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september 2011 $10.50 MAJOR SPONSORS

Perth Pathology

WA’s Independent Monthly

www.mforum.com.au

Taking The Sting Out of Allergies

Wicked’s Lucy Durack

Enticing the Brits The Rural GP, the Plastic Surgeon

Good Witch of the West

Clinical Updates Hyponatraemia, FH, Dyspnoea & PFTs, Diabetes, Squint, and Psoriasis


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Contents 10

Rural GPs: Try Before You Buy?

Dietary Allergies in Perspective

News & Opinion Dr Sara Bird

Perth Pathology

14

20

Profile Boost for Health Management.

Alcohol Position Statement.

35 Treatment of Localised Psoriasis.

12 New to Aussie Medicine.

37 Understanding the Allergy Epidemic.

Dr Stewart Flemming

Male DV Victim Support. Stopping Pseudo-runners.

Dr Revle Bangor-Jones

Mystery Solved! 6 Beneath the Drapes. 8 Have You Heard? 15 21st Century Break Out.

A/Prof Susan Prescott

Dr Rob McEvoy

Dr Mini Zachariah

5 Hyponatraemia. Dr Wayne Smit

Lifestyle & Entertainment

25 Obstructive Sleep Apnoea and Type 2 Diabetes. Dr Paul Myhill

27 Obesity and the Lung. A/Prof Alan James

28 Identifying the Risks for Pulmonary Embolus. Ms Nerissa Ferrie

Ms Tellisha Dunlop

17 Specialist Services Go National.

38 Evaluation and Management of Postmenopausal Uterine Bleeding.

Clinical Focus

Ms Wendy Wardell

16 Lucy Durack: A Fairy Tale Come True

29 Therapies for Adults with Type 1 Diabetes. Dr Joey Kaye

18 Sports Medicine heading to Perth. Indigenous Respiratory Health. 19 Medicare Locals: South West Challenges.

31 The Patient with Chronic Dyspnoea.

22 Profile: Ear Science Institute. 23 New GP Accreditation Standards. Practice Nurse Incentive Program. 24 Undetected COPD in Need of Spirometry.

33 Treatment of Adult Strabismus – More Than Meets the Eye.

Mr Shane Cummings

Dr Rob McEvoy

Dr Sina Keihani

6 Win a copy of The Allergy Epidemic. 40 Recipe: Gluten-free Chicken and Vegetable Pie. 42 The Madness of Being Creative. Ms Tellisha Dunlop

Competition Winners – July edition. 44 Competitions. What’s On 45 On the Grapevine: Whisson Lake. Dr Craig Drummond

32 Familial Hypercholesterolemia: New Screening Options.

46 The Funny Side.

Dr Eric Whitford

Dr Ross Agnello

34 Spirometry: Useful Tool vs Meaningless Numbers.

31 Event and Conference Corner. 37 Indemnity for Retirement.

ISSN: 1837–2783

Dr Chris Quirk

A/Prof Hilary Fine

Prof Alfred Allan

Medical Forum Magazine 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

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4 Smoking: How Low Can We Go?

Adj A/Prof Kim Gibson

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Race to Paradise!

Guest Columns

2 Letters. Child Health Record Access?

Major Sponsors:

Directories 47 Clinical Services Directory. 70 Classifieds.

Ms Sally Young

Advertising Mr Paul Morgan advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Mr Shane Cummings (9203 5222) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

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

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reflect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.


@

Letters to the Editor Send your letter to: editor@mforum.com.au

Correction In our interview with Dr Denis Cherry (Dr Denis Cherry – Men’s Special Business, July edition), he referred to the “Keogh Institute” (currently under medical director Dr Bronwyn Stuckey). This was incorrect. He was referring to the Reproductive Medicine Institute under medical director Dr Ted Keogh (as is stated earlier in the same article) and confusion arose because the Reproductive Medicine Institute was renamed the Keogh Institute for Medical Research in 1996 in remembrance of Ted Keogh. Dr Cherry’s comments refer to events of two decades ago that pre-date that time. Dr Denis Cherry has offered further comment here …

Response: Dr Denis Cherry At no stage in my reminiscence of a medical career would I wish to infer that the Keogh Institute has ever done anything wrong. There has never been any grievance on my part. I was delighted to work at the then Reproductive Medicine Research Institute, and as I attempted to point out in the article, I benefited the most. In that situation, I received something more precious than money. By seeing large numbers of patients, I gained the valuable clinical experience and thus a compelling education in the then emergent field of sexual medicine. It was then – and still remains – a priceless asset; I will be

forever grateful to the late Ted Keogh, Alastair Tulloch, and Anne Jequier as well as other staff at RMRI. I hold the Keogh Institute, as it is now known, in high regard and consider myself lucky to have a collegial friendship with those I know well.

Child health record access? One of our readers asks Dr Sara Bird (Who Can Access Children’s Medical Records? August edition) if it would be best for doctors to check with the court to see if orders exist that prohibit access of a parent to a child’s health record, just in case the other parent is lying.

Response: Dr Sara Bird This is an interesting issue that touches upon the lengths to which medical practitioners are required to go to in order to verify information provided to them. In my view, in this situation, it is not part of the doctor’s role, or legal duty, to independently verify the information provided to them. If Jason’s mother advises the GP that there are court orders in place, it would be reasonable to ask for a copy of these

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• Already performing spirometry but wish to refresh their knowledge and skills • Considering introducing spirometry into the clinic but are unsure where to begin Includes presentations & practical session on

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orders to confirm that they do, in fact, prohibit access to the child’s record. However, it is certainly not the GP’s role to have to contact the court to confirm whether or not any orders are in place. In short, medical practitioners are entitled to rely on the information provided to them by their patients. If it transpires that the patient has lied, the responsibility for this falls to the patient and not the doctor.

Stopping pseudorunners Dear Editor, The increase in highly divertible medicines for use in the illicit market has resulted in the development and introduction of Project STOPTM in pharmacies (http://www.projectstop. com.au/). Pharmacists are required to record all over-the-counter (OTC) sales of products containing pseudoephedrine. Those seeking to divert pseudoephedrine (used in the manufacture of methamphetamine) are now resorting to other avenues of supply. There has been a discernable increase in the number of reports from pharmacists of ‘pseudorunners’ returning with prescriptions for pseudoephedrine when their request for the OTC product has been declined. Another worrying trend has been the increasing number of stolen prescription pads and forged scripts presented for dispensing, despite the use of electronic prescribing. There is no clear pattern of a particular target group and all prescribers appear to be at risk. The medicines being forged that have come to our attention are those with a high street value such as oxycodone, benzodiazepines, pseudoephedrine, and steroids. We urge you to store prescription pads and computer stationery securely at all times. Please advise Pharmaceutical Services and the police immediately if a prescription pad is stolen. The increasing availability of Schedule 8 (S8) medicines in a topical form, such as fentanyl (Durogesic®) and buprenorphine (Norspan®) patches appears to be associated with a degree of complacency among prescribers. Contrary to common belief, the topical formulation has a significant addictive potential. The oral morphine equivalent of a fentanyl (Durogesic® 100microgram/hr) patch is 360mg, which is a significant dose! There are whole websites devoted to extraction techniques for S8 medicines from such patches which makes them valuable street drugs. The demand for S8 medicines continues to increase. Please maintain vigilance at all times and contact the Pharmaceutical

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Services Branch on 9222 4424 during normal business hours if you have any concerns or queries. Dr Revle Bangor-Jones Regulatory Support Unit

Alcohol position statement Dear Editor, The Clinical Senate is the peak multidisciplinary clinical body within the Department of Health (comprised of 75 clinicians and two health consumers). At our December 2010 debate, the Senate considered the role clinicians can play in the societal debate on alcohol, in light of the very concerning data on alcohol-related harm in WA. The Senate recognised the need for cultural change and resolved to form a Position Statement on Alcohol to empower clinicians to act through all their spheres of influence. The full text can be accessed in the free online publication Australasian Medical Journal, 30 April 2011 edition (www.amj. net.au) and includes the recommendations that the legal age for drinking alcohol be increased in WA and the price of alcohol be raised either through an increase in absolute price, introduction of volumetric taxation, or a uniform floor price. We hope to raise awareness and foster more discussion and debate on this important issue. Adj A/Prof Kim Gibson, Chair, Clinical Senate of WA Ed. Medical Forum’s August edition featured two articles on Foetal Alcohol Spectrum Disorder, and we had more authors lining up to comment, so alcohol consumption patterns in WA are clearly an issue on many medicos’ minds.

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

DV victim support Dear Editor, Whilst more females than males are victims of intimate partner abuse (IPA) and generally suffer more harm, male victims require a variety of services. Three out of four medical practitioners in your e-poll (Male Medicos Comment on Men’s Health, July edition) perceived a need for a greater level of such services. In our research (Tilbrook, Allan & Dear, 2010), we found that male victims were reluctant to disclose abuse. Their reasons included shame, denial, fear of not being believed, and fear that they would not be assisted or would be blamed for the abuse. Even men who sought medical help after an incident of IPV would not disclose the cause of their injuries. Service providers who we surveyed believed that male victims would be more likely to disclose abuse if there were greater public awareness that males can also be victims of abuse, appropriate services were available for men, and if men were confident that they would be provided effective help. Removing the barriers to disclosure would not only facilitate men to access support, but would also increase the supports provided to children in these families and services to the perpetrators.

Mystery Solved! Who is it? Dr Kevin Murphy – semiretired, ex-FMP WA director, ex-Freo Hospital GP clinic – phoned to say the bust is that of Dr John Bamford, a South Perth GP, educator, and RACGP stalwart from the 1960s who died in the early 1970s of a blood disorder. He was chairman of the RACGP Board just before Max Kamien’s days. If the College has an archive, now is the time to dig around! Medical Forum is glad to get them kickstarted.

