination now supplies 50% of our drinking water. I’ve seen that if you want to set a visionary agenda you have to do it in steps and stages. We’ve done that here in Perth.”l
By Mr Peter McClelland
FACT BOX • WA is the fastest growing state in Australia. • Population: 2.2 million. 14.3% increase since 2006. • Average increase: 154 residents per day. • Median age in WA is 36. • City of Perth has experienced a 43% population increase since 2006. • 54,000 WA households have at least four cars. Source: 2011 Census medicalforum
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Students' Future Concerns medico Dr Sally (Dr Feelgood) Cockburn to express their concern at the prospect of modest internship numbers in relation to the projected number of graduates. Mr Churchill said that up to 450 graduates may not obtain an intern placing next year.
n Ian Olszewski Convenor AMSA Convention 2012
n James Churchill President - AMSA
The Australian Medical Students Association (AMSA) held its national convention in Perth last month and scarce intern placements in the post-graduate years were very much on the minds of the 1000 delegates who came from all over the country. The national president James Churchill (Melbourne University) and convenor Ian Olszlewski (UWA) held a press conference alongside Dr Rosanna Capolingua and TV
All were particularly concerned that the future would be more clouded if the proposed new medical schools at Curtin University and Charles Sturt University in New South Wales were given the nod. All four suggested the situation was at crisis point and said that they feared for the future of the profession and for the quality of the health system. The issue was given a broader airing with more than 400 students witnessing a vigorous panel discussion between Prof Fiona Lake (Head of School at UWA), Dr Neale Fong (project director of the Curtin medical school proposal) AMA national vice-president Prof Ian Dobb and Mr Churchill representing AMSA. Prof Lake acknowledged the challenges of finding a balance in the system of education and training and thought strong leadership
n Tom Eldredge, Jared Fairbank, Kathnik Venkataraman, Moktika Tandon
would be crucial in planning the future. Dr Fong suggested that the shortage of GPs needed to be addressed at the DIT level and the one thing the mining boom had shown West Australians was the necessity for all professions to go where the work was. Delegates to the seven-day conference also heard from the likes of former AFL coach Mick Malthouse, former Prime Minister Kevin Rudd, (who was to appear in person though did his presentation via video link at the last moment), and Dr Fiona Wood, Dr Patrick McGorry and Dr Karl Kruszelnicki. And there was plenty of time for fun with social events and competitions running throughout the week. l
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A Passport to Childhood Once playtime was home before dark, now children are cocooned and managed, but nature is fighting back. Do you remember your mother saying with some exasperation, “Get out of the house and play”? And as small feet stampeded for the door, her voice could be heard over the slamming door, “Be back before dark”. That was the reality for many childhoods in the 1950s, 60s and 70s. But things have changed. In one generation children’s play has been managed like an army operation. According to Griffin Longley, CEO of Nature Play – a not-for-profit organisation which encourages children to get outside and explore their world and their own capabilities – it hasn’t been a simple change but a complex web of cultural shifts. 20
“Consider the effectiveness of awarenessraising campaigns such as stranger danger, slip slop slap – they have worked really well and are very important, but they have had unintended consequences adding to the general sense of danger outside your house. “Combine their accumulated effect with the 24-hour news cycle and it has left us with a view that the world is a very dangerous place from which we need to protect our kids. Parents have been marinated in fear. We expend a lot of effort making sure our kids don’t have any time on their own, certainly not on their own outside of the house.” There has also been immense social change as well. The back yard has shrunk
and often both parents are working. The neighbourhood is not the known, friendly community it once was and playing inside is no longer empty hours of boredom, nature’s great stimulant. Technology has connected children virtually so there’s less need for physical connection. Griffin said public liability has also emerged in the past two decades creating a significant road block to free play. “Recently a group of parents in Cottesloe put up a series of rope swings on the verge in front of their houses and the neighbourhood kids started playing together. Kids got to know each other better, parents got to know each other better – from their perspective it was a huge medicalforum
n Mr Griffin Longley
local success. However, the council insisted that the swings be removed, citing the chance of someone being injured and the council being sued.” “Another example at a primary school in Victoria last month – the principal banned high-fiving and hugging (all forms of physical contact) because apparently there had been some injuries as a result of rough play. So what that means above and beyond the patently ridiculous fact that kids can’t shake hands, was they can’t play kick to kick, can’t play tag … all the games that allow kids to learn about moderating their physical behaviour; all games that teach them about empathy if they knock someone and they’re upset. All those opportunities for development are lost in that one step.”
terrified by stranger danger; terrified of traffic; terrified of being sued. We also fear being judged by other parents. Rolling out things like the passports is a way of giving parents and children a slow, moderated almost led introduction to unstructured play.” “Research shows that if children have time every day for unstructured play it helps their health, their wellbeing, their development and their NAPLAN scores. It’s important to learn Mandarin but it’s also important they go outside and play cubbies.” l
By Ms Jan Hallam
“It all boils down to adults in authority worrying not so much about kids getting help getting hurt.” The fear of litigation has also eroded an individual’s own sense of responsibility; that it was someone else’s responsibility to keep us safe. “And that makes it hard for adults to feel safe in taking any kind of risks with kids in their charge,” Griffin said. Nature Play has been operating for about 12 months and has offices in the Department of Sport and Recreation. One of its initiatives has been the Passport for Childhood – a book that has a list of 15 things a child should do before they are 12, and free pages for “missions” of their own devising as well as ideas and resources for parents and children to get outside and be active. With minimal promotion except the wholehearted support of the WA Primary Principals Association, Nature Play has distributed just shy of 50,000 passports in 10 months to schools, playgroups, scout groups and the like. “The level of interest in the concept has been pretty extraordinary. So far, I suspect, we have largely been getting the converted – people who are already aware of the issues of what I call nature deficit disorder – and who are trying to do something about it.”
n Munglinup Beach, east of Hopetoun. Photo courtesy Tourism WA
Workers’ Comp matters By Chris White A/Chief Executive Officer, WorkCover WA
Approved Medical Specialists have an important role in the workers’ compensation system. Approved Medical Specialists (AMS) conduct impairment assessments that determine whether injured workers can access certain benefits and settlements or pursue a common law claim for damages.
Becoming an AMS Medical practitioners undertake training in the American Medical Association’s Guides to the evaluation of permanent impairment (5th edition) (AMA5), followed by supplementary training in the WorkCover WA Guides for the Evaluation of Permanent Impairment. For information on becoming an AMS, including upcoming training sessions in AMA 5, call WorkCover WA’s Advice and Assistance Unit on 1300 794 744 or visit the WorkCover WA website at www.workcover.wa.gov.au.
“There’s a lot of fear in parents. We’re medicalforum
Steady Hand in Changing Times Ngala has been supporting WA families with calm words of wisdom, sound health advice and a friendly ear for anxious parents in the early years of their children’s lives for 122 years.
the increased involvement of fathers in the parenting of their children, but with WA’s population boom, Ngala’s Helpline is receiving more calls from people who are without extended family close by and social isolation is becoming a significant problem.
Its Helpline operates every day from 8am to 8pm and took more than 24,000 calls last year – in the past 6 months, child sleep issues and unsettled infants comprised 65% of the calls but the help extends wider and deeper than that.
“Parents are raising children with less support – grandparents are often still working, aunties are still working … these are the networks that are traditionally called on to help when a mother brings home her baby. It can be lonely for anyone caring for a small child.”
What began as a refuge for unmarried mothers, Ngala has become a multidisciplinary organisation that offers practical help when it’s needed most. Along with the Helpline, Ngala also has a residential program supervised by child health nurses and allied services of up to 4 days duration for young families struggling with child-rearing issues. A referral from a GP is required. However, the past decade has seen the work of Ngala push out into the community. CEO Ashley Reid said that while these family services were Ngala’s main focus, the organisation also ran early learning development programs; programs at Bandyup women’s prison; courses for fathers, support clinics in the Pilbara
n Ngala’s Helpline and Family Services Manager Gail Wells and CEO Ashley Reid
and the Wheatbelt and support for those families where there was chronic illness and children with disabilities. And there were eight family centres around the city. Ashley said information overload was a significant issue for today’s parents. “A lot of information comes from the internet and with that there are many voices and that causes serious anxiety. So Ngala has to cut through those voices with quality sound advice. We estimate that we are in touch with about 40% of families in WA, so we have a responsible to be a credible source of information.” Ngala has seen immense social changes over the generations, none more so than
Gail Wells, Ngala’s Helpline and family services manager, has seen many of these changes up close. “There is an expectation that family life should run as smoothly as a business, but raising children isn’t like that. Parents have to make an emotional shift to normalise the raising of children. Good attachment needs good adjustment.” “Our aim is to make parents confident.” l
Fact Box • • •
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Creating a New Paradigm
After 35 years of working in the area of children protection A/Prof Peter Winterton urges an new era of political will and vision.
have been involved in child protection work for more than 35 years. I saw my first case only 15 years after C. Henry Kempe published his landmark paper ‘The Battered Child’ in JAMA in 1962. When I started to work in child protection, child sexual abuse was a newly recognised phenomenon that was being voiced by an increasing number of women. In those early days of child protection work we were trying to come to grips with what constituted normal genital female and male anatomy in children, thereby establishing the ground rules on which opinions could and should be based. Over the years we have improved in interpreting injury causation and injury mechanisms in children and this has resulted in better and more robust opinions being issued to both Police and the Department of Child Protection (DCP). In June, 2007, the Howard government launched what is now known as the Northern Territory intervention. This was in response to the publication of a report investigating child sexual abuse in the territory ‘Little Children are Sacred’. The response of the Federal Government to use troops in indigenous communities in the Territory to address the issue has been much discussed and in my opinion has resulted in mixed blessings. In WA in 2002, there was the Gordon inquiry into the death of Susan Taylor at the Lockridge Community. The outcome of this inquiry, ‘Putting the picture together’,
resulted in many recommendations which have resulted in better outcomes for some children who have been abused. One of these was the establishment at Princess Margaret Hospital of the Therapy Service of the Child Protection Unit. This service is open-ended – there are no restrictions on how often a child is seen, and any child is seen where child abuse has been an issue and where the child’s current safety can be assured.
The Public Health Model of Child Abuse, i.e. child abuse is due to a failure to protect, just as measles is due to a failure to protect. This idea is not new. Prof Fiona Stanley in Perth, Prof Dorothy Scott in South Australia, Prof Kevin Browne in the UK, all concur with this model. Vincent Filletti, in the USA, in his studies called the ACE Study, has shown that all forms of child abuse lead to an increase in all forms of ill health in later life.
Neglect and emotional abuse continue to be overlooked by our current paradigm. There is great difficulty in reaching consensus as to what constitutes either of these issues, which in the extreme are easy to diagnose but at the soft end of the spectrum become a matter of judgment.
Public health according to the father of public health in this country, JHL Cumpston, “is the sum total of the health of the individuals across this country”. I am thus proposing that we must rethink child abuse, we must put more resources into the carrot end of the response – community nursing and community development – through such means as “homemaker schemes”, community nursing and general practice interventions – because only by early intervention and prevention will outcomes for individuals be improved.
In the Kimberley this is very apparent. Failure to thrive due to neglect and malnutrition has been called by some ‘Child Growth Faltering’. Child sexual abuse is called “pushdown sex” by others. The facts are clear: children are not reaching their full potential as a consequence of their environment or because of what is being inflicted upon them in their environment. Workers on the ground feel overwhelmed and disempowered by the current DCPPolice paradigm. Reporting to DCP often results either in a response that is not constructive and on occasion is destructive. Police involvement is limited by the rigid nature of the laws of the land. What do I think is the solution?