Doctors may need to be vigilant when a male presents with injuries and symptoms that could be associated with intimate partner violence and follow the same protocol as they would when they suspect that a female patient is a victim of partner abuse. Prof Alfred Allan, Ms Emily Tilbrook, and Dr Greg Dear, ECU

Refer with confidence. Lions Hearing Clinic’s university trained team of audiologists provide comprehensive hearing assessment and reporting for adults, paediatrics, tinnitus, auditory processing and referrals for implantable devices. Our research activities ensure that we maintain world’s best practice in the diagnosis and treatment of a range of hearing disorders. To make referrals see www.lionshearing.com.au/referral_form

Tel: 1800 054 667

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By Dr Wayne Smit, General Pathologist

Perth Pathology

Dr Wayne Smit is a General Pathologist. He completed his Fellowship in Melbourne in 1996 and has worked in Perth since 1999, including a term as CEO at Clinipath Pathology (Sonic). Wayne co-founded Perth Pathology with like-minded ‘corporate refugees’ in 2006 and remains Managing Partner.

(Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 Ph 9433 5696 Fax 9433 5472

www.perthpathology.com.au Collection centres throughout the Perth metropolitan area including: Fremantle (Main Lab); Perth CBD, Atwell, Bedford, Belmont, Bentley, East Perth, Ellenbrook, Hilton, Joondalup, Kardinya, Kinross, Maddington, Malaga, Palmyra, South Lake, South Perth, Southern River, Subiaco, West Leederville

Hyponatraemia By Dr Wayne Smit, General Pathologist

H

yponatraemia (low serum sodium) is the most common electrolyte disorder. Maintenance of sodium is important to sustain blood pressure and normal nerve and muscle function. In its most severe form, hyponatraemia is associated with significant morbidity and mortality. While the list of causes is long (see Table 1), unexpected cases can usually be resolved with clinical assessment and some basic laboratory investigations.

Clinical presentation Most patients with hyponatraemia are asymptomatic, especially if the fall in sodium has been slow. Symptoms may not develop until the [Na+] falls to 120mmol/L or less, and even then may be nonspecific (e.g. lethargy, headache, and nausea). However when reduction in sodium has been rapid, patients may be symptomatic well before a level of 120mmol/L is reached. In severe hyponatraemia neurological symptoms predominate. As the level of sodium outside the cells falls, there is movement of water from the extracellular fluids into the cells in an attempt to maintain the normal sodium concentration. Most tissues can

accommodate this cellular swelling but the brain is more sensitive because of the confinement by the skull bones. The risk of seizures and coma increases as the sodium level decreases.

Assessment & Investigation The identification of hyponatraemia should be followed by clinical assessment of the patient for symptoms but particularly to exclude important causes including CCF, liver or renal failure, malignancy, hypothyroidism, Addison’s, and IV or irrigation fluid administration. The patient’s hydration status should also be assessed and hydration status is important to help distinguish causes of hypotonic hyponatraemia.

In many cases the underlying cause will be evident following clinical assessment but where the aetiology is less clear, further investigation may be indicated. Applicable laboratory tests may vary with the clinical situation but serum osmolality, urine osmolality and urine sodium concentration are frequently useful. LFTs, TFTs, cortisol, glucose and lipids may be helpful to narrow the differential diagnoses. Assay of ADH (antidiuretic hormone) is rarely helpful.

Management Treatment, if indicated, is generally directed at the underlying cause of the hyponatraemia. Water restriction may be useful. In euvolaemic hyponatraemic patients, hypertonic saline may also be used but the risks of osmotic pontine demyelination caused by rapid restoration of sodium levels should be considered. References are available on request.

Table 1: Common Causes of Hyponatraemia: (after Walmsley) Pseudohyponatraemia (normal plasma osmolality)

Hyperlipidaemia Hyperproteinaemia

Hypertonic hyponatraemia (high plasma osmolality)

Hyperglycaemia (Diabetes)

Hypotonic hyponatraemia (low plasma osmolality) Hypovolaemia

- Extrarenal (urine Na <20mmol/L) GI loss: diarrhea, vomiting Skin loss: excessive sweating - Renal (urine Na >20mmol/L) Diuretic Rx Salt losing nephritis Addision’s disease

Euvolaemia (urine Na <20mmol/L) Acute water overload

Increased intake PLUS hypovolaemia: haemorrage, burns, drugs including IV hypotonic fluids Stress: post surgery, psychogenic Renal insufficiency

Euvolaemia (urine Na>20mmol/L) Chronic water overload

SIADH Drugs Chronic renal failure Endocrine: hypothyroidism, cortisol deficiency

Hypervolaemia (urine Na <20mmol/L): Oedematous states

Cardiac failure Hepatic cirrhosis Nephrotic syndrome

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Perth Pathology General Pathologist / Managing Partner: Dr Wayne Smit 0410-488736 Histology / Cytology: Dr Michael Armstrong  Dr Tony Barham  Dr Bruce Latham 

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Specialists available to take enquiries on tests: Michael Musk, Eli Gabbay, Justin Waring and Richard Nolan.

Win a copy of The Allergy Epidemic Local medico Dr Susan Prescott has just launched her new book, The Allergy Epidemic: A Mystery of Modern Life (UWA Publishing), which aims to promote allergy awareness for patients, parents, and clinicians alike. Sue’s book describes each allergic disease and its treatment, but more importantly, it delves into the intriguing story behind the epidemic rise in immune diseases and the fields of developmental origins and epigenetics, which are changing the way we understand the effects of modern environmental changes on our immune systems. The book is available from http://uwap.uwa.edu.au or all good bookstores for $29.95. All author proceeds from the book will go directly to allergy research. For your chance to win one of five copies of the book, email editor@ mforum.com.au with the subject line ‘Allergy book competition’ and your name, address, and phone number in the body of the email.

The latest research findings, interventions and techniques for prescribing exercise, assessing sports injuries, drugs in sport, motivating patients and much more. •D  eal more effectively with sports or other injuries presenting at your practice. • Hands-on workshops: Taping Techniques; US Guided Injections; Shoulder Instability; Assessing Physical Activity; Lower Limb Paediatric Problems

Internationally renowned speakers and sessions including:

•D  r Richard Bouché “Medial tibial stress syndrome” •P  rof Ken Fitch “Asthma, exercise and the athlete” • Prof  Martin Hagger “Promoting kids’ sport and physical activity”

•S  ymposium: C  ancer survivors’ experiences through to rehabilitation

Up to 30 RACGP Category 2 points; CPR sign off for this triennium (5 Category 2 pts). Great social program: Welcome Reception, Poster Drinks and Conference Dinner all inclusive. One day registration also available. Contacts: Email acsms@sma.org.au or see the full program http://sma.org.au/conference/ 6

Beneaththe Drapes u Dr Eric Moses has been appointed Winthrop Professor and Director of the Centre for Genetic Epidemiology and Biostatistics at UWA. Prof Moses is an Australian scientist currently living in the US where he is head of the Texas Biomedical Research Institute in San Antonio, Texas. u Prof Neale Fong has been appointed President of the WA Branch of the Australasian College of Health Service Management (ACHSM) and to the College’s national board. He is currently Director of the Curtin Health Innovation Research Institute and project leader for Curtin University’s push to develop the third medical school in WA. He replaces Thelma Burnett. u After stepping down from her long-standing position as Research Director of the Telethon Institute for Child Health Research, Prof Fiona Stanley has been appointed to the ABC board as a Non-Executive Director. u Dr Ashwini Davray has been appointed the Head of Palliative Medicine at Bethesda Hospital where she has been a consultant since 2009. u Dr Greg Caddy has been nominated for the 2011 Medical Observer/GPET Supervisor of the Year Award. u Nursing research and training at The University of Western Australia and Sir Charles Gairdner Hospital has been boosted with the appointment of Desley Hegney as Winthrop Professor of Nursing at UWA and Professor of Nursing Research at SCGH. u Serco Australia has been awarded the Facilities Management Services Contract for Fiona Stanley Hospital. This contract, together with related sub-contracts, is worth up to $4.3b over 20 years. The services covered by the contract include catering, cleaning, linen, security, energy and utilities, estate and grounds maintenance, sterilisation, health records management, internal logistics, supplies management, and reception services. u The Leukaemia Foundation WA has formed a Business Advisory Council comprising chair Dominic Sheldrick (life coach), Tim Goyder (Chalice Gold Mines), Linda Kenyon (Wesfarmers), John Poulsen (Minter Ellison Lawyers), and David Flanagan (Atlas Iron). The Council’s goal is to offer guidance and advice to the Foundation, and in particular, secure long-term accommodation for patients close to Perth’s major hospitals. u WA biotech bioMD recently acquired Allied Medical, with the latter’s shareholders having 70% of the share capital of the new entity named Allied Healthcare Group (ASX:AHZ). Prior to the merger, Allied Medical was tied up with Coridon Pty Ltd (Coridon), founded by Prof Ian Frazer, and in 2010 acquired Medevco Pty Ltd a supplier and distributor of medical devices. On the AHZ board is executive director Michael Bennett known to WA people through the company he established, Bennett Medical, before selling it in 2001.

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Rural Medicine By Dr Rob McEvoy

Rural GPs: Try Before You Buy? An ex-Brit GP believes his disenfranchised UK colleagues can be enticed to the bush through a contest where everyone wins.

Narembeen GP Dr Peter Lines left North Yorkshire in 1998 to try rural practice in WA, first Pingelly for two years and now his current home town, where he enjoys life with his spouse Lucy and their three young children. Peter has recently proposed a trybefore-you-buy scheme for recruiting GPs to the bush. His idea springs from his recall of what was behind the disillusionment of UK GPs working the NHS (his target audience) and the known problems of attracting doctors to rural WA. It is fuelled by the growing need for another doctor at Narembeen. In a nutshell, he suggests publicising a competition that would see the winner flown from the UK for a two week ‘suck and see’ that is half work and half holiday. It would be aimed primarily at those ripe for a career and lifestyle change (as he was). “The UK’s 43,000 GPs should be worth considering as a source of recruitment, and perhaps an innovative approach would further improve the situation,” he suggested. He said research results into dissatisfaction

amongst UK GPs have not changed much in 10 years. The biggest bugbears are hours of work, recognition and remuneration for good work, paperwork, and increasing workloads with insufficient time. The positives that GPs are seeking are lower job stress, involvement in decision making, high job interest and an ability to meet conflicting demands. He related scenarios involving the NHS that conscientious doctors would recoil from (see inset). “What is needed is to reach out to those GPs who have not even considered coming to Australia yet.” He suggests a competition for an expenses paid trip to Australia would create enough awareness and appropriate applicants that did not end up in the winners’ circle could be offered alternatives to spark further interest. The winners get return flights, a hire-car, someone to meet-and-greet and arrival accommodation before being hosted by the local GP who dishes up a taste of rural general practice. The second week is pure holiday before returning to the UK. The cost to the organiser is around $8000 per winner, which includes $2000 paid to the rural GP for acting as host.

n Dr Peter Lines about to perform a skin excision in the local hospital assisted by one of the nurses recruited from Zimbabwe.