We know prevention as a public health model works, look at the eradication of smallpox and the marked reduction in infectious disease in childhood, but it requires political will, money and longterm vision to ensure it happens. Health professionals do possess the skills to make improved outcomes for child abuse victims.l ED: Prof Peter Winterton is Medical Director of the Child Protection Unit at PMH
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Beneaththe Drapes u Dr Piers Yates, the Head of Orthopaedics at Fremantle Hospital, has been on a six-week ABC fellowship visiting 15 orthopaedic units across the USA and Canada. The fellowship (America, Britain, Canada) was set up in 1948 to promote ideas and knowledge in orthopaedics between America and Commonwealth countries. u Gio Terni has been appointed as acting Executive Director of the Health Consumers Council of WA until October. He has a back ground in law and disability.
ALL THE BEST FROM SUBARU
u Sarah McGarry, a senior occupational therapist on the Burns ward (postsurgical services) at Princess Margaret Hospital has been awarded the Gordon Baron-Hay scholarship for 2012-13. u Dr Marcus Tan has been appointed chairman of the Perth Central and East Metro Medicare Local. u Dr Thomas Rex Henderson, has been awarded an Order of Australia in the Queen’s Birthday honours list for service to rural and remote medicine in WA as a paediatrician and neonatologist, to indigenous health and welfare, and as a mentor. u The National Drug Research Institute, based at Curtin University, will share a Federal Government grant of $24 million over three years with the National Drug and Alcohol Research Centre (NDARC) and the National Centre for Education and Training on Addiction. The three-year funding will enable a particular focus on areas such as reducing harm from alcohol, Indigenous substance misuse and workforce development. u Alzheimer’s Australia WA’s longserving CEO Mr Frank Schaper will retire from his role on September 28. Mr Schaper has held the position for 15 years has been instrumental to the sustainability and growth of the company and the awareness of dementia in the WA community. u The list of 2012 Churchill Fellows has been released. Celebrating are: Dr Alan Kop, who will undertake research in Singapore, UK, Netherlands, Belgium, Germany, Austria and Italy to establish a tissue engineering service at Royal Perth Hospital. Ms Tanya Dupagne, for the WA Department for Child Protection to research US programs aimed at stopping the generational cycle of domestic violence. Ms Katherine Rundus will investigate new strategies and innovative treatment for patients with hand injuries. medicalforum
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Doctor in the House Kate Emery, the daughter of GPs Dr Geoff Emery and Dr Henrietta Bryan, Molly Gilfillan, whose father is cardiothoracic surgeon Dr Ian Gilfillan, and Monty Whitfield, youngest son of GP and MDA medico-legal consultant Dr Jane Deacon share some of their reflections about growing up a doctor in the house. Monty Whitfield: Year 10 student at Hale School “I can’t really remember when I realised that my mum had a special job. It seems like I’ve always known it really. But I don’t think I’ll become a doctor because you have to memorise a lot of stuff and work really hard. Also you have to deal with lots of people who think they’re sick when they’re not." “My friends at school sometimes ask me for medical advice because they know Mum’s a doctor.” [Jane: My children have a distressing habit of sending me photos of their friend’s rashes and sores and asking my opinion. They’re disappointed when I tell them to go and see a doctor.]
n Kate Emery
Kate Emery: Journalist at The West Australian “Mum and Dad used to take me on house calls when I was pretty young and that was fun. Elderly patients used to give me a lot of cake! As I got older some of my school friends assumed my family was very welloff because my parents were doctors.
“I have to go to school unless I’m really sick. When that happens Mum says, ‘have an early night, take two Panadol and talk to me in the morning’. If I have any other health worries she usually says, ‘Don’t worry about it’. My dad and I reckon she probably didn’t go to those lectures.” [Jane: It’s a family myth. I didn’t miss any lectures.]
“I’ve only been to a doctor once in my life. The worst thing that’s ever happened is when I hurt my knee and Mum held me down and squeezed out the pus. [Jane: It was a small abscess.] Because she’s a doctor Mum gives me ‘tough love’.” [He’s referring to the abscess again. What a Wuss, it was tiny!] And the last word to Monty’s mother. “Lucky it’s not doctor’s spouses spilling the beans. I told my husband to stop whingeing about a calf-strain. He went and had an ultrasound and it turned out to be a DVT.”
Molly Gilfillan – Fourth year medical student at UWA “While other dads went to the office, mine was cracking open other people’s chests. I’m proud of what he’s achieved but I’m very aware of the sacrifices he’s made. What I’m most proud of is that his job is still his passion." “Dad works in an area of medicine where intervention comes with a certain degree of risk. He’s an exceptional surgeon but it’s extremely stressful and I know it takes a toll, especially on those rare occasions when things don’t go according to plan."
“I’ve certainly wished that I wanted to study medicine but I’ve never actually wanted to be a doctor, if that makes sense? I’m sure Mum and Dad would have liked it if one of their children had taken over the family surgery, but it was never on the cards for me. I’ve always been more interested in language than science or maths. My brother and sister work in tangential fields, the former as a psychologist and the latter as an occupational therapist. “It was always interesting when we were sick as children. We’d have to stay in bed without a book or TV if we wanted to miss school and I seem to remember ‘dry toast’ was a persistent theme." “It’s nice to feel proud of what your parents do and I’ve lost count of how many times I’ve told the story about Dad saving the life of a family friend. He had a meningococcal infection and Dad got him to hospital just in time. On the other side of the coin, it’s easy to drift into the habit of not establishing a relationship with your own doctor when it’s so easy to ask your parents.”
n Monty Whitfield
“We wouldn’t see Dad for days when I was in kindergarten. He was a young consultant and this was difficult for the family. I know he regrets not being there more when I was growing up. I think that’s a strong reflection of professional attitudes at the time and I hope that work/life balance will become a stronger focus for doctors." “I was about 14 years-old when I decided I wanted to become a doctor. Recently I was on a placement at RPH and got a real feeling of déjà vu. I realised that I’d spent a lot of time there as a young girl with Dad and remembered playing a computer game with a medical theme. Perhaps I was being groomed even then! Seriously though, both my parents emphasised that whatever we did was fine as long as we were passionate about it."
n Madeline Colvin and her dog, Zeke
Juvenile Rheumatoid Arthritis – A Personal Response
n Dr Ian Gilfillan and daughter Molly
“On Christmas Day it’s a family tradition that Dad takes his three daughters on the ward round. We used to wear Santa hats, which was cute when we were younger but some of the patients are a little unsure about having three tall 20-year-olds in their hospital room. It explains why I’m so comfortable in a hospital – I practically grew up in one! “My medical student friends appreciate the finer points of my dad being a cardiothoracic surgeon. I think some of them feel I have an unfair advantage. In fact, I find I have to work harder because there’s often an expectation attached to my surname.” “If it hadn’t been medicine I probably would have chosen music. I play the cello which is a different sort of intellectual stimulation. Although, to be honest, if it hadn’t been medicine, I think I would’ve kept persevering until it was medicine. I’m doing something I would do for free!.”l medicalforum
ello, my name is Madeline Colvin. I’m 11 years-old in Year 6 at Methodist Ladies’ College and I love playing with my dog, Zeke. I also love playing netball and hanging out with my family and friends. And one more thing, I have Juvenile Rheumatoid Arthritis.
It all started when I was eight years old. We were on holiday and we got off the plane and my hips were really sore. I couldn’t walk very far. My dad carried me on his shoulders, so it was lucky I wasn’t too big. My parents thought it was from the long flight and that it’d get better, but it continued for the two-week holiday. When I went back to school I started playing Minkey Hockey and my ankles started getting really painful. Luckily, my coach is a physiotherapist and she suggested I go see a doctor. His name is Dr Kevin Murray and he’s great fun! It took six different medications and needles in hospital before it settled down. I had the medicine through a drip in my arm and injections in my joints while I was asleep. One of the visits to the hospital was good fun because I used the hydrotherapy pool and I visited the Starlight Room.
For the first six months I went to SJOGH for hydrotherapy three days a week after school. Natalie, my super-cool physio, showed me lots of exercises to help my wrists and ankles. She also suggested I use wrist bandages and wear Skins during winter to keep my joints warm. Now I manage my JRA with Methotrexate which I take every Friday night at dinner time. I’m supposed to take Ondansetron as well, but the fizzle on my tongue tastes disgusting! I think the medicine makes me hungry, too. I also see a psychologist, Hans Willem, to talk about the pain and how it makes me feel. I’m doing pretty well at the moment. I’m still on Methotrexate and, when I have occasional flare-ups, I take Redipred for two weeks. I love playing netball and running around with my dog, Zeke. I usually don’t get sore all that often anymore. The worst part about having JRA is that, for a while, I couldn’t do things I liked such as Minkey, soccer and netball. When the other kids at school ask me about JRA I say, ‘show me your fingers’. I show them mine and ask if they can see the difference. They can usually see that my joints are more swollen. When they ask me why I wear Skins, I say it’s to keep my joints warm so they don’t hurt as much. l 27
Reporting Child Abuse: A Case Study Medico-legal adviser Dr Jane Deacon explores the rights and obligations of medical practitioners when it comes to reporting suspected child abuse.
rs Jones brings her 12-yearold daughter in to see you and asks for a referral for some counselling for her daughter. When you ask why, Mrs Jones tells you that her daughter has just disclosed that an older boy (16 years) has been touching her inappropriately. The older boy is the son of some family friends of the Joneses, and has been a regular visitor to their house. Do I have any mandatory reporting obligations here? Under the Children and Community Services Act doctors are mandatory reporters of child sexual abuse in Western Australia. Since 1 January 2009, practitioners must make a report to the Department for Child Protection’s Crisis Care Mandatory Reporting Service if they form a belief, based on reasonable grounds in the course of their work, that child sexual abuse was occurring or has occurred. If you believe that Mrs Jones’s daughter has been a victim of sexual abuse you are obliged to report it.
Should I tell the child or his/her parents that I am going to make a report? You may want to inform the parents that you are obliged to make the report, and that may be helpful in terms of open and honest communication with your patient and his/her family, but you are not obliged to tell them. What happens if Mrs Jones tells me that she does not want me to make a report? You are obliged to make a report, with or without the knowledge or consent of your patient and his/her family. Even if you feel the child is no longer at risk, a report must still be made. If Mrs Jones says she is going to the police herself, should I make a report as well? Yes, you are still obligated to make a report. Is there any legal protection once I’ve made a report? Your identity as a reporter will not be disclosed. As long as your report was made in good faith, you are protected from breach of duty of confidentiality and any civil or criminal liability which might arise.
How do I make a report? You can make a verbal report, but this must be followed by a written report within a reasonable time-frame, preferably within 24 hours. Written reports can be submitted by fax, post or email or via the DCP Crisis Care Mandatory Reporting Service (DCPCCMRS) at www. mandatoryreporting.dcp.wa.gov.au. Written reports can be typed directly into the DCPCCMRS secure Mandatory Reporting Web System at www.mandatoryreporting. dcp.wa.gov.au. Please leave a reliable contact number, including after hours. It is important for DCPCCMRS and/or police to be able to contact reporters if required, particularly in high priority situations. l This article has been provided by MDA National. This information is intended as a guide only. Always contact your indemnity provider when you require specific advice in relation to your insurance policy. The case history used is based on actual medical negligence claims or medicolegal referrals. However, where necessary, certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved.
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Culturally Competent Care Dr Sam Febbo, and Head of the Transcultural Mental Health Service, says more than language barriers can be broken down with good communication.
hile the debate rages over Australia’s border protection policy, asylum seekers who have been assessed as bona-fide refugees are now settling in the wider community. Unfortunately, many face significant barriers in rebuilding their lives in a new country where unfamiliar values, norms and language only compound the trauma of their refugee journey.
Whatever side of the debate we are on, as health practitioners, we have a duty of care not to exacerbate the trauma and to work transculturally with patients. Transcultural mental health care recognises the reciprocal influences of culture between the patient and the practitioner during a consultation. The aim is to arrive at a mutually agreed treatment and management plan that does not devalue the beliefs of either party. A fundamental requirement for culturally competent health care delivery is effective communication. Despite some patients
being able to converse perfunctorily in English, their comprehension of clinical issues, when conveyed in English, is poor. This limits their ability to accurately report symptoms. The patients we see at the TMHS are seen with an interpreter which enables us to negotiate explanatory models with a view to agreeing on a treatment plan that can be readily followed. Many of our patients with little or no English proficiency have experienced medical appointments where interpreter services were not provided. Confusion, distress, fear, anger and ultimately a negative clinical outcome was the result. Simple things such as repeat prescriptions, the need and rationale for a referral to a specialist service, discussion about possible effects of prescribed medication, and the right to explore an alternative can be issues denied many refugee patients if they are not explained in their own languages. Working with interpreters usually means a longer consultation. After registering with
Translation and Interpreting Services (TIS) and obtaining a provider number, GPs may book a phone interpreter. The service is free for GPs. In general, for the purposes of observing cultural sensitivity, it is preferable for interpreters to be of the same gender as the patient. Most phone interpreters are interstate hence anonymity is assured particularly for patients from small and emerging communities. The process is simple. Doctors communicate with the patient normally, in the first person, making eye contact; after each segment of communication, allow the interpreter to convey whatever has been communicated. The TMHS – based at the Department of Psychiatry at RPH, provides education and training on how to work effectively with interpreters and on cultural competency in clinical practice. Slowly, education has led to change in practices which have benefited patients from refugee backgrounds and helped doctors deliver much needed health care. l References available on request.
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E-poll: Child Health
Waiting Times are Critical Wait gain This month we asked GPs about child health and their views on how the system was coping with children’s special needs. As usual, there was a vigorous response from the 120 who responded (63% men and 37% women. Among the hotly debated topics were the long wait lists for allied health, particularly of importance in the crucial developing years of a child’s life, and antibiotic use. Waiting times struck a nerve, with more than 43% of doctors reporting undesirable waits for a speech pathologist and 19.4% registering long waits for occupational therapy in a public service under pressure. Here’s what some said: “Lack of paediatric speech pathology is unacceptable. We are losing important developmental time for the patient while they wait for appointments. Access is dependent on money only. Psychologist wait is excessive too!”
Assuming that increased demand for services is behind the difficulties parents report in getting their sick child to see a GP, which of the following do you consider a desirable solution [multiple responses possible]? Percentage Education of parents to better ................. 50.8% self-manage their sick child at home. Better triage of patients in ........................ 55.8% general practices. Doctors delegate less important .............. 21.6% tasks to others (e.g. review of test results) Seen by nurse practitioners with ............. 35.8% child health skills, working from within general practice.......................................... No solution possible..........................................5% Other
Undecided ...................................................... 2.5%
Health Direct – a national system of nurses giving phone advice to health consumers – was not welcomed by some in the medical profession. Which of the following statements best describes your position on Health Direct for giving Child Health advice? Percentage It does no harm and may lessen ................ 8.3% the doctor’s load. It is a waste of money and ......................... 20.8% human resources. It has little impact on patient ................... 16.6% care overall. It is a useful adjunct to what I do................7.5% Its purpose is mainly political, ................ 20.0% not medical. Patients/parents report assistance.............17.5% from phone advice when doctors are usually unavailable.
GPs report children have difficulty accessing allied health practitioners, especially when parents cannot afford private help. In these circumstances, in the last 3 months, have any of your child patients encountered an extended wait you consider clinically undesirable? If yes, tick the appropriate service [multiple choices possible]
2500 juveniles went through the courts in 2009-10. Three strikes legislation is suggested as a deterrent to re-offending. Do you consider any of the following alternatives would work better than three-strikes legislation [multiple choice possible]
“Need to prioritise appointments for most disadvantaged. Manage clinic lists better at hospitals and look at running clinics in the community, closer to people.”
Detention if found guilty of the ..................7.5% first offence.
“Access to allied health is not an issue if you have MONEY but private health insurers and Medicare do not provide anywhere near the rebate needed for any chronic issues requiring prolonged therapy.”
Speech pathologist....................................... 43.2%
“Parents of children with developmental delay always encounter barriers; no one assumes responsibility; disability services do not talk to health services.” GPs need more experience in paediatric medicine before venturing into General Practice. More GPs – less waiting.
“There should not be a waiting time. It takes the same effort to have no waiting list as to be 3 months behind – generally public funded and work factor not there.” Not surpisingly, things in the country were worse. “In rural areas there may not be a private option and hence the limited public service is under significant pressure. It is also hard to recruit allied health to rural WA.” “Sometimes, the older the children are, the longer the wait times and that’s very undesirable for children with a stutter or anxiety related problems. Same is true with neurosciences study, as it is impossible to access the services for months and months. Another service is Country Autism assessment service run by DSC, 18/12 months waiting. Very unacceptable.” 30
Occupational Therapy................................ 19.4% Audiologist....................................................16.1% Neurofunctional Testing............................ 19.4% Dietitian ..........................................................11% Other
Not applicable to me................................... 45.7%
It is hoped to reduce antibiotic use in children, such as for respiratory tract infections, by 25% nationally. To achieve this, what do you consider will be most important? Percentage Reduce demand from parents ...................59.1% through their education. Educate and resource doctors to ............. 22.5% use alternatives to antibiotics Encourage pharmacists away from ............7.5% providing ‘remedies’ of any sort. Place more restrictions on .......................... 0.8% script writing. Nil – disagree with the idea......................... 6.6% Undecided....................................................... 1.6% Other................................................................ 1.6%
Other................................................................ 5.8% Undecided....................................................... 3.3%
State-run boot camp in the outback........ 38.3% Community service..................................... 53.3% Victim mediation and compensation......... 40% Re-education and retraining program.... 43.3% Nil. Three-strikes legislation works .......... 2.5% well enough Other................................................................ 8.3%
Of the 2500 juveniles who went to court in 2009-10, 26% were found to have a mental illness. The State Government has recently announced the establishment of a Mental Health Court. Do you think juveniles with a mental illness who have broken the law should be processed by the courts at all? Percentage Yes
Do you believe mental illness in juveniles is over-represented, mainly as a legal defence tactic?
Percentage Yes.................................................................. 41.6% No................................................................... 15.8% Uncertain......................................................42.5%
In your experience, how often do poor parenting skills appear as a major contributor to the illhealth of children you see?
“I see many children and I think... you poor little bugger with these two idiots as your parents.” “The personality of children is largely learned from their parents. Loving discipline is good, neglect and punishment is disastrous.”
Percentage Regularly 42.5% Occasionally.................................................40.8% Rarely
Cure for antibiotics
The campaign to cut antibiotic use hit a nerve with GPs who overwhelmingly believed that the campaign should educate parents first and foremost to reduce their demand for prescriptions.
Some say our society today has an aversion to exposing young children to physical risk during play. What statement best describes your take on this ‘aversion’? Percentage A good thing for children................................5%
Here’s what some doctors said:
Appropriate in some circumstances........ 31.6%
“GPs prescribing habits should be monitored and flagged when obviously outside best practice.”
Of relatively minor importance.................. 5.8% Prevents children reaching their ............. 38.3% full potential. Very detrimental to children ....................14.1% and society. None of the above.......................................... 1.6% Uncertain........................................................ 3.3%
Would you like to see more on offer so parents can control the TV and Internet content viewed by their children? Percentage Yes .................................................................... 70% No ...................................................................14.1% Uncertain...................................................... 15.8%
One major not-for-profit fundraising body took cash receipts from fundraising activities of $8.4m in a year. Roughly, what amount do you feel is acceptable for that same body to spend on suppliers and employees in raising that amount? Percentage $6 to 7m ........................................................... 0% $5 to 6m ........................................................ 2.5% $4 to $5m ........................................................ 3.3% $3 to 4m .........................................................9.1% Less than $3m.............................................. 66.6% Undecided..................................................... 18.3%
It’s child’s play On society’s aversion to exposing young children to physical risk during play split opinion. More than a third of doctors thought it was justified if not a good thing, while more than half said it was an important part of childhood, some agreeing it was detrimental to society not to expose children to these learning experiences through play. Here’s your take on childhood risk-taking: “It’s how we learned not to do stupid things. And it did hurt a lot of the time. But I hate kids missing out on bush walks and tree climbing and cubby building and walking to school in a bunch because of helicopter parenting.” “Children need to learn responsibility for their actions so they can become 'responsible adults'. Legislating responsibility to others diminishes society.” “Children need to learn risk management early in life so that they have a better handle on it when they become teenagers and young adults. Risk exposure should be developmentally appropriate.” “To not allow some level of risk-taking stunts independent living and maturity. The problem is how to judge the level!” “Control of the electronics is in the hands of whoever pays the power bill!”
“Encourage and have Medicare item for fingerprick CRP to indicate whether antibiotics may be needed or not (eg show a patient a low CRP means they don’t need an antibiotic).” “At the coalface an explanation takes time – also need to be able to provide prompt review if the child worsens. Teamwork by all doctors is the answer.” “Sometimes, the distinction between bacterial and viral infections especially for the respiratory tract is blurred. With growing intolerance for diagnostic errors and their consequences, difficulties with repeated access to a health unit for followup and the potential for rapid deterioration of children with bacterial infection, there is often a compulsion to hand out scripts to parents with instructions. However, this practice, while possibly subverting the consequence of missed bacterial infection, shifts the responsibility of decision on antibiotics use to parents of sick children.” “Educate parents that antibiotics are not always the answer, and some can be harmful. It will also be harmful for patients to waste money on a variety of cough remedies being peddled.” Last word I hate the association of gambling and sport. Kids watch sport and this "sells" gambling as a fun, normal activity. I would like discussion of gambling, including betting odds, to be banned in sporting programs. The winner of the E-poll prize is RF. l
New Fix for Chronic TM Perforations Paediatric otolaryngologist Prof Harvey Coates AO has alerted Medical Forum to some exciting ideas from Japan to heal chronically perforated tympanic membranes, where healing has otherwise come to a halt. The simple treatment and excellent results echo the early days of the H. pylori discovery, as does the lack of excitement in the ENT world. Prof Coates and Prof Gunesh Rajan are now in trials to validate the technique. We spoke to both Perth surgeons to find out more. Complete healing of at least 90% of chronic perforations following a 7-10 minute
n Prof Coates and Prof Kanemaru (2009)
procedure under LA sounds unbelievable. And using a growth factor to stimulate the body to close the perforation itself is breathtakingly simple. Results were presented in 2009 and published last October by Prof Shin-Ichi Kanemaru from Kyoto University. Not only is hearing improved within weeks, patients (>95%) reported improvement of associated tinnitus and aural fullness as well. “The Editor of Otology/Neurootology, Prof Robert Jackler, in his April 2012 editorial stated this may be the greatest advance in otology since the cochlear implant,” Prof Coates said. We checked it out and he’s right. Prof Jackler also said, “Not only would it obviate the need for many thousands of microsurgical procedures each year [he is talking myringoplasties under GA], it could bring a simple and inexpensive remedy to millions of patients around the world for whom capital intensive microsurgery is not available.” Prof Coates and UWA researcher Prof Rajan, who have both kept contact with Prof Kanemaru since they met at a USA conference in April 2009, have over the past two years prepared for the Australian trials. They see this as possible good news for the 106,000 Australian adults and children
with chronic perforations, particularly ATSI children. Prof Gunesh Rajan can see the potential. Normally, larger perforations spanning greater than one third of the TM require tympanoplasty. This new technique applies to small or large chronic perforations. “Hearing loss from chronic ear drum perforations has a huge public health impact, especially in children; strong hearing means a strong start. If children can’t hear they can’t be educated and thus can't break out of poverty. Another forgotten aspect is that chronic ear disease is life-threatening. Worldwide every eight minutes a child dies because of the complications of chronic ear disease, mainly due to meningitis,” he said, before hinting at the politics involved – the presentation of results in 2009 being untimely and the resistance to change in the ENT world. Prof Jackler’s editorial did caution the use of bioengineered fibroblast growth factor b-FGF and its theoretical potential to be oncogenic or cause cholesteatoma, so there was a need for more validation trials. “Prof Kanemaru used the technique in adults” Prof.Rajan explained. “As we have a significant disease burden in children
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n Prof Gunesh Rajan
in WA and worldwide as well, we want to validate it in children and adults. Longterm results will be an important variable especially in children. We want to see what happens to the repair as the child grows.” At Fremantle hospital they have done 17 cases so far, five children and 12 adults. Three children have healed completely with normalisation of their audiogram, one child is in the healing phase, while the fifth child went swimming after surgery with subsequent loss of the repair! Among the adults, six have healed completely and the rest are in the healing phase. Prof Rajan says about a third of the patients had perforations involving more than 50% of the TM. The trial at Fremantle is ongoing, while PMH will start a surgical trial in children later in the year.