In suggesting this, Peter remembers the assistance River Medical Services gave in fast tracking his immigration. He was taken around to set up bank accounts, meet the Medicare adviser, complete Medical Board registration and other things before being driven to meet the Pingelly Shire Council, take possession of the grace-and-favour house and car, and start up his new career after a crash-course in the Australian medical system. Later he moved to nearby Narembeen, where he has been the family GP for 11 years, and he gives no indication of wanting to leave. “I had a palpable feeling this was going to be the right place for me and Lucy. This is home. Some years ago we relinquished the Shire house provided and bought our own, which we have extended greatly, have three wonderful children, Lucy’s mum came out to live with us a couple of years ago, and my practice has built up steadily.” He and the original management company have parted ways so he is now truly independent. Why is he still there? “Over the years we have had several holiday locums, who have all been excellent, but apart from occasional flying visits to Perth we stay put. Many people here reckon that the best view of Perth is in the rear view mirror.” “I love nearly all of my patients, which is something I could never say in the UK. I feel very appreciated and that I am making a difference, and I now have several hundred patients from other towns coming to see me. It’s not that I am particularly special, but it is clear that language and cultural barriers are an issue for many of these patients who feel they cannot engage with other IMG doctors in their own towns.” “I am now working to capacity, and yet every week there are new patients enrolling. It has

10

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Why UK GPs Might Want Out reached the stage where there is enough work for a second doctor. More fundamentally, it tells me that as well as finding country GPs for unfilled jobs, provision must be made to eventually replace some existing ones with doctors who can offer the service to their communities that is often sadly lacking.” “It is possibly short-sighted to think that employing any doctor in these places is good enough. It is not. Although the job should be rewarded it is crucial that the doctor actually wants to be part of their community and is in tune with their patients. They should be headhunted in what ought to be a buyer’s market.” “I came up with a scheme that seeks out GPs who are disaffected with their own health system and, like me, would flourish in Australian rural practice. When I left the UK I had no family or property commitments, and I felt optimistic enough to take a chance when plunging for a new life after just a few e-mails. There will be many more GPs who, sensibly, may need more tangible evidence that moving out here would be a good move.” He does not think bland adverts in the medical press and stands at medical conferences will attract those doctors who still practice successfully but would be inspired by a lifestyle change. “I have had positive feedback from several people concerning my idea, including Rural Health West, WA Country Health Services, and the National Party, but perhaps it will need more groundswell support before it might be trialled. I have no direct evidence that it would work, but I know from my own experience that such a scheme would have appealed to me had it been available.”

n Is that a plastic chicken on Peter’s consulting desk?!

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• NHS GPs are paid a “capitation fee” depending on patient allocation numbers, with weighting for the young and elderly; financial rewards are for meeting certain clinical targets (e.g. Pap smear and vaccinations rates); and there is no fee-forservice. • Consciously or subconsciously, there is little incentive to be overly thorough at any particular consultation, nor to address much other than the immediate presenting problem. Consequently, appointments are typically 5-10 minutes and crammed into a morning or afternoon surgery session lasting 2.5 - 3 hours.  • Free consultations means little incentive for patients to be judicious about seeing a doctor – the system is massively oversubscribed. Waiting three weeks to see a doctor of choice is typical. The practice nurse often ends up being the first point of contact.  • Patients usually have no choice of which surgery they attend but most are multidoctor. If irreconcilable differences occur between doctors and patients it is difficult for either party to end the relationship.

While ‘doctor shopping’ is prevented, chronic disharmony can be a source of unhappiness in some cases. • Home visits are enshrined in the NHS doctrine, originally intended for the very unwell or infirm, but now used by patients to jump long queues at the surgery, even though this means missing work or school. The GP can find this a colossal waste of time. • After hours care is now optional but there is almost no triage/assessment service available other than telephoning the doctor on-call directly, at all hours of the day and night. • GPs only have access to local hospital services, access for imaging is limited, and waiting times are often lengthy. Specialist procedures and outpatient appointments have very long wait times. There is virtually no private practice. In desperation, GPs seeking hospital admission for a patient may send them to Emergency, and then have to persuade some exhausted intern or resident. The net result – patients, GPs, and hospital staff are frustrated and disillusioned.

Reflecting back on his experience in taking the plunge and immigrating, he related some favourable tipping points about working as a GP in rural WA, which we have summarised here:

is no language barrier, a good mix of cultures without large enclaves, and 25% of WA residents are UK born. Sports and recreational facilities are usually far superior to those in the UK.

The health system. A good mix of private and public. Income rewards effort well, and feefor-service encourages results. Rural incentives are more than favourable (underwritten salary, incentive payments, complimentary house, car and surgery, local hospital with admitting rights and 24 hour nurse triage) and safe phone advice is possible in rural areas. Patients and doctors choose whom they see. Doctors can choose their hours, although they would be honour-bound to provide local hospital on-call.

Weather. A strong consideration – warmer, more daylight, and less pollution.

Culture and attitudes. Country people generally are very friendly, much less timepressured, and have a more grateful and stoical approach to health care. Patients are often much more proactive and responsible than their UK counterparts. Aboriginal health is an unmet challenge but overall, health issues are broadly the same as the UK (except snake-bite!). There

Shopping and travel. Easy thanks to high quality roads, negligible traffic outside Perth, easy flights, top class shopping in Perth with an excellent courier service to smaller centres, or high-speed broadband internet shopping. A companion. He said coming to rural WA with a ‘significant other’ would provide the intimacy that a solo doctor would miss, and might prevent unhappiness within the closed-in nature of rural life. Town folk. “It is people who can make a place feel like home. Integrating oneself into the community will be the most satisfying aspect of enjoying the life.” Weekend Perth commuters must suffer much travelling and less sense of belonging. l 11


Guest Column

New to Aussie Medicine Fremantle Hospital Plastic Surgeon Stewart Flemming gives light-hearted but thoughtful insights into cultural differences for the immigrant Brit doctor. Moving to a new country can be daunting. Sharing the same language, it is tempting to think other things will be the same too. Working in Kentucky taught me that this is far from the case but in Australia, the differences are often more subtle. Sense of humour and many life values are similar, making assimilation easier, but differences crop up in everyday life that remind you of the different culture. Like the rhyming slang. Here, the whole phrase is used, such as “Have a sticky beek” or peek, whereas UK people use a shortened slang such as “Have a butcher” [hook] or look. Then there is “To” [and from] or POM, hence the double meaning in the title. Although I am beginning to understand Aussie Rules and ‘barrack’ for the Eagles, I still talk about ‘putting a few miles on the odometer’ and ask for a ‘4 inch bandage’! Like Farrokh Daruwalla (another 59-year-old surgeon) in the book A Son of the Circus, I find that the country I have left is changing as well. I am no longer completely English and becoming truly Australian seems impossible. Nonetheless, this is home now. It’s all about mateship, giving someone a fair go, and learning it’s OK to

‘have a go’ (as long as you don’t whinge!). Clinically speaking, I am very grateful to colleagues for support and help in starting a new career in WA, as well as their tolerance for my lack of understanding of the Australian way. General practice is a good example. As a surgeon, I have admiration for a GP’s ability to tolerate a degree of uncertainty. In hospitals it is easy to do tests to confirm your diagnosis, or get staff to monitor the patient to see if

500km from the nearest hospital, you have to be pretty certain of your diagnosis. they deteriorate. But 500km from the nearest hospital you have to be pretty certain of your diagnosis to get RFDS to fly them to Royal Perth for surgery. Get it wrong and everyone asks why you couldn’t diagnose simple appendicitis. Problems were similar in the UK but the distances smaller and the costs and

consequences less. I am grateful to CTEC and UWA for giving me the opportunity to work with rural GPs in the Cutting Edge lecture series, as well as teach in some more remote parts of WA. Listening to these GPs, the difficulties of providing a service so far from tertiary hospitals is mind boggling. Even in larger remote communities the population is often so small that investigations we consider normal are not available. My involvement with tele-health while on call at RPH suggests this seems to be one way of helping remote GPs. A computer, a web cam and a suitable internet connection takes the consultant right into the home, GP surgery, or local hospital. This is a good time to parade my Aussie ancestry. My great grandfather set up a successful sheep station in the Flinders ranges in the 1850s and had the wisdom to marry a good Australian woman, Ellen Lichfield, before returning to England. Three of their 11 children later came to Geraldton and one, a lawyer and goldfield poet Andree Hayward, subsequently went on to edit the Sunday Times in Perth. I love the life here and am looking forward to Australian citizenship. l

Go the distance reap the rewards the satisfaction of providing health and medical services to rural communities professional support through training, medical indemnity and other incentives generous remuneration packages and attractive conditions. Visit www.health.wa.gov.au/doctors4ruralWA for more details of the incentive packages that are available. Then email doctors4ruralWA@health.wa.gov.au or phone 08 9223 8589. 12

“Professional fulfilment is clearly only one aspect of country life. I enjoy living in York which has a strong emphasis on community spirit.” Dr Matt Archer

DOH12078 AUG’11 MEDICAL FORUM

Come and practise medicine in rural Western Australia and you will get:

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Feature Article

Dietary Allergies

In Perspective For doctors entrusted with the welfare of patients, managing allergies may be more about helping shape someone’s environment. “May contain traces of nuts” may be a useful legal disclaimer, but it has left many allergy sufferers wondering what is safe to eat. Nut allergy is a good litmus test for the world of allergies, even though other common foods cause allergies. Interestingly for doctors, drug reactions account for up to 50% of anaphylactic deaths, with food reactions making <10%, and insect stings about 20%, with the rest undetermined. In 2007, the Carpenter government spent $6.6m on an Anaphylaxis Action Plan to educate doctors and consumers, set up specialist medical units, and changed legislation so child care workers and teachers could administer adrenaline.

hyper-vigilance helps explain food over-labelling.

‘Death by Snickers’ could be a realistic scenario and possibly a parent’s worst nightmare, which is why education of the severely allergic has to be definite and implemented at an early age.