The b-FGF is bioengineered using E Coli. It is also used for treatment of skin ulcers or decubitus owing to its strong inductive effects on both fibroblasts and blood capillaries. One vial can treat around 10-15 patients at a cost of about $300. The b-FGF stimulates regrowth of the TM after the edges of the perforation have been “freshened up” using the myringotomy knife. The b-FGF impregnated gelfoam is inserted like a plug into the hole, and glued in place using fibrin (which also seals the foam and prevents the healing TM from drying out). “What we have observed is that the healed tympanic membrane has the normal threelayered structure like the normal ear drum. The tympanic membrane is one of the few organs of the body that can heal without scarring. Our impression is that the healed TMs look normal, without scar formation,” Prof Rajan revealed. “The feedback from the ENT community and the public has been encouraging. Of course we are very clear that this is a pilot study aimed at validating and refining, in close collaboration with Prof Kanemaru in Japan. Our team is convinced this kind of technique can have a positive impact on ear and hearing health.”l
By Dr Rob McEvoy Reference Regenerative Treatment for Tympanic Membrane Perforation, Prof Shin-Ichi Kanemaru et al, Otol Neurotol 32:1218Y1223, 2011.
The Surgical Technique This is in situ tissue engineering – endogenous cells from the TM are encouraged, using fibroblast growth factor, to grow across a gelfoam scaffold placed by the surgeon into the chronic perforation. Best-suited patients are those with no infection or discharge in the last three months or longer. • Local anaesthetic is applied. • Tissue around the rim of the perforation is excised using a myringotomy knife to create an active healing edge. • Gelfoam cut to size is immersed in b-FGF and inserted into the perforation like a plug. • Fibrin glue is then dripped over the sponge. • The procedure is repeated up to 4 times if there is not complete closure of the TM within 3 weeks after each procedure. • Patients are advised to keep their ear dry, not to blow their nose and/or sniff strongly for a while. • Adequate visualisation of the edges of large perforations may prove a problem, but can be overcome using endoscopic viewing.
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TRANSLATIONAL RESEARCH FEATURE
The good news and the warning bells L ongitudinal research undertaken at the Telethon Institute for Child Health Research over the past 14 years involving children with Down syndrome and their families is showing some positive trends and areas of future need. Senior Research Fellow Clinical A/Prof Dr Helen Leonard, said studies had been undertaken which examined changes in the health of children with Down syndrome and how they had been using health care over time. Comparisons of questionnaires undertaken in 1997 and 2004 found a 70% reduction in their having a current problem due to a cardiac condition.(1)
conditions now has more to do with enabling them to participate more in family and community life.
Obesity looming as a risk Studies are also highlighting the need for family and practitioner vigilance on lifestyle issues such as obesity. Prof Leonard said that a study was currently investigating this increasing problem. Acknowledging that obesity was also a problem in the general population, she said that physiological and behavioural factors made children and adults with Down syndrome more at risk.
n TICHR rearchers Terri Pikora, left, Patrick Fitzgerald, Helen Leonard, Jenny Bourke and Katherine Bathgate
Routine screening of newborn children for heart problems and advances in surgical techniques have meant that cardiac disease is diagnosed and treated earlier, so more children with Down syndrome are surviving their first year and are likely to have improved health and a better quality of life. Regardless of whether the child was born with or without a cardiac condition, there was also a corresponding decrease in reported episodic illnesses with the greatest reductions being in tonsillitis and ear infections. Subtle changes in the recognition and identification of some conditions were noted. Sleep apnoea seemed to be increasingly recognised over time with 20% of parents reporting this condition in 2004. Other conditions remained apparently unchanged over time. There seemed to be similar identification and treatment of thyroid problems with about 13% of parents
reporting that their child had a condition in 2004 compared with 14% in 1997. Bowel problems continued to be of concern – particularly constipation. More than one third of the children were reported to have flat feet and half this number to wear orthotics. In 2004 there was a reduction in the number of visits to GPs reported as well as in the use of specialist services. This could be partly due to the phasing out of some medical and other specialist disability medical services previously provided by Disability Services Commission. This was of concern as audiology and podiatry were important for the management of hearing and musculoskeletal concerns. These issues may have a bearing on children’s capacity to learn and participate in social relationships and sport. So while survival is less of an issue for children with Down syndrome, identification and treatment of medical
“A PhD student here is examining this issue now. People with Down syndrome generally have smaller statures and their BMI tends to be higher. They also have an increased risk of hypothyroidism, which should be treatable, but their body configuration makes them more at risk of being overweight. Research is analysing data on growth while information on food habits, dietary intake and physical activity is about to be collected from families as well as body composition studies into patterns of lean mass and fat etc.”
Depression emerging as an issue While studies are showing the physical health of a child with Down syndrome has improved markedly in the past decade, Prof Leonard says that more attention needs to be paid to mental health issues, especially in adolescence, as these were impacting negatively not only on the children but also their families and carers. “As people with Down syndrome head into adolescence and adulthood they are prone to depression and there’s not a lot of data on that. Using longitudinal data we can assess levels of depression as they age so we can get a real picture of these mental health issues.”
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“We are now asking for data about their contact with mental health professionals. Less than 10% have said they have sought help from a psychologist or a psychiatrist. That’s a real issue especially in Western Australia where many children and adults with an intellectual disability are ineligible for services. It’s just not been appreciated that people with intellectual disabilities can have mental health problems as well.” “One of our researchers presented a paper in Canada last month (July) on this issue. People with Down syndrome present differently from other patients, so depression and other mental health issues can be hard to pick up. However, they are there.” “We need more resources here in WA – there are more psychiatric services available in other states than we have here, so it is clearly an area of need in terms of the medical profession.”
Needs for family support As mental health and behavioural problems were being identified in some children, studies were also revealing a decline in the mental health of their parents and carers, especially mothers. “There’s tremendous variability in the function of children with Down syndrome. Some children are quite able – they can communicate well and hold down jobs in open employment. However, more than half struggle to communicate well and also have behavioural problems. These children are much more dependent on basic care.”
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
Cryopreserving Australia’s Future Population When I was studying embryology in London (1976-80), I had the unique experience of working with David Whittingham, prominent mammalian embryologist who, with his scientific mate Stanley Leibo, attempted the first human embryo cryopreservation studies. These were on research embryos generated in my lab at the Royal Free Hospital! I had already learnt the process of sperm freezing at the Animal Research Station in Cambridge from Chris Polge who pioneered bull sperm freezing in 1949 using glycerol as the cryprotectant.
“About a quarter of our study group were in the clinical cut-off for having mental health problems needing further investigation. These behavioural disturbances put pressure on families and these young people are in need of extra help in their daily living and managing difficult behaviour – and that’s even before you get into the health problems.” Prof Leonard says that more research is needed in the area of family support so that better policies can be developed. However, there were also good news stories with physical health greatly improved with the advancements of cardiac surgery and a cost study has found that by adolescence health costs for a person with Down syndrome were more similar to the general population. “That’s a good message for GPs. There will be issues around lifestyle and mental health for the patient and their family, which require study but physical issues may be less difficult to manage.” Literature available on request. Variation in Time in Medical Conditions and Health Service Utilization of Children with Down syndrome, KellyThomas,BSc(OT)(Hons),JennyBourke,MPH,Sonya Girdler, PhD,AmiBebbington,BSc(Hons),PeterJacoby, MSc,and HelenLeonard,MBChB,MPH, Journal of Pediatrics
Medical Forum thanks researchers at the Telethon Insitute for Child Health Research for assistance in preparing this feature, supported by an independent education grant from Avant.
Medical Director Dr John Yovich
Co-authors & PIVET Embryologists Jesmine Wong and Jason Conceicao perfecting vitrification of human blastocysts for repeat cryostorage
Subsequently human embryo cryopreservation evolved using a slowfreeze technique with polypropylene being PIVET’s preferred cryoprotectant. Since 1984 this was applied using controlled seeding of ice crystals at -7°C within an expensive Planer computerised freezer enabling graded temperature ramps down to -80°C prior to plunging into liquid Nitrogen at -196°C.
In Medical Forum 2008, I described Vitrification as the new method of cryopreservation at PIVET using a combined cryprotectant recipe with ethylene glycol, DMSO and sucrose. We adopted the Cryotop method using a polyethylene strip. This now enables all stages to be successfully cryopreserved – unfertilised oocytes, pronuclear oocytes, cleavage-stage embryos and blastocysts with total preservation of cells, blastomeres and early differentiated tissues such as the inner cell mass and trophectoderm – with 90% recovery being usual after warming. Vitrification has proven so successful, in fact, that PIVET is now often advising patients to cryopreserve their “best” rather than “ leftover” embryos from the fresh IVF cycle. Furthermore, as patients recycle for FET (frozen embryo transfer), we have been culturing up embryos previously stored at early stages (pronuclear to 8-cell) using slow-freeze protocols, to blastocysts for single embryo transfers. Residual blastocysts are then re-frozen by vitrification. This program has been so successful it was reported in a recent publication (RBM Online; March 2012; 24, 314-320)
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Treatment of amblyopia A
Dr Steve Colley, Ophthalmologist. Tel 9385 6665.
mblyopia (Greek amblys “dim” ops “eye”) is reduced vision due to abnormal wiring of the visual cortex as a result of impairment to the visual experience of one or both eyes. Amblyopia affects 2% of the population. It is readily treatable, if detected early. The typical pathologies that result in amblyopia include refractive error (blurring), strabismus (misalignment) and, less frequently, deprivation (cataract, ptosis, vitreous haemorrhage).
The rationale for treatment is to improve visual function, not only to provide a useful “spare eye” but also to prevent limiting career opportunities. Although it is important to treat amblyopia as early as possible, some studies suggest children will respond to treatment even after the critical first seven years (and some children even as teenagers).
This is the most common type of amblyopia. The deviating eye most commonly turns in (esotropia) or out (exotropia), and is suppressed in order to prevent double vision. This suppression can become so effective that the affected eye loses its visual potential. The diagnosis becomes difficult when the deviation is small and thus is not obvious. The cover test is essential in diagnosing this condition.
This is the most difficult type of amblyopia to detect. If the two eyes have significantly different refractive states, the young child may rely on the sight of the more focused eye, causing the other eye to lose its visual potential. The child will appear to have normal vision because the better eye is being used for visual tasks. If both eyes are out of focus, both may become amblyopic. Cycloplegic retinoscopy is essential for diagnosis and to determine the correct spectacles for treatment.
This usually causes the most severe vision
loss. It typically affects children with unilateral or bilateral congenital cataracts but also may occur in those with corneal or vitreous opacity or severe ptosis. The lack of a red reflex on ophthalmoscopy or even standard photography should be taken seriously.
Atropine has shown to be as effective as patching treatment for moderate amblyopia and may only require instillation once a week. Systemic side effects are possible. Frequent follow-up is suggested as 25% of patients may experience a reduction of vision within 12 months of cessation of treatment. Failure of a child to respond to treatment may be due to poor compliance but it should also trigger further examination, and if no obvious cause is found, then electrophysiology or neuro-imaging should be considered.
An organic cause for vision loss must be ruled out, and any obstacle to vision treated (e.g. cataract). Congenital cataracts must be removed as soon as possible and aphakic treatment (contact lens or glasses) instigated. Significant refractive errors need to be corrected (particularly anisometropic hypermetropia – unilateral long-sightedness). Studies have shown it may take as many as five months for visual improvement to maximise with corrective spectacles. If residual amblyopia persists then penalisation therapy, in the form of patching of the ‘good eye’or atropine drops, is warranted. It is important to remember that the majority of treatment is carried out by the parents of the affected child and that it can be difficult and time consuming, making compliance a real issue. Contemporary randomised trials have shown that significantly less patching than was previously advocated, can be just as effective. In moderate amblyopia (6/12-6/24). two hours a day is advocated, while with severe amblyopia (6/30-6/120) six hours per day is now considered appropriate.
Declaration: Perth Eye Centre Pty Ltd, being the management company for the Eye Surgery Foundation, has supported this clinical update through an independent educational grant to Medical Forum. Author – no competing interests.
Fact Box • Amblyopia is the most common form of monocular vision loss in children (and young adults). • Early recognition and prompt treatment are essential in preventing permanent vision loss. • Most treatment is delivered by the child's parents, and may be arduous for them. Fortunately, contemporary management regimes have lessened that burden. • Relapses are common and failure to respond may suggest other pathology, so close follow-up is important.
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Early intensive rehabilitation in children N
By Dr Jane Valentine, HOD Paediatric Rehabilitation, PMH. Tel 9340 8006
eurological rehabilitation is rapidly changing from a focus on compensation and adaptation, towards functional recovery optimised by intensive early stimulation of the nervous system after injury. Neuroscience, neurophysiology and neuroimaging are providing greater insights into the mechanisms of rehabilitation therapies (1). Neural plasticity is enhanced in the developing brain and activity-dependent plasticity at synapses combined with reorganisation of motor and sensory maps in the brain is a major mechanisms for plasticity. Targeted therapies can enhance recovery and take advantage of the brain’s intrinsic plasticity mechanisms(1). A new service for children and adolescents in WA seeks to offer a patient focused, developmentally appropriate, time limited, and goal focused rehabilitation program.
Early Intensive Input
social work, therapy assistants, neuropsychology, clinical psychology, community mental health nurse, clinical nurse specialist and education services.
Early intensive targeted therapy post injury is important in neurological recovery and is considered in part to be harnessing the physiological process of plasticity (1) Intensive therapy programs in conjunction with targeted medical management (eg Botulinum toxin therapy) post-congenital or acquired injuries remain the cornerstone of treatment. However, specific targeted therapies including Constraint Induced Movement Therapy (CIMT), first used in adult stroke, are now being applied to children with promising results(2). More novel therapies using Transcranial magnetic stimulation, robot-assisted movement practice and virtual reality interventions also have been applied to children with promising results(3-5).
It supports the acute tertiary hospital system by reducing acute bed stays and readmission rates. However, it is expected that 70% of the patients referred to the service will be receiving new resources. Referral is via medical or surgical teams within PMH. Service use and outcomes are rated against known national and international benchmarks.
Using activity to improve outcomes New terms such as Activity Based Rehabilitation (ABR) are now used where the goal of (ABR) is to use activity as a tool for neurological recovery that goes beyond obtaining compensatory function(6). Activity is defined as both function specific motor task and exercise, and is important for optimising functional, metabolic and neurological status in chronic neurological conditions such as SCI and CP. ABR tools include patterned motor activation (locomotor training functional electrical stimulation ergometry) and non-patterned activation such as strengthening, task specific training and sensory stimulation (i.e. sensorimotor therapy)(6).
important to maximise the functional outcome of the child . Developments in smart phones and tablet computer devices are transforming communication options for children with impaired verbal output. These devices are also offering much improved education opportunities for children with physical disabilities, and need to become part of mainstream rehabilitation and edcuation practice.
New service in Perth
For many children and adolescents with chronic illness or disability, limited mobility and deconditioning leads to secondary co-morbidities including bone resorption, muscle loss, fat gain, metabolic syndrome, pain, depression, spasticity etc. ABR also addresses many of these.
A new service for children and adolescents “iRehab Service” (or Intensive Paediatric Rehabilitation Service) runs as an in-patient day unit with 10 “ bed equivalents”, five days a week, 9am-5pm (funded through the COAG National Partnerships Agreement 2011-2014) and will be at full capacity in a purpose-built facility at PMH from October 2012.
Mental health is another significant comorbidity particularly in adolescents with chronic illness and disability, with rates in adolescents with disability up to three times higher than the general population. Long-term outcome of the child post injury is highly influenced by family functioning and intensive psychosocial input is very
The main target groups for the service are children with moderate to severe acquired brain injury, severe congenital or acquired spinal cord injury, and severe musculoskeletal or neurological disorders. It has a comprehensive multidisciplinary team including medical staff, physiotherapy, occupational therapy, speech pathology,
Co-morbidities assisted as well
Seventeen patients have completed up to 10-week programs and 7 are children currently enrolled. Between January and June, 2012, 639 allied health therapy sessions have been provided, with significant gains on functional outcome tools along with very positive feedback from the families. Importantly follow up at 6 weeks and 6 months post discharge from the program has shown all gains have been maintained in 90% of children. ED: The Paediatric Rehabilitation Department at PMH also offers programs in Spinal Rehabilitation, Acquired Brain Injury, Cerebral Palsy Mobility (including spasticity management with Botulinum toxin and complex movement disorder management including intrathecal Baclofen), and Early Intervention and Neurodevelopmental. References (1) Johnston M. Plasticity in the Developing Brain; implications for rehabilitation Dev Disabilities research reviews 15; 94-101 (2009). (2) Sakzewski L, Carlon S, Shields N, Ziviani J, Ware RS, Boyd RN, Impact of intensive upper limb rehabilitation on quality of life: a randomised trial in children with unilateral cerebral palsy. Dev Med and Child Neurol 54 (5) (pp 415-423) May 2012 (3) Kirton A, Chen R, Friefeld S et al. Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial. Lancet neurology 2008 June 507-13. (4) Frascarelli F, Masia L, Di Rosa G et al . the impact of robotic rehabilitation in children with acquired or congenital movement disorders. Eur J Phys rehabil Med 2009 ; 45: 135-41. (5) Mitchell L, Ziviani J, Oftedal S, Boyd R. Efficacy of virtual reality interventions to increase physical activity in children and adolescents with cerebral palsy; a systematic review. Dev Med Child Neurology vol 54 supp 5. P 48. June 2012 (6) Sadowsky CL, McDonald JW. Activity – Based Restorative Therapies: concepts and applications in spinal cord injury related –neurorehabilitation. Dev Disabilities Research Reviews 15: 112116 (2009).
Talking to Get the Facts Straight Education is the key to stem the rise of STIs. While sexual health education is not mandatory in WA schools, many schools are taking the safe messages to their students and parents.
ith the increasing incidence of STIs, particularly chlamydia, the time is now to deliver quality sexual health education but despite the subject being in Department of Education’s health education syllabus and the WA state curriculum framework it is not mandatory. Maryrose Baker, of DoH’s Communicable Disease Control Directorate, said it was hard to gauge how many schools taught the subject as it was dependent on each school’s interpretation of the curriculum framework and the individual teachers view of and confidence in the subject matter.
However, the directorate has worked tirelessly on programs and resource material to cover all groups – teachers, students and parents to aid positive communication about sexuality and responsible behaviour.
resources extensively to teach sexual health to her Years 8 and 10 students. “Year 8 is an introduction to sexual health focusing on puberty and changes, while in Year 10 the 12-14 week course focuses on relationships, contraception, STIs, resilience (to peer pressure and media), legalities of sex and cyber safety. Each year there’s something different to discuss.” “The kids are very engaged with the subject matter and make interesting comments, and sometimes it’s conversations they would not have at home. I think the kids realise that this course has useful information that they can use throughout their lives. You can hear them talking about it to each other after the classes.”
“The primary focus of the directorate is stopping the spread of STIs, but to get young people skilled enough to make good decisions about relationships and their body, we have to start early and we have to do it holistically – sex isn’t just plumbing,” Maryrose said. The various resources not only informed teachers on the subject, they also helped to raise their confidence and competence to teach it well. Karen Edwards is the health education teacher at Bunbury Senior High School and she uses the internet and the teaching 40
At his school, health discussions start in Year 1 with age appropriate material. In Years 5 and 6, girls and boys are separated for discrete class discussion that deals with the physical and emotional changes during puberty. “We have these classes in a casual environment – kids are made to feel relaxed and encouraged to ask questions. Kids have the chance to ask private questions as well, so there are many ways to encourage talk.” “The book gives parents who might be nervous about discussing issues around sexual health, more confidence to have dialogue. A story I can relate is of a boy who after school went home and talked to his father about our class discussion and what was a potentially awkward discussion became a natural one.”
For teachers there’s the Growing and Developing Healthy Relationships (GDHR) website including student worksheets, for parents there’s the book, Talk Soon, Talk Often, booklets for 10-12 year olds on puberty and for adolescents there’s the Get the Facts website, which is a self-navigating resource giving teenagers clear, nonjudgmental information from STIs to sexuality. On the next page we have asked four doctors to critique the Get the Facts website, which was launched in March 2009 and has just undergone its first revision.
material, use the information they feel comfortable with and to discuss with their children the material that is consistent with their values and beliefs. But the most important thing is for them to have a conversation with their children, because it’s the primary responsibility of parents to teach their children about sexual health. The text is there to support their decision making.”
“Discussion about sexual health then becomes a celebration of a rite of passage, not something to dread and it’s really encouraging to see the number of boys talking and sharing things about themselves.” “Chlamydia is an issue in our area, so sexual health is a really important conversation to be having with this demographic.” Gavin Nancarrow, principal of Kalamunda Christian School, an independent primary school, says from his experience, teaching sexual health education can have real positives for parents and their children. “The concept of sexual health is a generally contentious issue, not just in a Christian school. The way we use the Talk Soon, Talk Often text is as a prompt for parents to start a conversation with their children.” “We encourage parents to review the
Primary teacher Wendy Wright agrees on the importance of teaching children about their sexual health … “in fact it starts from the time they’re born” she adds. ”I teach Years 6/7 about menstruation and puberty and I start by calling the body parts by their correct name. Then there’s no sniggering. It’s also about teaching kids to set boundaries.” “The kids enjoy the classes; they really connect and understand that it is relevant and it’s about their lives. It is a bonding activity. Students appreciate their teachers being honest and it forges a better relationship in the classroom.” l
Management of grommet tube otorrhoea W
By Clin/Prof Harvey Coates AO, Paediatric ENT Surgeon. Tel 0418 208 902
ith insertion of grommet tubes relatively common in childhood, plus a climate conducive to swimming and upper respiratory tract infections in children, it is no wonder that grommet tube otorrhoea can occur in up to 35% of child patients. The cardinal symptoms are persistent aural discharge, hearing loss and occasionally bleeding from the ear. The discharge can persist for weeks or even months and may not resolve with oral antibiotics alone. The tube may be ejected if the tube lumen blocks with biofilm/dried mucopus. The child with a history of recurrent acute otitis media may have more otorrhoea than a child with otitis media with effusion.
Some children with longstanding grommets and recurrent infections may have developed recalcitrant infections due to bacterial biofilm around the grommet, or there may be an underlying immune problem such as subclass IgG2 deficiency. Generally, if the otorrhoea has been cultured and an appropriate ear drop used but there is no improvement within a month, then an immunologic workup is advised. Otorrhoea may obstruct the grommet and thereby affect hearing. Discharge from the middle ear can aggravate or perhaps cause a secondary otitis externa.