Limiting access to peanuts for young people requires the wisdom of Solomon, he suggested, and government departments were not overreacting. We note that controls on imported foods have reached some prominence with the recent recall of crumbed fish from China, contaminated with peanuts.

However, it was only three years ago that Prof Nicholas Christakis, a medical sociologist, suggested that well-intentioned efforts to reduce exposure to nuts actually fan the flames of hypervigilance by parents, prompting more to have their children tested, which in turn yielded mild and meaningless ‘allergies’ to nuts and other foods. We checked with some doctors working in this field (and yes, peanut is really a legume!). Dr Simon Mallal pointed to the major dilemma that everyone faces ­– a single preventable death or severe reaction is unacceptable. “We have evolved to be very vigilant to recognise adverse reactions to anything we ingest. An effective media makes us more efficient in keeping to our instincts to be hypervigilant to avert even a single severe reaction or death, even at the price of being over-the-top. I don’t think parents, doctors, the Education or Health Departments, schools, the media or public have any choice but to go for 100% sensitivity at the price of specificity. There is no place for a Receiver Operator Curve (ROC), to choose the best cut-off,” he said, adding that

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“If anything, I would say more attention is needed to correctly label and prevent drug and insect sting allergy, especially for adults who tend to be relatively underserved and at even higher risk of death. Dedicated drug hypersensitivity clinics at Royal Perth and Sir Charles Gardiner Hospitals are providing a very valuable service for such patients.” Dr Peter Hollingsworth agrees there is a balancing act around the allergic individual, using peanuts as the example. “I think people have to make difficult judgments around these things and balance the needs of the occasional severely allergic individual with the needs of the other people to eat a cheap and readily available protein source (i.e. peanuts).”

Paediatrician Dr Rama Naidoo said any overreaction was driven by people suing, although some patients may become overly anxious about food allergies. “I do, in part, agree that it makes life difficult for agencies [such as airlines] that have to serve many other people who don’t have allergies, but just because there’s few of them, it’s hard to say it’s irrelevant.” “We are getting a lot of feedback from people at PMH that they expect certain precautions to be taken. So it’s more about responding to the needs of the people rather than different agencies. One death is still 100% a disaster for one family,” he emphasised. On the subject of airlines, Qantas minimises peanut risk by non-strict removal from meals and lounges, fully aware that it has no control over what passengers carry. The airline recommends that allergic passengers carry critical medication. Dr Richard Loh is a paediatric immunologist who looks at the big picture. “Although fatal reactions are rare, they do occur. Moderate to severe reactions are common. Small amounts of peanut and other foods can cause severe reactions and can be hard to avoid – 50% of children with a food allergy despite avoidance strategies have an accidental

reaction within three years of diagnosis, and 80% of fatal reactions have mild to moderate reactions prior to the fatal reaction.” “We do not have a test to identify which patients are at risk of severe allergic reactions,” he stresses. For doctors wanting further background he suggested www.siaip.it/upload/WAO_ anaphylaxis_guidelines.pdf and the coroner’s reports on the deaths of Nathan Francis, Hamidur Rahman, and Kylie Lynch following food allergy. “The impact of food allergy on quality of life is more than diabetes and juvenile rheumatoid arthritis. The increasing prevalence of food allergy – up to 10% of children by one year of age – means allergy is now a public health issue and a range of strategies, including education, are necessary to help prevent exposure to known allergens.” Dr Annkathrin Franzmann agrees. “The last thing an airline would want is peanut anaphylaxis in the air – it’s protecting a small group of society. We know that allergies are rapidly and drastically increasing. For example, we have never seen a severe allergy to egg in an infant but just last week there was in infant admitted to PMH that had a severe reaction and numerous doses of adrenaline after being fed egg for the first time in their lives at 6-7 months. Something is clearly changing with possibly more severe allergic reactions.” She would be surprised if any allergy specialist thought health or education authorities were overreacting. For the record, WA Hospitals have a peanut policy. Peanuts are used to a minimum, and peanuts and peanut butter are not allowed in ward areas or in the kitchen at PMH but “may contain traces of peanuts” foods are not excluded. “Like the Department of Education, we educate our families with children with food allergies that they must check all items and make a decision as to whether they will consume the item or not. There is no such thing as a safe zone with respect to food allergens, whether it is a school or a hospital. To give families the false sense of security that the hospital is ‘safe’, and therefore items do not need to be checked for allergens, is not recommended,” the WA Health spokesperson said. l

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Satire

21st Century Break Out In a less-than-serious diversion, Wendy Wardell describes the lengths people will go due to ‘allergy extremism’. Rashes, nausea, and headaches are now no longer just the signs you’ve had a good night out, but are increasingly symptomatic of our body’s reaction to the things we eat and surround ourselves with. Paranoia is the new normal because everything really is out to get us. Allergies, chemical sensitivities, and reality TV are simply nature’s way of telling us we’ve gone too far and need to reassess our lives. The problem of nut allergies in schools has become so huge that Nobby has become the new Bogeyman. The staff room at my daughter’s primary school had a wall of enlarged photos of the kids with nut allergies, presumably because other kids were faking anaphylactic shock to get out of stacking chairs after lunch. At high schools, authorities search bags and lockers for drugs, weapons, and jars of Nutella. Certainly, in my former career as a conference organiser, I had to be mindful of people’s dietary peccadilloes. There were more than a few episodes where an Irritable Bowel had led to a Crabby Disposition. I had a particularly bad run (no pun intended) at one event with Gluten Intolerant guests who had been radicalised. One told me that the entire buffet dinner should be gluten-free so he could eat everything. I felt like the proverbial soy protein in the Wuppa bread sandwich trying to convince the chef of that one.

to those who haven’t signed waivers and ambulance-chasing lawyers hand leaflets to patrons entering seafood restaurants. Eventually, all foods with allergenic reputations will be driven underground and we will end up with Cheese Sanger Speakeasies. Sweet ‘n’ sour pork will become the fugu fish of tomorrow for a generation with MSG sensitivity. Even Ladies of the Night will be armed with epi-pens in case the moment of ‘le petit mort’ threatens to become a much bigger mort thanks to an undeclared rubber allergy.

to environmental pollutants. I personally like the theory that the explosion in allergies can be alleviated by a less slavish addiction to wiping out bacteria. Admittedly, this is mainly because it suits my own approach to the art of housework, which can loosely be described as belonging to the Martha Stewart school, in her State Penitentiary period.

It’s only a matter of time before waitresses refuse service of satay sticks to those who haven’t signed waivers.

In Australia, we have seen cases in recent years where people have seemingly become allergic to everything synonymous with the 21st century, and it’s predicted that this will affect New Zealand within only a few hundred years. Sufferers of these extreme allergic reactions experience a very poor quality of life, confined to living in a sterile bubble or the National Party Policy Development Office. Many possible causes for this have been proposed, from a trigger-happy immune system

In fact, I’m developing a whole new range of products to meet the demand for less effective cleaning. These will have the additional benefit of being environmentally friendly, in large part due to their being pretty much useless. I think you’ll agree that the Home-eopathic range ticks all the boxes, being basically a thimble-full of detergent diluted in a swimming pool of water. It will be guaranteed not to irritate skin or to even mildly annoy germs. Bacteria will be laughing all the way to the bloodstream. Clearly, having very little content, most of the budget will be spent on clever marketing so the public will embrace it. Safe to say, I think they’ll be all over it like a rash. l

From that point on, I was very wary of Allergy Extremism and met all the demands of the Militant Wing of the Lactose Intolerant to avoid conference budget blow-outs on toilet paper. Seafood allergies were the scariest. It would have been a sad irony to survive Death by PowerPoint only to be taken out by a rogue prawn. I suspect it’s only a matter of time before waitresses refuse service of satay sticks

n Dr Percival may have been the last one to find out about Louise’s “Peanut Anaphylaxis” but he was first to rescue her from the Snickers Bar.

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Spotlight By Tellisha Dunlop

A Fairy Tale Come True From her fairy tale rise to fame in the ABBA musical Mamma Mia! to her fairy tale role as Wicked’s good witch Glinda, Lucy Durack considers herself truly fortunate. Local girl Lucy Durack is back in Perth for the final run of the Broadway smash Wicked, and as well as saying a renewed ‘hello’ to her Perth fans, she is saying ‘goodbye’ to a much loved role.

stressful on my hips, neck, and shoulders. We also have a company physio who we pick up in each city. Self-discipline is another way she stays healthy, but it leads to a lifestyle very much the opposite of acting’s glitz and glamour.

With Perth’s isolation, arts-wise, it could have been difficult for Lucy to snag her breakthrough role, but like her character Glinda the Good in Wicked, the WAAPA graduate’s life has been charmed.

“I’m not a big partier, and I certainly don’t go out very much, so I look after my voice. I don’t want to go to places where it’s very loud (where I have to speak over crowds), and I certainly don’t drink very much. And I make sure I drink plenty of water and eat fairly healthily and don’t eat anything too spicy close to the show.”

“I was really fortunate in that it wasn’t difficult [to score my first acting role]. I was in my third year at WAAPA, and by chance, I met up with some WAAPA friends who’d graduated a few years before me who were in the Melbourne production of Mamma Mia! and one of them recommended me for a part. I still graduated from WAAPA, but a little early to start the Brisbane and then Sydney seasons of Mamma Mia!” she said.

One of Lucy’s career role models is actress and singer Kristin Chenoweth who rose to international fame as the US Glinda and has since appeared in film and television.

“I had a real fairy-tale start to my career. I was extremely fortunate.” As well as featuring in musical theatre, television, radio, and recently, film (Finding Nigel and Goddess, out later this year), Lucy finds time to sing for charity concerts and

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benefits – in part, due to being motivated by personal tragedy.

“I’m not looking to depart from the world of musical theatre, but I’d love to be able to do different genres of the arts. So I really look up to the way that Kristin Chenoweth has done that. She has done a lot of musical theatre, obviously, and Pushing Daisies and The West Wing and various films. That seems pretty fun to me.”

Wicked is the untold story of the witches of “The Light the Night charity concert is Oz and is based on the best-selling novel particularly close to my heart because the whole by Gregory Maguire. It is one of the most reason it was set up was because of my good successful shows in the world and the winner friend, Shaun Rennie. He set it up because he of 35 major awards, lost his brother Matt, who I knew including a Grammy, personally, to leukaemia a few three Tonys, and six I’m not a big partier, years ago. We were doing the Helpmann Awards. concert while Matt was and I certainly don’t go out As well as smashing still alive for the first very much, so I look after box office records, the couple of years Australian production and then Matt my voice. of Wicked sold its one passed away millionth ticket last and we now May. do it in his This month is the last honour.” time audiences will see Lucy as Glinda, a role With high-energy singing she has made her own for the past four years. and dancing required for “It’ll be really emotional. It’s been the most her role in Wicked, and amazing time. It’s something I wanted so badly particularly with back-toand I’ve really been very grateful for every back performances, the single moment. I’ve loved all of it and it’s demands on her health are been really hard work, but so rewarding and high, and she relies on health satisfying. It’s sad to say ‘goodbye’ to a dream, professionals. but you’ve got to keep moving forward. “I’m a fairly healthy person “But I like the idea of ending on a high, and I do go and have being in my hometown and finishing up the massages occasionally Australian tour. Having been the Australian because, for instance, Glinda is something I’m really proud of.” one of the dresses that Wicked run ends on September 11. Lucy’s next I wear in the show is role will be as Faith in Strange Bedfellows, 20kilos and so that which begins in Melbourne on October 19. l weight can be quite

medicalforum


Medical Market Forces Dr Rob McEvoy

Specialist Services Go National With some specialties depleted, national registration and service amalgamation offers solutions through economies of scale, as Medical Forum discovered. In an earlier edition, we suggested that some health services, particularly specialty services, would be using national registration to springboard expansion across Australia. One such player is Genesis Care, an investment consortium with employee doctors as shareholders, nine overarching directors that include two medicos – an oncologist from NSW and a cardiologist from Queensland – and economies of scale that facilitate equipment purchases, research, training, and staff recruitment. Its core business is radiation oncology and cardiology (with some sleep medicine), and in that respect, Genesis Care now has a large footprint in WA, claiming to employ over 200 staff here.

developing a cancer service in Joondalup for 2012. Last month, Genesis Care acquired Perth Radiation Oncology (PRO) based in Wembley. It also won the RPH tender from PRO to take over radiation oncology there. PRO is now promoted by Genesis as the only private provider of radiation oncology services in WA, with principle Dr Chris Harper. The Wembley site boasts top-of-the-range equipment (including 3 linear accelerators) for treating cancer patients. It now forms part of the Genesis Cancer Care WA network, along with RPH and the newly established cancer centre at Bunbury, a partnership arrangement with SJOGH and State Health.

Sydney and the Tennyson Centre in Adelaide. Genesis expects to employ 150 new staff in WA as services develop over the next three years. However, there is a nationwide shortage of staff and training posts. It plans training posts for radiation oncologists, medical physicists and radiotherapists, research and an electronic medical record system for cancer patients in conjunction with the Swedish based Elekta AB, supplier of its linear accelerators (of which there are 12 in Perth at $2.5-3.0m each). Autonomy of local clinicians is said not to be affected and it is hoped services will expand by working smarter with the use of what is becoming a relatively depleted workforce. l

Genesis Care has upgraded technology in the RPH department and MD of Genesis Care Mr Dan Collins has said treatment capacity for cancer patients requiring radiotherapy will more than double in WA over the next four years. Certainly, State Health will be pleased with the injection of capital works.

It operates Heart Care, a fresh amalgamation of what was Mount Cardiology and Coastal Cardiology, and in February this year was advertising widely for personnel such as radiation oncologists, physicists, and radiation therapists after being appointed by the WA Department of Health as the radiation oncology provider for the South West Health Campus in Bunbury, Royal Perth Hospital, and Fiona Stanley Hospital (2014). GenesisCare is also

Genesis says it employs more than 800 health professionals and support staff, including over 100 doctors. It has 59 sites in WA and interstate, including comprehensive cancer services at Macquarie University Hospital in

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News

Indigenous Respiratory Health was the second most commonly reported health condition.

With poor environmental conditions, socioeconomic disadvantage, and risky behaviour (particularly smoking), respiratory diseases are the second most common category of chronic illness (after eye conditions) affecting Indigenous Australians.

Researchers at ECU’s Australian Indigenous HealthInfoNet (www.healthinfonet.ecu.edu. au) are keen to help doctors to improve the situation. The HealthInfoNet is a useful resource for medical professionals working in frontline areas of Indigenous health – in particular, the management of chronic diseases under the Practice Incentive program (PIP) Indigenous Health Incentive.

Disease of the respiratory system was reported by 27% of Indigenous people who participated in the 2004-2005 National Aboriginal and Torres Strait Islander Health Survey. Respiratory conditions were reported more frequently by Indigenous people living in non-remote areas (30%) than by those living in remote areas (17%). With 15% (17% in non-remote areas; 9% in remote areas) of Indigenous people reporting having asthma, it

Key sections of the HealthInfoNet’s respiratory section include: • Resources – a comprehensive list of health

promotion and practice resources (including guidelines and toolkits). • Policies and strategies – both Indigenous and those relating to the general population. • Programs and projects – descriptions, links and contact information of current and completed respiratory health programs and projects. • Publications – includes journal articles, reports, unpublished materials and conference presentations. • Reviews – reviews and background information on respiratory health among Indigenous peoples. l

Sports Medicine Heading to Perth Dr Peter Nathan is a keen cyclist who recently came a cropper, temporarily stalling his role as match day doctor for Super Rugby WA. But as a sports medicine physician, he is involved with the national Sports Medicine Australia (SMA) conference Science and Medicine in Sport to be held at Fremantle (October 19-22). He wants other GPs involved. “I particularly like the SMA conference parallel programs that cater for all groups and offer a diverse range of topics. While I like to keep up with the latest advances in sports

n Dr Peter Nathan

medicine I am also extremely interested in the exercise physiology and sports science program. There’s research into exercise and activity and its benefits in physical and mental health which I am sure would interest many readers of Medical Forum,” he said. Workshops, keynote speakers, and topics to keep people interested in exercise and injury-free are all in the conference mix. Sports Medicine is now recognised as a medical specialty (Sports and Exercise Medicine). See http://sma.org. au/conference/ l

Dementia Master Class 2011 Full day symposium Saturday 24 September 2011 VENUE Mark Liveris Theatre Building 405 Curtin University, Bentley Carpark 23A

TIME 9.00am to 4.30pm COST Free

REGISTER Call (08) 6271 1023 or email julia.staunton@alzheimers.org.au An opportunity for GPs, pharmacists and nurses to discuss up-to-date, independent, practical and evidence-based information on the management of dementia. Topics covered: • • • • • • •

Palliative care for people with dementia Dementia differential diagnosis Quality dementia care The anticholinergic load End of life considerations Working with Aboriginal communities What it means to be a carer Event sponsored by:

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medicalforum


Primary Care By Shane Cummings

Medicare Locals: South West Challenges The first regional WA Medicare Local has big plans and a huge area to cover, but South West WA Medicare Local Chair Dr Mostyn Hamdorf sees plenty of potential. The South West WA Medicare Local (ML) is run by the South West Health Alliance, a company comprised of three GP Networks, although Chair Dr Mostyn Hamdorf said the Alliance predates the Medicare Local by six months. “The four GP Networks that comprise our Medicare Local boundary met in December last year, before we had any firm sounding from Canberra. Regardless of what happened at the Federal level, we resolved to Dr Mostyn Hamdorf proceed with our own primary health care reform in our boundaries [as the South West Health Alliance].” The Wheatbelt GP Network later decided not to join the Alliance. The idea that MLs are GP Networks by another name (as 20% of surveyed GPs said in our August edition e-poll) is a “misconception”, according to Mostyn, who plans to contract services back to GP Networks in his ML’s boundaries (including the Wheatbelt GP Network). “Existing GP Network programs, in the four

month transitional period, will be novated to the Medicare Local. We will then contract them back to the GP Networks. The Medicare Local will assume the financial responsibility.” Despite the shifting layers of bureaucracy, Mostyn denied any fundholding would negatively impact on GPs. “GP Networks are already fundholding organisations … but Medicare Locals don’t have anything to do with fundholding for general practice services. It’s just not on the agenda. The day to day business for the GP in his relationship with his individual patient will not be changed.” Lack of detail in the ML contract – the loudest criticism from ML detractors – is an opportunity in Mostyn’s eyes. “Even though there has been a lack of detail, it doesn’t mean there’s not a shared understanding of how Medicare Locals will work. In some respects, we’ve been advantaged by not having detail forced upon us. We haven’t been faced with the problem of a forced solution from a metropolitan area that may be applicable but we know will never work.” South West ML will forge partnerships with many of the usual suspects – the WA Country Health Service, Aboriginal Health groups, and

allied health providers – but one of the ML’s key partnerships will be the 73 local governments in their territory. “They have field workers and health planning officers, and they’ll be an important resource for us. One of the things we’ll develop is Local Health Hubs. Some already exist in Walpole and Kojonup, which were previously facilitated by local government. We will use them to garner information to provide really good population health planning.” However, Mostyn said the government’s rush to create Medicare Locals “hamstrung” South West ML’s consultation with concerned GPs and primary care stakeholders. “The government was keen to see this happen quickly, and the timeframe became shorter and shorter. We’ve been mindful of the fact that we didn’t have the time to consult during the tender process … We would really encourage the GPs in our patch to get in contact with us, and we are exploring the opportunity to sit down face to face with the AMA and come to a mutual understanding.” AMA (WA) declined to comment on this story. For more information on the South West Medicare Local, see: www.sw-medicarelocal. com.au l

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Encouraging Leadership Dr Rob McEvoy

Profile Boost for Health Management The fledgling ACHSM has an important role in building both the profile and esteem of health managers, according to the new WA chair Dr Neale Fong. Prof Neale Fong says he will use his personal contacts and experience in the health sector to open doors and get things moving for the Australasian College of Health Service Management (ACHSM). As the new chairman of the local branch he will also sit on the national board. “I said when I came onto Council two years ago we had a place in the industry as the peak body responsible for ongoing professional development of leaders and managers in health care, to provide those resources, and build the esteem that a career in health should bring in the community,” he explained to Medical Forum.