Preventing infection Post-operative: Immediately after grommet insertion, a three-day course of nonototoxic ear drops containing ciprofloxacin can reduce post-operative infection and help keep the grommet lumen patent. If the child has a history of recurrent acute otitis media but no middle ear fluid is noted at the time of surgery, a single post-operative instillation of drops can be effective as a preventer in more than 90% of cases. Water in the ear: Some children are able to swim in the ocean without any protection at all, and without infection developing, so a trial of this for two weeks without ear protection would be my first suggestion. However, some children develop grommet tube otorrhoea with the smallest amount of water ingress into the ear canal, so not allowing dives to the bottom of the pool and protecting the ear using moulded ear plugs, Blu-Tac or silicone ear putty may be best. Swimming with grommets in, and whether to protect the ear canals, remains
Most cases of otorrhoea will clear with three drops of a ciprofloxacin ear drop, 2-3 times a day, for 5 days. If fungal infection is suspected, the safest anti-fungal ear drops are Locacorten-Vioform eardrops.
n Discharging grommet
controversial. In the northern hemisphere and Europe, where children may swim less hours than Australian children, some parents have success with no ear protection at all, while swimming in clean water or the ocean.
Managing discharge It is important to remove any discharge if active otorrhoea is to settle; eardrops or systemic antibiotics will often not do it alone. The ear canal may be cleaned by irrigation with a 0.5% povidone-iodine (Betadine) solution to wash out the discharge, before removing any remainder with an ear suction device or by dry mopping with a broach probe tipped with cotton wool. Parents can clean the ear using a tissue spear gently applied to the ear canal, until the tissue spear is not contaminated with discharge, and then insert the eardrops. Generally, most otorrhoea will settle with twice daily ear toilets for 3-4 days followed by the ear drops.
Antibiotic use It is critical that non-ototoxic eardrops be used in the presence of a tympanic membrane perforation or patent grommet because of rare but well documented cases of permanent sensori-neural hearing loss. When the infection has cleared there is increased potential absorption through the round window membrane into the inner ear.
If otorrhoea persists, then culture and sensitivity testing may be necessary – in most cases chronic otitis externa organisms such as Pseudomonas aeruginosa will show with this normally being sensitive to ciprofloxacin ear drops. Occasionally, following upper respiratory tract infection, acute otitis media organisms such as Haemophilus influenzae or Streptococcus pneumonia will be cultured, for which an added oral antibiotic such as amoxicillin is indicated.
Grommet polyps Granulation polyps arising from the tympanic membrane, perhaps even occluding the grommet, or polyps in the middle ear may present with active bleeding that is concerning for parents and child. Over summer, this is seen often (see Figure 1). The management of this is to use a non-ototoxic eardrop together with steroid such as Ciproxin HC, (ciprofloxacin and hydrocortisone) for 2-3 weeks, with review. Rarely, polyps may require surgical excision if there is no resolution.
FACT BOX • Grommet tube otorrhoea is a common complication, particularly in summer. • Ear toileting followed by application of non-ototoxic eardrops is the treatment of choice. • Consider fungal infection or immunologic deficiency for recalcitrant grommet tube otorrhoea, which may require specialist referral.
Declaration: Competing interests. The author is on an NHMRC grant application proposing Ciprofloxacin eardrops in the management of CSOM in Aboriginal children. Nil else.
n Polyp in grommet
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The PSB and stimulant prescribing in WA T
By Ms Alpa Dodhia, Pharmacist and Coordinator Stimulant Regulatory Scheme, PSB DoH
he Pharmaceutical Services Branch (PSB) provides advice, develops policy and administers regulatory controls for Schedule 8 medicines including stimulant medicines (dexamphetamine and methylphenidate), the monitoring of which includes taking over 200 phone calls and sending out over 250 letters each month to prescribers over monitoring issues. PSB also provides education, training and support to prescribers and pharmacists. Prescribers can check the prescription history of new and existing patients prior to initiating stimulant medication by ringing the Stimulant Co-ordinator on 9222 2483 (Mon-Fri 8.30-16.30).
Stimulant Prescribing Code This Code, established in 2003, is the overarching regulatory framework that sets the clinical criteria for prescribing of stimulant medicines in WA. The aim is to ensure the most effective medication is prescribed and overall patient health and safety is maintained. Useful information and further resources on stimulant prescribing is located at www.health.wa.gov.au/stimulants. PSB processes approximately 1000 stimulant Notifications from specialist prescribers every month. General practitioners can be nominated as co-prescribers by the specialist medical practitioners who hold Stimulant Prescriber Numbers (SPNs). Patients with a history of substance abuse, bi-polar disorder or psychosis, require prior written authorisation from the Chief Executive Officer of Health before initiation of treatment. Prescribing of atomoxetine, a non stimulant does not require Notification to the Department of Health (DoH).
Stimulants Assessment Panel The Stimulants Assessment Panel meets monthly and provides advice on all applications for authorisation and consists of specialist psychiatrists and paediatricians from the public and private sector. In the past year, 68% of applications were declined and an appropriate stimulant treatment was recommended as per the strict protocol the panel uses when assessing applications.
Interim authorisations Interim authorisations may be issued to
GPs to prescribe stimulant medicines whilst patients are transitioning between specialists or have recently arrived from interstate/overseas. The GP needs to refer the patient to the most appropriate specialist and indicate a definite referral date on the application to prescribe a drug of addiction (see: www.health.wa.gov.au/ S8). An authorisation to prescribe a Schedule 8 medicine (including stimulants), which is granted by the CEO of the WA Department of Health, is separate to a Pharmaceutical Benefits Scheme (PBS) ‘authority prescription’, which is a Commonwealthfunded scheme providing affordable access to basic treatments for chronic health conditions under Medicare (see Schedule of Pharmaceutical Benefits, or phone 1800 552 580). Stimulant medications covered by WA’s PSB Stimulant Regulatory scheme are currently authority prescriptions requiring Authority approval numbers issued by Medicare or Department of Veteran Affairs (DVA). Note that paediatricians do recommend that children have regular holidays from stimulant medication i.e. during weekends and school holidays.
Diversion of stimulant medication As well as diversion for financial gain, DoH has come across several occasions where stimulant medication prescribed to children is being used by parents. The DoH liaises with the specialists, schools and hospital departments and a multi-
CASE HISTORY KM and her two children were diagnosed with ADHD and all prescribed stimulant medication. Over a 23 month period, KM accessed 8000 dexamphetamine tablets, 1430 more tablets than her notified dose. It became apparent that KM was also using the dexamphetamine tablets prescribed for her son and daughter. This was achieved by: • visiting multiple specialists (psychiatrists/paediatricians) and medical practitioners; • having prescriptions dispensed at multiple pharmacies; • requesting prescriptions due to ‘lost/ stolen’ tablets or prescriptions; and • taking advantage of times that medical practitioners were away. The PSB was alerted to the patient’s activities from phone calls from various parties, including pharmacists and PMH where the mother had presented without the children and requested dexamphetamine ‘on their behalf’. The children’s stepmother contacted PSB, concerned the children were not getting their medication. Finally, a paediatrician rang to express concerns that KM’s daughter was not getting the medication as prescribed and informed the department that the medication would now be dispensed at school.
disciplinary approach is used to confirm the diagnosis of ADHD in the child and then ensure the children receive their required medication.
New Initiatives for Fast-Growing Peel Peel is the happening location. Last month the state government committed $140,000 a year for five years to help establish a mobile health service for those in outlying areas in the region. The Peel Mobile Health Service, which starts this month, will provide health and health promotion services to the communities of Pinjarra, Waroona, Boddington, Serpentine and Jarrahdale medicalforum
from a modified vehicle which can operate at difference locations, even sites without water. It is a joint initiative between WA Health, the Peel Health Foundation and GP Down South. The Peel Health Foundation raised more than $220,000 to buy and modify the vehicle, and the WA Health commitment will keep it on the road. GP Down South are the service providers.
The Peel Health Campus has also recently launched the PHC Community Fund to raise funds for community campaigns raising health awareness and wellbeing programs. Health Solutions WA, which manages PHC, kicked off the fund with a $250,000 contribution. The grants procedure is explained on the PHC website or through the community relations team.l 45
GP’s Rapid Response
GP Geoff Emery reckons there’s time enough for calm waters. Right now there’s the Avon to tame. Flashing across the finish line is a ‘good feeling’ according to GP Geoff Emery. He’s got five boats tucked away in his garage, he’s done eight Avon Descents and he’ll be lining up again in the early morning mist at Northam Pool on the first Saturday in August. It wasn’t all that long ago when Geoff was dressed in leather and leaning into corners on his Harley Davidson motorbike. Now he’s charging down Bell’s Rapids in midwinter in a plastic container. It sounds like the full existential midlife crisis straight from central casting but there’s a lot more to the story than that.
“Guys in their early 60s like me can still hold their own and I’d like to think I’ll still be doing this when I’m 70.” Mucking around in boats isn’t always a solitary and competitive pursuit for Geoff. His wife, GP Henrietta Bryan enjoys it too. They’ve paddled around the
Whitsundays living out of a double kayak and camped on the beaches around Shark Bay. But the Avon River is more demanding and not for the faint-hearted, especially after solid winter rains. “The Avon gets the adrenalin pumping. You do have moments where you can imagine being upside down, screaming and thinking about dying. Once you get
“The Avon’s a beautiful river and a welcome break from the surgery. No one’s going to ring me out there and, in any case, I switch my phone off so they can’t. You leave your troubles behind and there are so many magic moments. I remember one morning in particular, it was so still I actually got a touch of vertigo looking down at the sky perfectly reflected in the water.” Competitors come from all over Australia and overseas, especially from South Africa, for the two-day, 133km white-water classic. For Geoff, training for the Descent begins in February with gym work and some mountain biking but he says there’s no substitute for just getting into the boat and paddling long and hard on Perth’s waterways.
down past Emu Falls you’re relying on other paddlers to get you out of trouble if things go wrong. There are about 30 rapids in a 30km stretch with names such as Terminator, Bone Breaker and Heart Stopper. It’s a rite of passage for those who haven’t paddled the Valley before.” And, sadly, things on the Avon River can go horribly wrong. The river has claimed two lives, one a race competitor in 1995 and the other during a practice session at Bell’s Rapids. The river is always changing and, when it does, a particular section of the course can turn into a real nemesis. “At times I’m terrified of Emu Falls and then I’ll do a good run and get my confidence back. I’ve trashed my kayak at a place called Deadly Mistake when the footrest was ripped out of the boat. But being able to control the fear is part of the challenge.” When it comes to the Avon Descent, you need a lot more than a big splash of raw courage and a little bit of technical expertise doesn’t go astray either. Geoff passes on his skills as an instructor
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at the Swan Canoe Club in both white water and sea kayaking. One of the younger club members, Kynan Maley will be competing in London in the C1 and C2 kayaks. It’s not entirely surprising that Geoff is one medico who has a healthy regard for his own wellbeing. He’s a great believer in having his own GP to give him his yearly check-up. “I like him to treat me as a ‘real’ patient. I don’t want it to turn into a negotiation where he says, ‘what do you think Geoff?’. It’s nice to hand that responsibility over to someone else. I make a point of going to someone who’s not in our practice and every year around my birthday I go and get the once-over.” As to his own practice of medicine Geoff says he’s enjoying the work but finds the bureaucracy an increasing strain. “All the paperwork and the expectations of patients and government can be a bit tiresome. I do a bit of hypnosis and that’s a welcome break from all the usual stuff. But, having said that, I really enjoy my work and it’s hard to imagine retiring. I work about 35 hours a week and make sure I get a few afternoons off to go kayaking.” As the Avon Descent edges closer, Geoff reflects on some of his more idiosyncratic techniques to get him across the finish line. “The last 30km is hard work and I do a Heart of Darkness thing. I imagine I’m being chased by canoes with people shooting arrows at me. It’s a good feeling when you stagger across the line.”l
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By Mr Peter McClelland medicalforum
You won a Taste of Wales award, what was the criteria? Kiren: Producing the highest standard dining experience using local produce. A lot like the awards for excellence and the Gold Plate we have won here. What led you to the Swan Valley? Do you live in the valley? Kiren: The local produce. The restaurant is perfectly positioned, surrounded by local farms and region; and there’s some great wild produce as well. We live about 10 minutes from the restaurant but over the five years we've had Dear Friends, we’ve spent more time at the restaurant than our home. What do you love most about Swan Valley? Kiren: We are really proud to be a part of such a great region. There has been a serious move of late towards the finer side of the valley, which is great. New winemakers like Alon Arbel from Bella Ridge, Archie Kosovich from John Kosovich are bringing new exciting wine styles and improving the quality of the local wines, while the iconic winemakers like Dorham Mann of Mann and John Griffiths from Faber Wines are still producing some of the best wines in the state. How important is cooking with local and seasonal produce? Kiren: It's a no brainer, really. It's as important and inspirational to the grower who grows it as it is to the chef who cooks and the person who eats it. Do you have a kitchen garden? If so, what excites you the most when you see it bursting out of the ground or on the vine?