He said giving people the incentive to talk to others and getting a conversation going would be fruitful. More formal education is also a key to the group’s success. “I set up the Institute for Healthy Leadership that looks after the public health leadership, and the private operators do their own in-house things, but some operators are small or cannot mount the professional education, which is what the college does.” “We have a dedicated education subcommittee who plan out a calendar of events, which we are doing now, alongside the national body with its web-based seminars and road shows.” “Last year we hosted some health policy forums that have been very successful. We looked at the issues of health boards, Medicare Locals, and the opinions of past Health Ministers.”

His says his approach remains apolitical and he points to the wide mixture of people involved with ACHSM, a relatively new organisation with 3,000 members nationally and a relatively low profile. “Anyone can be a member of ACHSM. Everyone is a [potential] leader in the health care system because they have the ability to influence the outcome for the patient. We are not a political lobby group. It is a professional college that is about supporting and developing managers and leaders across the system.” “There is probably no more difficult role in health than being a manager or leader, whether private, public or non-government, and the job of the College is to support those people professionally.” ACHSM Council has the expected mixture of CEO’s from major WA hospitals, Health Department managers and academics.

But with people like non-clinicians and nurse managers taking part, how can ACHSM maintain focus and momentum that is meaningful? Neale suggested this might make a good topic for a future educational event. “We formed an Advisory Board that is made of all the senior CEOs and leaders, retired and present in WA, and that met with the Minister early this year for a full briefing from him. The idea is to build the college so it is a significant voice and provides resources for people to improve themselves and network with other senior leaders. We are developing an emerging leaders program that will allow our members to network with senior health people.”

“Along with the Council I’m trying to make ACHSM a lot more relevant as there is an absolute truck load of health reform coming from Canberra in the next twelve months, let alone the continuing micro reform that is happening in the public health system in WA, and then there is the aged care sector. There is a heck of a lot happening and we are a nonpolitical forum for debate and discussion,” he said. l

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Medical Research

Profile: Ear Science Institute It’s well resourced and purpose built, with ethical governance, goodwill to burn, and people hungry to help. It cost around $20m to build and is bursting at the seams already with its 40 or so full time staff, but the Ear Science Institute of Australia is all about funding research, treatment, and teaching under the institute model that is familiar now to West Australians. Under general manager Brett Robertson, the driving force is Prof Marcus Atlas, the governance structure is in place, private enterprise turnover is building, and by adding back into the community, ESIA is becoming an indispensable part of the Perth landscape. Research and clinical services are dedicated to helping people with ear and hearing disorders improve their quality of life. Major contributors to the capital fundraising (2006-10) included the George Jones Family Foundation, Lotterywest, The Saraceni Family, Mr Vern & Mrs Jo Wheatley, The Pourzand Family, and the Lions Hearing Foundation, so ESIA has friends in high places. Restoring hearing or balance has created a large pool of grateful people. ESIA Trustee Mr George Jones received an MOA this year and was recently named WA Citizen of the Year for his services to the community – he heads their fundraising committee and is a major benefactor. Winthrop Prof Marcus Atlas was recently acknowledged

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anchored hearing aids and middle ear implants; alternative amplification for those unable to wear or benefit from conventional hearing aids. ESIA Balance Centre – patients with dizziness, vertigo and/or imbalance disorders.  ESIA e-Health Research Laboratory – Cheers for Ears program plus research. Centre for Ear Nose and Throat Education and Research – undergraduate medical, nursing and physiotherapy students, surgeons, nurses, general practitioners, allied health workers, audiologists and speech pathologists. by AMA (WA) and the ESIA’s ‘Cheers for Ears’ hearing loss prevention program got the Healthway “Healthier WA Award”. Together, the ESIA, Ear Science Centre UWA, SJGHC, and Notre Dame will use $2.7m Commonwealth funding through the Clinical Teaching and Training Grants program to construct and operate a new medical and surgical training facility for head and neck diseases (the Centre for Ear Nose and Throat Education and Research).  Within the impressive building, ESIA entities are:

S U B I

ESIA Implant Centre – cochlear implants, electro-acoustic implant systems, bone

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The commercial tenants within the ESIA-owned building are: • The Perth ENT Centre

• Professor Marcus Atlas

• Subiaco Private Hospital • Med-EL Hearing Implants

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Public Health

Undetected COPD in Need of Spirometry The COPD burden of disease is emerging from amongst non-smokers, and Barry Blaikie is campaigning for consumers to pressure doctors for more ‘lung testing’. Former Liberal member for Vasse Barry Blaikie has COPD severe enough to require oxygen 24/7 and he is on a campaign to encourage health consumers to have a lung test through their doctor. Although he gave up smoking in 1974 when his father – a chronic smoker – died of emphysema, Barry was not diagnosed or had spirometry until a respiratory illness in 1988, when he was approaching his 60s. He feels he had symptoms of emphysema going back to his 30s and two aunts on his father’s side who never smoked both had severe emphysema. Therein lies the dilemma for Barry and most doctors.

Respiratory physician Dr Peter Bremner said any adult who has no respiratory symptoms and normal pulmonary function tests (PFTs), probably does not need further testing unless there is a reason. However, symptomatic people and smokers need regular PFTs to see who is at risk of developing COPD. There is no evidence that early smoking leads to later COPD, it just speeds up the rate at which it develops.

While smoking has been the major cause of bronchitis and emphysema (COPD), up to 20% of non-smokers develop emphysema and 80% of smokers do not.

What PFTs are best? Peter says peak flow meters have such low diagnostic ability, even as a screening tool, they are best discarded for spirometry. The RACGP is pushing spirometry in the latest accreditation standards but in practice, uptake has been less than ideal. It takes half an hour to do proper spirometry.

A major genetic component seems to explain why some people are more susceptible to the ravages of smoking, pollution, occupational exposures and such like, and why females are more likely to develop COPD.

Barry and Peter agree on one thing – a strong family history of emphysema (smoking or not) requires screening lung testing in adults at least once, and more often if there are respiratory symptoms.

However, there is no genotypic screening that is accurate, so the family history and respiratory history become paramount. In Barry’s case, the family history was pointing to his need for testing early on, plus he was a smoker.

Barry is pushing this message via a new website, www.lungtest.com.au, his logo says it all, and he has recently donated to the Lung Institute of WA to help promote the ‘get tested’ message to consumers.

Inadvertently, the anti-smoking lobby may have done people prone to COPD a small disservice. Barry explained. “If you say yes to the question ‘Did you smoke?’ then the perception is you have been responsible for circumstances. Even if you did not smoke, the anti-smoking campaign has been so effective that any reference to lung disease is perceived to be wrongly tobacco related.” l

Understanding the triple test for breast cancer

The Triple Test is (in sequence): 1. Clinical breast examination and taking a personal history. 2. Imaging tests i.e. diagnostic mammogram* and/ or ultrasound. Ultrasound has a lower false positive rate and is more sensitive in younger women than mammography. 3. Non-surgical biopsy i.e. a fine needle aspiration and/ or core biopsy for cells or tissue. The women who show possible signs of cancer on one or more of the tests may be advised to see a breast specialist for a consultation.

www.breastscreen.health.wa.gov.au

How accurate is the triple test? If used on their own, none of the tests will be able to find all cancers. However, if all tests are done and none show signs of cancer, it is very unlikely that cancer will be present. If all three tests are performed, more than 99.5% of cancers will be found by one or more of the tests. The triple test is positive if any component is indeterminate, suspicious or malignant. Any positive result therefore requires specialist referral and further investigation, with the likelihood of cancer increasing if more than one component is positive. National Breast and Ovarian Cancer Centre. The investigation of a new breast symptom: a guide for General practitioners. February 2006. Accessed at http://www.nbocc.org.au * please note that BreastScreen WA offers only screening mammography for asymptomatic women. Women requiring investigation for breast symptoms should be referred elsewhere for diagnostic mammograms.

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Hp 8980 AUG’11

Breast cancer is the most common cancer in Australian women, with 1 in 9 Australian women diagnosed with breast cancer by the age of 85. It is therefore important that health professionals are aware of the National Breast and Ovarian Cancer Centre’s recommendations for investigating breast changes e.g. a breast lump.1

Helping Deliver a Healthy WA

24 MEDICAL FORUM my pt size Sept'11 188X125.indd 1

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hilst causality has not yet been demonstrated, there is a strong epidemilogical evidence that obstructive sleep apnoea (OSA), insulin resistance, and diabetes are closely associated. The pathophysiological link between OSA, impaired glucose metabolism and insulin resistance is complex and multifactorial. Intermittent hypoxia and sleep fragmentation, sympathetic activation, HPA axis abnormalities, increased anti-insulin hormones, inflammatory cytokines and endothelial dysfunction have all been implicated in contributing to glucose alteration.

Size of problem OSA occurs in 2-4 % of the middle aged population. High risk groups are fortunately able to be identified and in obese diabetic men the prevalence of OSA is as high as 75 %. Screening tools such as the Epworth Sleepiness Score and the Berlin score can aid with identifying high risk patients, however in clinical practice a sleep study is often necessary to exclude sleep aponea.

Insulin resistance Research interest in modifying insulin resistance has led to trials of CPAP therapy in non-diabetic OSA populations, with studies showing improved insulin resistance. Hope that this would translate into HBA1c reduction has led to a few small clinical trials of short duration, with conflicting results. The only randomised trial showed no improvement of HBA1c with CPAP therapy over 3 months, although there were only 20 patients in each arm. It has been hypothesised that the lack of HBA1c reduction reflects that OSA is a

smaller contributor to insulin resistance than obesity. It is still unclear what benefit in glycaemic control can be expected with CPAP therapy in diabetic patients with OSA.

Cardiovascular risk Independent of obesity, men who have OSA have proportionally greater all-cause mortality and stroke, cardiovascular mortality, hypertension, arrhythmias, and diabetes mellitus. There is evidence in non-diabetics treated for sleep apnoea that cardiovascular risk is reduced. Recent large clinical trials looking at CVS outcomes in diabetic populations have failed to include sleep apnoea as a risk factor. Research is underway to look at CPAP therapy influence on cardiovascular risk amelioration and cardiovascular endpoints and results may direct management of high cardiovascular risk diabetic patients with OSA. Patients with type 2 diabetes who undergo treatment for sleep apnoea usually experience an improvement in quality of life with more

By Dr Paul Myhill, Endocrinologist, Western Endocrinology and Diabetes. Tel 94179636

energy and less daytime somnolence. CPAP adherence has a significant influence on expected metabolic benefits –less than 4 hours’ nightly CPAP may not be sufficient to alter metabolic outcomes. Blood pressure usually decreases and further research is ongoing to determine whether lipids, inflammatory markers and sex hormones are benefited by treatment with CPAP therapy in type 2 diabetics.