10 minutes with... Kiren and Kelli Mainwaring Chef Kiren Mainwaring and his Sommelier wife Kelli have travelled the world and have found themselves in the picturesque Swan Valley cooking up a locally inspired storm at Dear Friends. What influence has your Welsh heritage had on your cooking? Kiren: Not only Wales but Pembrokeshire have had an enormous influence on the early days of my cooking career. The food style of Pembrokeshire’s fine-dining scene in the early nineties was unique – we had a great produce manager at the local council by the name of Kate Morgan, who brought all the local small-holding farmers and top chefs together with the idea of creating unique bespoke menus using only locally sourced ingredients. This is still my philosophy today.
Who or what have been the greatest influences on your cooking? Kiren: I am extremely proud of the training I received in Wales – the hours were extreme but my mentor Mike Lewis is an unbelievably gifted chef and far ahead of his time. I was trained to produce everything from scratch – all aspects of dairy techniques from locally sourced milk, to hand picking livestock and in-house butchery to curing, ageing and smoking. I use all these methods at Dear Friends and with the help of local farmers and growers we can produce a degustation menu that is a true representation of WA. What is one of the most important cooking lessons you’ve learnt along the way? Kiren: Wow, that's a tough one because, really, you are learning every day. But when it comes down to it, I think the most vital lesson is to keep the highest level of hygiene, safe storage and preparation of food. A lazy chef can kill!
Dear Friends, 100 Benara Rd, Caversham, phone 9279 2815. Email: email@example.com
Kiren: I consider the Swan Valley as my kitchen garden. We use a lot of seasonally foraged wild ingredients and anything we can find from local orchards and farms. On the restaurant grounds, we have three rows of old-vine Grenache. We use these for sourdough starters for our breads, dolmades, frozen for a predessert, and hand-picked as an appetiser. Kelli, as sommelier, what do you look for in a wine? Kelli: I look for characters and textures that will balance well with Kiren’s dishes. I’m also always looking for new or exciting passionate producers from small boutique wineries, locally and from around the world. I'm also a sucker for acid, I love a crisp Riesling, which is such a versatile food wine. Your wine list is extensive and far-reaching, how much maintenance does it need? Kelli: I print the list every week to keep it up to date as there are always new wines and vintages. We also do regular staff tastings and training so everyone is familiar with all the wines and the wines are consistently moving. We have a lot of beautiful rare and unknown wines that we like to introduce to people. Luckily our customers trust us to recommend new and interesting wines, which keeps the list flowing. How do the Swan Valley wines stack up to others on your list? Kelli: Every wine we purchase we personally taste to see if it is suitable. With the local wines we visit the vineyard, taste the wines and gather all the information we can from the winemaker. Only the best-suited wines make it to the list and personally I am biased towards the great local wines – there are some really passionate and talented winemakers in the valley and the Perth Hills should get a mention. Myattsfield do a straight mouvedre, which is excellent. They are a boutique winery run passionately by a husband and wife team. What would be your last meal? Kelli: A degustation with the theme of our life together, every dish being a memory of somewhere on our travels, a signature dish from the restaurants we’ve worked at over the years. Kiren: I guess I'd be cooking it then! I also catered for our wedding and provide the famous after-work dish of welsh rarebit.
By Ms Jan Hallam medicalforum
Jim and Bev Gilbert established their vineyard near Mt Barker in the heart of the Great Southern Region in 1985. Being third generation cattle and sheep farmers they decided like a number of others in the area, to diversify and so, with no previous experience, planted vines. However, unlike many others who have not survived in the wine industry, they have built upon their experiences and become one of the high-profile boutique operations in the region — all a result of hard work and dedication. Their 14ha are planted to Riesling, Chardonnay, Shiraz, and Cabernet Sauvignon, and wine production, together with their very successful on-site cafe, have grown into a full-time family business. I have known Jim and Bev since their label began and have followed their wines closely. Their Rieslings have always impressed me and have deservedly won numerous awards over the years including best wine at the Qantas West Australian Wine Show, which is held at Mt Barker each year. Also their Shiraz wines have gone from strength to strength and often impress. Gilberts Wines are well worth sourcing. They are available at www.gilbertwines. com.au, via cellar door, and through selected liquor outlets.
By Dr Craig Drummond Master of Wine
growing in stature
2011 Riesling, $25
This wine shows plenty of lime-citrus aromas and flavours. The fruit is intense and focused, with mineral elements and firm acidity giving length and a clean finish. Has an edge of austerity – typical of youthful Rieslings of the region – but it’s beginning to mellow. Will have a great future and could be enjoyed for the next five years. 2011 Hand-picked Chardonnay, $25 The nose is showing cashew and tropical aromas and fresh oak. The palate has stone fruit and peach flavours. There is nice texture to this wine, and a mineral edge with firm acidity giving a linear palate profile. The oak is integrating. 2008 Three Devils Shiraz $18 This is a 'second label' wine in the Gilberts’ range, aimed at earlier consumption. It certainly represents great value. Aromas of allspice lead to flavours of redcurrant and mulberry. The finer/lighter tannins make a supple, easy-drinking wine. 2010 Three Lads Cabernet Sauvignon, $25 This is another 'second label', but with plenty of life still left in this one. There is a bouquet of cloves and lavender, with blackberry and herbs and a touch of liquorice on the palate. Drying, fine-grained tannins give structural definition. This wine will drink well for a few more years. 2009 Reserve Shiraz, $28 This is the 'Rolls Royce' of the tasting. Deeply coloured and intensely concentrated. Deep, rich, with plenty of the regional pepper and spice , black fruits and a touch of chocolate. It has ripe tannins and great oak. Enjoy now, or cellar up to 10 years for a complex, developed wine.
WIN a Doctor’s Dozen! Which Gilberts Wine is aimed at earlier consumption than others in the stable? Answer:
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Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, July 30, 2012. 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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Musical Theatre Showbiz
Nancye Hayes’ feet haven’t stopped moving in 60 years and she’s heading our way in the smash-hit musical, Annie. Nancye Hayes can’t remember a time when she didn’t tap dance. She would tap dance around the wireless as a child in her Manley home as a little girl, she’s hoofed her way into countless musicals over the past 50 years and this month her feet will lead her to the stage of Burswood Theatre at the age of 69, when she appears at Miss Hannigan in the much-loved Annie. “Theatre is what I’ve wanted I wanted to do all my life and apart from a stint as a secretary because my mother insisted that I needed something to fall back on, I’ve always worked in theatre whether it be on stage or as part of a production team, or as a choreographer or director.” Nancye Hayes' big break was in the title role of Sweet Charity in the late 1960s and she’s rarely been out of work since. While she has performed in dramatic plays, musicals are her heartbeat. “Musicals have always been popular in Australia, and the classics – the shows that are beautifully crafted and have all the elements, great stories, great scripts great music, great dance – they will always be wonderful when they are revived because they have everything going for them.” 50
“Annie is like that. It’s got a lot of heart. It’s a rags-to-riches story of a little girl determined to find a family and a lonely man who discovers that all the money in the world doesn’t mean a thing if you don’t have anyone in your life. And it’s set in hard times when some people are doing it tough and just trying to get by and that’s not dissimilar to what some people are going through at the moment, here.” This is Nancye’s third production of Annie and she’s seen it from lots of angles. “In 1978 I played Lily St Regis, in 2000 I was the resident director looking after the company after the original director, Michael Sharman, returned to Broadway and now, with this great cast.” Sadly Perth will not get to see Anthony Warlow as Daddy Warbucks. He’s been given an opportunity of a lifetime to head to New York to play the part in the Broadway production. However, in true show biz tradition, the show will go on with Michael Cormack in the role. “Michael’s a fine performer. Anthony will be very missed but the thing is when you’re in a long run – and we will be well over 200 performances by the time Michael joins us, a cast change brings a new way of looking your performance and it can be quite refreshing.”
The other cast change sees veteran stage and TV performer Bert Newton (seen most recently in Perth in Wicked) replace Sydney shock jock Alan Jones in the role of US President Franklin D. Roosevelt. “The cast is a tightknit group and incredibly professional. Every actor has to remember that it may be their 200th performance but for the people who bought those tickets, it’s their first time and you don’t want them to see anything less than the best. It’s a discipline. You need a lot of discipline in the theatre to make sure it's spontaneous and in the moment.” “It’s the most important quality for an actor because it’s a hard business. You have wonderful work, then when it all finishes, you have to get up and start it all over again.” l
By Ms Jan Hallam
WIN For you chance to win tickets to see Annie, which opens at Burswood Theatre on August 24, go to www.medicalhub.com.au.
Fun on Four Wheels Winding country roads and muddy dirt tracks were all part of a fun dayâ€™s motoring in the new Subaru SUV.
The SUV segment of the Australian car market has been the most popular section in the past few years. Subaru has joined the race with its recently released, compact SUV called the XV. As it is one of the main sponsors of the new professional Australian cycling team, Orica Green Edge, we thought it would be fun to load it up with a road bike, three adults and head to the Hills for a road/offroad test.
The car had a reliable grip around corners with great road-feel and feedback to the driver. While the Subaru XV won't break any speed records, its performance was adequate and still enabled us to enjoy the drive in comfort. Despite excessive acceleration and off-road driving, we averaged 7l/100km which is outstanding, perhaps in
Photo: Stephanie Robinson
FACT BOX Subaru XV Crossroad Sport Price: From about $28,500 Warranty: 3 years/unlimited km Engine: 2 litre; 4 cylinder petrol Boxer Transmissions: 6-speed manual, CVT; AWD Economy: 7l/100km (manual) 7.3l/100km (CVT); CO2 168g/km (manual & CVT) Safety: 7 airbags, stability control, ABS Fuel: 60l tank, 90RON
On the way to Serpentine Dam, we did an extensive drive through muddy tracks on a horse property in Mundijong and were pleasantly surprised with its ability to handle the very soft terrain. Its off-road ability would be more than adequate for most people.
This car is smaller than the Forester and is based on the new Impreza wagon. It is allwheel drive and comes with a revvy 2.0 litre Boxer motor and a choice of manual or automatic transmission.
After Devonshire tea with the various native birds at the dam, we put the car to the test on some winding country roads, where it again proved to be comfortable and fun. With its allwheel drive, traction control and low centre of gravity, the car had good grip and impressive neutral handling around corners. Despite the highly treaded tyres, there was minimal road noise inside
There are three choices of model level. While we testdrove the high-spec model, even the basic variant comes very well equipped with reversing camera, blue tooth capability and numerous safety features. Our car had electric seats, xenon headlights, satnav and even seat warmers! The comfort level, finish and spaciousness were more than adequate. We also really liked its appearance, thinking it made an appealing change from the boxy, chunky shape of most of its competitors, and it will appeal to the younger sportier section of the market.
part due to the stop-start technology which is supposed to reduce fuel consumption by 5%. The ability to stop the motor when not moving seems to alienate some drivers but we didn't find it a problem. When easing your foot off the brake the motor will start again in 0.35 seconds.
the cabin. The XV is a fun car with lots of positive features in styling, safety and driving but it does come with one major fault. Our bottle of Knee Deep Chardonnay would not fit in the bottle holder in the door! l
By Dr Peter Bradley and Dr Daryl Sosa 51
If a face can tell the story of a life, then our photographer doctors this month have captured some amazing biographies from their travels overseas or their work closer to home. This month Dr Carol McGrath’s picture of girl on the Mozambiquan island of Ibo wins First place on a vote by the Medical Forum crew. Carol says she was walking along a dusty track on the island when this girl suddenly popped up to watch her group. The picture was taken on a Nikon D60.