Other considerations From the perspective of remission of diabetes and sleep apnoea, along with reduction in cardiovascular risk, bariatric surgery is arguably the best treatment available. Patient selection and procedure type are however central to the metabolic outcome expected. References available on request

Ed. Dr Myhill has completed an interventional trial in type 2 diabetics with OSA in conjunction with the Fremantle Diabetes Study and West Australian Sleep Disorders Research Institute. n

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

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

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Obstructive sleep apnoea and type 2 diabetes


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BS data show a steady decline from 1995 to 2005 in the number of males or females with normal body weight (Figure 1) and data (unpublished) from our current survey of “baby boomers” in the Busselton Healthy Ageing Study suggest that >80% of males and >70% of females aged 46-64 are overweight or obese! Breathing is affected by overweight and obesity, although not in ways that are immediately obvious, with implications for breathing during sleep and in the presence of lung disease.

Increased body weight, lung function and symptoms

result in a label of asthma (or a perception of more severe asthma). Of course, the possibility that increased weight may contribute to airway inflammation or reduced effectiveness of treatment is not entirely excluded.

Numerous studies have examined the relationship between lung function and body weight. Surprisingly, there is only a modest effect on forced vital capacity (FVC) and expiratory flows (assessed by FEV1) – see Figure 2. The main effect of increased body weight on lung function is to decrease the functional residual capacity (FRC) and expiratory reserve volume. This is likely to result in airway closure in the dependent portions of the lung, contributing to reduced arterial oxygen tensions.

Other lung diseases In patients with chronic obstructive pulmonary disease (COPD), interstitial lung disease or respiratory muscle weakness, increased body weight will add to breathlessness. In patients with COPD due to smoking, destruction of parenchyma (emphysema), airway narrowing (due to inflammation and remodelling) and altered gas exchange (due to ventilationperfusion mismatch) may all be compounded by obesity. Many patients with COPD are alarmed by shortness of breath when they bend over (their breathing feels “cut off”) because the already flattened (shortened) diaphragm is further compromised by pressure from the abdominal contents, a situation aggravated considerably by obesity.

How do these changes contribute to respiratory symptoms? The answer(s) are not immediately obvious or easy to assess with simple spirometry but mechanisms relate to the work of breathing, ventilatory mechanics and gas exchange. Increased body weight adds to the work of breathing – breathing muscles work harder to move the heavier chest wall and push against the obese abdomen – which increases sensations of breathlessness. In addition, closure of airways in the dependent parts of the lungs add to mismatch between ventilation and blood flow and reduced oxygen tensions. Airway closure may also add to lung stiffness and the work of breathing. All of these effects will be compounded during exercise. One thing unchanged by obesity is the ventilatory responses to hypercapnoea and hypoxia.

Increased weight and sleep

n F igure 1. Percentage of Australian males and females with normal body weight (BMI < 25 kg/m2) or who are overweight (BMI 25-30 kg/m2) or obese (BMI > 30 kg/ m2). Australian Bureau of Statistics.

Asthma Increased obesity has been mirrored by an increase in doctor-diagnosed asthma in adults from developed countries, including the Busselton health surveys, but without a parallel increase in airway hyper-responsiveness. This suggests the reported increase in asthma is not

Summary – Take Home Points

• Increased body weight is associated with a drop in FRC, airway closure, reduced arterial oxygen tensions and increased work of breathing BUT relative preservation of spirometry (FEV1 and FVC). • Obesity increases respiratory symptoms especially wheeze and shortness of breath which may confound the diagnosis and perceived severity of lung disease. • Obesity reduces ventilation and gas exchange during sleep and greatly adds to the detrimental effects of OSA and chest wall disease on breathing. • Assessment of lung volumes, airway responsiveness and blood carbon dioxide levels may be necessary for diagnostic and staging purposes in obese patients since history, physical examination, spirometry and imaging may be of limited use.

medicalforum

By A/Prof Alan James, Consultant Physician, Hollywood Private Hospital & SCGH

n F igure 2. Effect of body weight on lung volumes: TLC – total lung capacity; VC – vital capacity; RV – residual volume; FRC – functional residual capacity; ERV expiratory reserve volume. Adapted from Jones RL and Nzekwu MU. Chest 2006;130:827-833.

associated with an increase in airway pathology – increased body weight may be implicated instead. Obese patients with asthma report more symptoms (breathlessness and wheeze) and greater use of reliever medications. Community or clinic-based population studies have identified clusters of overweight or obese females that are labelled as having asthma but without any increase in airway responsiveness, allergy or markers of airway inflammation. Instead, symptoms related to narrowing of dependent airways and increased work of breathing may

During sleep, the rate and depth of ventilation is decreased, particularly during rapid eye movement (REM) sleep. The reduction in FRC, airway closure and reduced oxygen tension associated with increased body weight will add to the same changes associated with normal sleep. In the morbidly obese patient, this may be enough to result in recurrent hypoxia and hypercapnoea during sleep with the eventual development of daytime respiratory failure as the body’s ventilatory responses adapt. The threshold weight for this response may lower if there are other mechanical loads to breathing such as obstructive sleep apnoea (OSA), lung disease or chest wall disease (Figure 3). Often this may come to light in a catastrophic fashion when an additional load is added (e.g. chest infection) or the drive to breath is removed (e.g. sedation or anaesthesia). Remember, increased body weight is the commonest reversible contributing factor to OSA and contributes to increased oxygen desaturation. Conversely, in patients with OSA who are of normal weight, oxygen desaturation may be minimal so that screening tests that rely on desaturations may give false negative results. ▼ DRIVE

▲ LOAD

Sleep

Overweight / Obesity

Alcohol

Crowded Upper Airway

Sedation Reduced Chemosensitivity (adaptation)

Lung Disease Chest Wall Disease

›➤ DAYTIME RESPIRATORY FAILURE n F igure 3. The contribution of overweight and obesity and sleep to the development of respiratory failure.

References available on request. n 27

P D A T E

Obesity and the lung


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he ultimate challenge in T1DM is balancing tight glycaemic control (to avoid chronic complications) and the risks of hypoglycaemia within the context of all the subtleties and stresses of modern life. In the pivotal Diabetes Care and Complications Trial a sustained 2% reduction in HbA1c (9.1% vs 7.3%) produced a 40-60% reduction in both primary and secondary microvascular complications. The observational follow-up study (EDIC) demonstrated a 57% reduction in macrovascular events. However, despite these dramatic benefits, there remains a large gap between what is ideal glucose control and what is actually achieved in routine clinical practice. New approaches and advances in technology have provided some additional strategies that may offer people with T1DM greater individual flexibility and freedom. Australia can claim one of the highest rates of type 1 diabetes (T1DM) in the world (22 per 100 000 population, increasing ~3% per year) and as many adults present as do children – during 2000-06, some 6000 children (0-14yrs) were diagnosed in Australia, compared with 9000 new cases in those >15 years. In adults, men are three times more likely to be affected, with a peak incidence around age 15-24 years.

Diabetic ketoacidosis is an uncommon but potential risk if insulin delivery is interrupted, as patients are not protected by background long-acting basal insulin. Therefore, successful pump therapy requires a high level of motivation with frequent glucose monitoring, insulin dose adjustment and ongoing review and education. Cost, particularly for adults, remains a barrier.

Appropriate insulin adjustment is critical

Continuous glucose monitoring systems (CGMS)

Intensive insulin therapy, either with multiple daily injections (MDI) or a continuous subcutaneous insulin infusion pump (CSII) is the most appropriate therapy from diagnosis and is associated with better control and fewer long-term complications (DCCT/EDIC).

Frequent self-monitoring of glucose allows flexible and accurate insulin dose adjustment for eating and activity. More frequent monitoring may be associated with better HbA1c levels, but is time consuming and onerous. CGMS works by frequent sampling of tissue glucose levels and can provide either real-time “instant” feedback (including trends over time), or are “blinded” with recordings stored and then uploaded for retrospective analysis.

Newer insulin analogues are often preferred because of their greater stability and predictability, lower risk of hypoglycaemia and weight gain, and a better overall quality of life. Frequent insulin dose adjustment according to lifestyle, carbohydrate intake, exercise, stress and illness is critical to maintaining optimal glucose control and avoiding hypoglycaemia. Multidisciplinary teams with experienced diabetes educators and dieticians are central to achieving this. Structured education courses such as DAFNE (Dose Adjustment For Normal Eating; available in a limited number of WA centres) improve control and quality of life without increasing hypoglycaemia.

Continuous subcutaneous insulin infusion pumps (CSII) Insulin pumps deliver subcutaneous, rapid acting insulin continuously, according to a pre-programmed pattern with additional meal bolus doses given manually through the pump. Unlike basal insulin injections, pumps allow background insulin to be adjusted according to individual needs and changing circumstances throughout the day. Several randomised controlled studies show pumps can improve glycaemic control (0.5% lower HbA1c with fewer severe hypoglycaemic reactions) compared with MDI1. Pumps particularly suit those with severe or overnight hypoglycaemia; persisting poor control (where escalating therapy is limited by frequent hypoglycaemia) and in circumstances where greater flexibility of insulin delivery is desirable, such as shift workers, sportspeople, those with gastroparaesis and possibly during pregnancy.

medicalforum

CGMS can also be used to augment pump (or MDI) therapy to allow frequent fine adjustments of insulin delivery and real-time sensors can be linked to the pump alarms to warn of impending hypo or hyperglycaemia. Sensor augmented pump or MDI therapy in adults improves HbA1c levels by about 0.5% depending on how long the sensor is worn. However, CGM can be difficult to use for prolonged periods and frequent finger-prick testing is still required for calibration and confirmation of high or low levels. Short-term, blinded CGMS has also been effectively used as an educational tool to provide detailed insights into daily glucose fluctuations that may not be as obvious from intermittent finger-prick tests2.