Second is Dr Susan Downes joyful picture of three generations. Susan writes: “The wisdom, life's experience and devotion engraved in the grandfather's face is in great contrast to the freshness of the young woman. Both are ecstatic.” Third is Dr Marcel Goodman’s study entitled “Slight sadness of Ageing” (photographic specs: ISO 160, F5, 1/800). Placegetters in no particular order
1 Baby’s day out in a market in Laos by Dr Moira Westmore. 2 “Snow Princess – first time in the snow. Mrs Jo Marks’s daughter Euphemia. 3 "Eating ice cream is a serious matter" taken by Dr Farhat Mahmood during a visit to Albert Park in Melbourne.
4 Watching the world go by … a woman in India taken by Dr Janina Anderst. 5 A bridge and groom during a traditional Indian wedding ceremony by Dr Amba Roy-Choudhury. 6 A toilet attendant in a little village in the Colca Canyon in Peru taken by Dr Caroline Luke. The theme for the next photo spread is “And… Action!”
Send your photos to firstname.lastname@example.org by September 13 5252 for the October issue of Medical Forum.
funnyside n n Perks of Getting Old • Kidnappers are not very interested in you. • No one expects you to run – anywhere. • People call at 9pm (or 9am) and ask, 'Did I wake you? • People no longer view you as a hypochondriac. • There is nothing left to learn the hard way. • Things you buy now won't wear out. • You can eat supper at 4pm. • You can live without sex but not your glasses. • You get into heated arguments about pension plans. • You no longer think of speed limits' as a challenge.
• You quit trying to hold your stomach in no matter who walks into the room. • You sing along with elevator music. • Your eyes won't get much worse. • Your investment in health insurance is finally beginning to pay off. • Your joints are more accurate meteorologists than the national weather service. • Your secrets are safe with your friends because they can't remember them either. • Your supply of brain cells is finally down to a manageable size.
• You can't remember who sent you this list.
n n Too Clever for
Texan: “Where are you from?” Harvard grad: “I come from a place where we do not end our sentences with prepositions.” Texan: “Okay – where are you from, jackass?”
n n Hare today, gone tomorrow
A turtle was walking down an alley in New York when he was mugged by a gang of snails. A police detective came to investigate and asked the turtle if he could explain what happened. The turtle looked at the detective with a confused look on his face and replied “I don't know, it all happened so fast.”
n n Barking up the wrong
An Alsatian went to a telegram office, took out a blank form and wrote, “Woof. Woof. Woof. Woof. Woof. Woof. Woof. Woof. Woof.” The clerk examined the paper and politely told the dog: “There are only nine words here. You could send another ‘Woof’ for the same price.” “But,” the dog replied, “that would make no sense at all.”
n n Shot in the
A couple of city slickers are out in the woods when one of them falls to the ground. He doesn't seem to be breathing, his eyes are rolled back in his head. The other guy whips out his mobile phone and calls the emergency services. He gasps to the operator: “My friend is dead! What can I do?” The operator, in a calm soothing voice says: “Just take it easy. I can help. First, let's make sure he's dead.” There is a silence, then a shot is heard. The guy's voice comes back on the line. He says: “OK, now what?”
n n Elementary, of course Sherlock Holmes and Dr Watson go on a camping trip. After a good dinner and a bottle of wine, they retire for the night, and go to sleep. Some hours later, Holmes wakes up and nudges his faithful friend. “Watson, look up at the sky and tell me what you see.” “I see millions and millions of stars, Holmes,” replies Watson. “And what do you deduce from that?” Watson ponders for a minute. “Well, Astronomically, it tells me that there are millions of galaxies and potentially billions of planets. Astrologically, I observe that Saturn is in Leo. Horologically, I deduce that the time is approximately a quarter past three. Meteorologically, I suspect that we will have a beautiful day tomorrow. Theologically, I can see that God is all powerful, and that we are a small and insignificant part of the universe. But what does it tell you, Holmes?” Holmes is silent for a moment. “Watson, you idiot!” he says. “Someone has stolen our tent!”
Entering Medical Forum’s
competitions has never been easier! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).
Music: Mnozil Brass There’s no brass ensemble quite like Mnozil Brass, who will have you laughing, clapping and cheering their crazy antics and their superb playing. This seven-piece band from Austria have been referred to as the Monty Python of music, but don’t let that fool you, they are seriously good musicians. Just to whet your appetite, check out www.youtube. com/watch?v=eYRMbj6U2Ww, then hurry to enter or book through BOCS. Perth Concert Hall, September 19, 8pm
Music: Vienna Boys Choir The Vienna Boys Choir returns to WA with a special program that includes the premiere of a new Australian work by composer Elena Kats-Chernin based on the much-loved Australian poem, My Country, by Dorothea Mackellar. The choristers, aged between 10 and 14, will also sing from their classical repertoire including Schubert and Mozart. Tickets through BOCS. Perth Concert Hall, September 22, 8pm
Winning Wine: Straight to the Hartz The previous Doctor’s Dozen wine winner, Dr John Love inspired another Perth medico to enter the June competition. In fact, Dr Anna Maria Cianciullo graduated in the same year as John and his smiling face in the pages of Medical Forum prompted her to throw her hat into the ring. It was the first time Anna had entered and now, courtesy of a case of Hartz Barn wines, she’s smiling too. Anna loves Margaret River reds and is heading down to the South West on a family holiday. Anna’s birthday is coming up too. We can hear the screw-caps popping!
Musical Theatre: Michael Jackson HIStory II
From June issue
Michael Jackson may have gone but he’s not forgotten and in this tribute show, Michael Jackson impersonator Kenny Wizz shows the full breadth of the late singer’s talents. Wizz, who brings his own artistry to the role, backs up last year’s sold-out live tour with a tribute to the songs of the the Jackson 5 era as well as later hits. Tickets through BOCS. Perth Concert Hall, September 15, 8pm.
Amarcord – Concert: Dr Fred Faigenbaum, Dr Andrew Kam & Dr Andre Chong
Award-winning actor and singer Tom Burlinson brings an 8-piece band to Perth to get toes tapping with his latest show, Now We’re Swinging. In true crooner condition, Tom will sing the classics from Cole Porter to George and Ira Gershwin and channel a little Sinatra along the way. He's smooth and very cool. Tickets through BOCS.
Not Suitable for Children – Movie: Dr Jens Buelow, Dr Sue Martin, Dr Fraser Moss, Dr Karen Prosser, Dr Sara Chisholm, Dr Kwok-Keong Lam, Dr Sayanta Jana, Dr Jenny Philip & Switch to Be Dr Stephen Jarvis st Practice an on au tomatic SM
Your appoin tment remind the wash but er today’s patie cards may disappear in their jeans nts can’t forge pockets going t appointmen constant com ts when you through For just a few panion, their cents and virtu mobile phone remind them via the reply) in Bes ir ! t Practice can ally no effort, new automa tic SMS remind do much to e There’s no fas liminate the c ers (and confi ter, more strea rmation ost and disru ption o mlined system Benefits of SMS than BP SMS! f No Shows. in Best
for Health Professi onals
• Integrates Practice Manag seamless ement Appointment moduly into the Best Practice Features Management le. • Interchan • Patients c geable Pr an be rem messages with a sinactice SMS templates allow t appointment on th inded within minut gle click. ailored eir Mobile phone. es of making a new • Complies with National Priva • Seamless two-way out system. cy standards of an confirm an appoint SMS communications, allows opt in or • Exclude S ment via SMS with Patients MS Appo a simple YES reply. to • SMS mes made within a cert intments reminders for Appo saging sim ain number of days intments time and money w plifies Patient comm • Practice a . llocated mobile num hile greatly reducin unication, it saves appointments. • Delivery r ber (additional cost g the risk of No Sh eports - C ow SMS (2 delivery repoonfirmation the Patient rece s apply) ived the rts = 1 SM • Only qual ity Tier 1 Australian S Credit). SMS Providers used .
• 1000 SMS credit s = $200 +GST • 2500 SMS credit (20c Per SMS) s = $400 +GST • 5000 SMS credit (16c Per SMS) s = $700 +GST • 10000 SMS cred (14c Per SMS) its = $1200 +GST • 25000 SMS cred (12c Per SMS) its = Practice allocated m $3000 +GST obile number = $50 (12c Per SMS) +GST Setup Fee / $300 +GST per year (subscrip
us: T: (07) 4155
0427 767 833
For more informat ion contact
Octagon Theatre, September 1, 8pm
S reminders witch /replies
Good Food & Wine Show: Dr Charles Armstrong, Dr Liz Ferguson, Dr Susie Grainger, Dr Eng Hoe Kher, Dr Lauren Mott, Dr Mukti Biyani, Dr Edna Sun, Dr Byrne Redgrave & Dr Lorna Joyce
MEDICAL F ORUM
Music: Now We’re Swinging
Signs of Life – Theatre: Dr Richard Clarke, Dr Stuart Salfinger & Dr Karen Prosser
or E: SMS@bp software.com.au
School for Wives – Theatre: Dr Caroline Rhodes 11/01/12 4:48 PM
Taking the Fight to Diabetes • Kimberley Ren Service; Diab al etes & Cancer; Diabetic Maculopathy • Kim Snowba ; ll’s Balancing Act • Lexus GS 350 Hits the Roa d
Movie: Hit & Run Written, produced and directed by comic talent Dax Shepard (NBCs Parenthood), Hit & Run is the story of Charlie Bronson (Dax Shepard), a former getaway driver who busts out of the Witness Protection Program to drive his girlfriend (Kristen Bell) to Los Angeles so she can land her dream job. In cinemas, August 23
Switch to Best Practice and switch on automatic SMS reminders/replies
Your appointment reminder cards may disappear in their jeans pockets going through the wash but today’s patients can’t forget appointments when you remind them via their constant companion, their mobile phone! For just a few cents and virtually no effort, new automatic SMS reminders (and confirmation reply) in Best Practice can do much to eliminate the cost and disruption of No Shows. There’s no faster, more streamlined system than BP SMS! Benefits of SMS in Best Practice Management
• Integrates seamlessly into the Best Practice Management Appointment module.
• Interchangeable Practice SMS templates allow tailored messages with a single click. • Complies with National Privacy standards of an opt in or out system. • Exclude SMS Appointments reminders for Appointments made within a certain number of days. • Practice allocated mobile number (additional costs apply) • Delivery reports - Confirmation the Patient received the SMS (2 delivery reports = 1 SMS Credit). • Only quality Tier 1 Australian SMS Providers used.
• Patients can be reminded within minutes of making a new appointment on their Mobile phone. • Seamless two-way SMS communications, allows Patients to confirm an appointment via SMS with a simple YES reply. • SMS messaging simplifies Patient communication, it saves time and money while greatly reducing the risk of No Show appointments.
Cost Prepaid • 1000 SMS credits
(20c Per SMS)
• 2500 SMS credits
• 5000 SMS credits
(16c Per SMS)
(14c Per SMS)
• 10000 SMS credits
(12c Per SMS)
• 25000 SMS credits
(12c Per SMS)
Practice allocated mobile number = $50+GST Setup Fee / $300+GST per year (subscription based)
For more information contact us: T: (07) 4155 8800, SMS: 0427 767 833 or E: SMS@bpsoftware.com.au