Closed loop systems (artificial pancreas) A highly anticipated goal is to integrate CGMS, automatic insulin delivery and predictive algorithms to keep glucose levels controlled. Some success has been achieved in reducing overnight hypoglycaemia but delays in insulin action, differences in measuring tissue compared with blood glucose and the systems’ inability to anticipate exercise or meals limit their current use.

Beta-cell replacement Pancreatic transplants are typically performed in conjunction with renal transplantation due in part to the effects of immunosuppression on renal function in diabetic nephropathy.

By Dr Joey Kaye, Endocrinologist. Mob 0425 000 833

Combined kidney-pancreas transplants are associated with improved hypoglycaemic awareness and stabilisation, or even regression, of microvascular complications. The surgery and immunosuppression is a major undertaking with a significant associated morbidity and mortality3. Islet cell transplants are still considered an experimental procedure, however, they are available in Australia and their success has increased recently. Most patients will require 2-3 cadaveric donor transplants with about 50-60% insulin independent after 1 year, although only 15% remain so at 3-5 years. The majority will restore their hypoglycaemic awareness and responsiveness and as such the principal indication remains severe, life threatening hypoglycaemia3. n Extended references available on request 1. Aschner P, Horton E, Leiter LA et al. Practical steps to improving the management of diabetes: recommendations from the Global Partnership for Effective Diabetes Management. Int J Clin Pract 2010; 64: 305-15. 2. Nardacci EA, Bode BW and Hirsch IB. Individualising care for the many: the evolving role of professional continuous glucose monitoring systems in clinical practice. Diabetes Educ 2010; 36: 4S-19S. 3. Levy D (Ed). Type 1 Diabetes (Oxford Diabetes Library), Oxford University Press; 2011.

Take Home Points

• Intensive glucose control in T1DM significantly reduces both micro and macrovascular complications. • Multiple daily insulin injections (MDI) or pumps (continuous subcutaneous insulin infusion) produce similar improvements in glucose control. • Pump therapy may provide more flexibility with fewer problems (hypoglycaemia) in certain circumstances. • Continuous glucose monitors may assist with insulin dose adjustment, but automated closed loop systems (artificial pancreas) are not yet routinely available. • Beta-cell replacement (whole pancreas or islet cell transplant) is currently only indicated in a few special circumstances. This clinical update is supported by Hollywood Private Hospital

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Therapies for adults with type 1 diabetes


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By Dr Eric Whitford, Interventional Cardiologist, Western Cardiology.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS 

Medical Director Dr John Yovich

Laparoscopic Supra-Cervical Hysterectomy Dr Philip Rowlands Consultant Gynaecologist & Laparoscopic Pelvic Surgeon The vast majority of hysterectomies conducted at PIVET nowadays are performed as total laparoscopic hysterectomies. The procedures have become slick with very short hospitalisation, often overnight and post op recovery tends to be rapid, many women returning to work after a couple of weeks. However some cases remain difficult due to large uterine volume or dense pelvic obliteration from fibrosis and adhesions. Such cases can require prolonged surgical dissection with increased morbidity – both surgical and medical. Lasoo of the cervix following ligation of the upper uterine pedicles

Electro-cautical loop ideal for sub-total hysterectomy

Such cases can benefit from sub-total laparoscopic hysterectomy and a recently developed device – the laparoscopic electro-cautery loop – facilitates this procedure. Once supra-cervical excision is performed, the uterus is removed following electronic morcellation. Where practicable the uterine arteries are bipolar coagulated and resected, but in the more difficult situation it is only necessary to ligate the ascending branch.

Operating times are reduced by at least one hour and patient recovery has been remarkably swift, most proceeding home the next day despite the removal of a large multi-fibroid uterus, extensive pelvic endometriosis or advanced uterine adenomyosis. Patient follow-up indicates high satisfaction with well supported vaginal vault, no problems with vaginal prolapse and the former concern of cervical stump cancer is negligible when the index smear has been normal.

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Familial Hypercholesterolemia: new screening options F

amilial Hypercholesterolemia (FH) is a genetically mediated condition characterised by increased Low Density Lipoprotein (LDL) cholesterol. This LDL can deposit in the arteries and cause premature vascular disease, as well as other tissues. Early identification of FH is important as we now have treatments that can substantially reduce the risk of premature vascular disease. Most patients at risk from FH are currently undiagnosed and careful selection of those who might benefit from screening is based on clinical suspicion and starts with family members of index cases (i.e. those who present with problems).

When to suspect FH The prevalence of FH in Western Australia is estimated to be 1 in 500. It should be suspected in patients: • with premature (men<55 yrs, women <60 yrs) coronary, cerebral or peripheral vascular disease or who have a strong family history of premature vascular disease • especially if LDL>4.0 mmol/L

• and especially if arcus cornealis (<45 yrs), xanthelasma and/or xanthomatous tendons are present

Underlying genetic problem LDL receptors on the surface of liver cells bind to apoliporotein B 100 (APO B) on the surface of circulating LDL particles, allowing these LDL particles to be taken into the liver cell and metabolised. Mutations have been identified in the four main groups of genes involved with this process, and sometimes a combination of these genes is affected. These mutations can interfere with the uptake of LDL particles and consequently cause high circulating levels of LDL particles. These different mutations also help to explain why some patients are more resistant to the LDL lowering effect of statins.

Clinical suspicion important Most patients with FH have a mild phenotype and do not have the classical arcus cornealis, xanthelasma or tendon deposits. However many do develop premature vascular disease. Unfortunately clinical diagnosis alone misses many of these patients. Global population genetic screening for FH has problems because of the many different genes that can be the cause of the problem as well as the logistics, ethical issues and the expense.

Cost-effective cascade screening Instead, ‘cascade screening’ is a strategy for identifying at risk people that does seem to be cost effective. An index patient is diagnosed, (usually on the clinical criteria above), the patient is then genetically screened for relevant genetic mutations and if found positive, permission is gained to contact first degree relatives to undertake the same genetic screening. Participation is voluntary. This approach can identify many at risk people before they have clinically apparent problems and appropriate assessment, counselling and treatment can be recommended. With support from the WA Health Department, Dr Gerald Watts at The Lipid Clinic at Royal Perth Hospital has established a cascade screening service. I would suggest if you have any patients you suspect may have FH you discuss with them if referral to this clinic is appropriate for them. This program may also prove to be especially useful to assist with the difficult issues involved regarding the assessment of children and adolescents. n

For ALL appts/queries: T:9422 5400 F: 9382 4576 E: info@pivet.com.au W: www.pivet.com.au

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ontrary to the commonly held view, there are considerable functional benefits in treating adults with strabismus, beyond the obvious psychosocial benefit from altered appearance. In experienced hands, specialised strabismus surgery techniques can achieve an alignment success rate of 90% in these patients, with a very low risk of adverse events such as overcorrection or diplopia. There are two main types of adult strabismus.

Acquired strabismus As the adult CNS does not have the plasticity required to suppress the image from the deviating eye, intermittent or constant diplopia results. Other symptoms include asthenopia (ocular fatigue), an abnormal head posture or any combination thereof. Causes include microvascular cranial mononeuropathies, thyroid orbitopathy, myasthenia and retinal detachment surgery. These patients may or may not have an obvious misalignment, but will seek treatment for symptoms and are generally adequately investigated and managed. Treatment strategies include occlusion, prism glasses, botulinum toxin and surgery.

Pre-existent childhood strabismus Whether recurred or carried over from childhood, adult strabismics will have developed central (sensory) adaptations to their misalignment. The image from the deviating eye is suppressed, eliminating diplopia and confusion of visual direction. Apart from the appearance of an often very

By Dr Ross Agnello, Ophthalmologist, Duncraig. Tel 9448 9955

obvious misalignment, these patients are otherwise asymptomatic.

and employability. Repair offers obvious advantages.

This is the group who are commonly wrongly discouraged from pursuing treatment.

Treatment misconceptions delay

Treatment benefits While improved appearance is one outcome, strabismus repair should be considered reconstructive surgery that seeks to restore normal structure and function, in much the same way we repair a cleft lip and palate.

The most common misconceptions for not referring earlier for surgery are:

All strabismus is an abnormal anatomical and physiological state. In terms of visual function, surgical realignment of the visual axes demonstrably improves sensory and motor fusion and stereopsis in over 80% of successful surgeries. The benefit here is the improvement in long term alignment stability. The psychosocial impacts on adults with obvious strabismus can be substantial – embarrassed about appearance, a large proportion have low self-esteem, will avoid eye contact and will often try and camouflage the misalignment. In fact, these people are discriminated against and negatively regarded in terms of perceived intelligence, trustworthiness, attractiveness

Eye Surgery Foundation Perth’s only freestanding Ophthalmic Day Hospital

Expert day surgery for • Cataract Extraction and Lens Implant • Pterygium • Glaucoma • Oculoplastic Surgery • Strabismus • Corneal Transplant • All types of Refractive Surgery – LASIK, LASEK, PRK, CTK, Phakic Lens and Refractive Lens Exchange (RLE)

• Supporting ophthalmic research and development • Certified to ISO 9001 Standard

In one large series, the mean delay in seeking treatment was 19.9 years, with a range of 1 to 72 years. Only a minority of treatable adult strabismics eventually have corrective surgery.

• ‘Nothing can be done with a longstanding squint.’ It is extremely rare for a longstanding or previously operated squint to be inoperable, or for surgery to result in post-op visual dysfunction. • ‘Recurrence after surgery is high.’ Most patients only require one operation over a lifetime. • ‘Without a visual benefit, surgery is purely ‘cosmetic’.’ Reconstructive surgery restores normal anatomy, with both functional and psychosocial benefits. • ‘The risk of a worse squint is high.’ Risk of overcorrection is only 5-10%, for which further surgery is usually curative. n

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

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

Contact: Matthew Whitfield Ph: 9216 7900 Email: info@eyesurgeryfoundation.com.au 42 Ord Street West Perth WA 6005 medicalforum

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P D A T E

Treatment of adult strabismus: more than meets the eye


P D A T E

Spirometry: useful tool vs meaningless numbers By Dr Sally Young PhD, CRFS, Respiratory Scientist, ProHealth Training

S

pirometry may at one extreme be a useful clinical tool in the diagnosis and ongoing management of asthma and COPD or at the other an exercise in random number generation, producing results of limited clinical value. The latter reduces confidence in the ‘gold-standard’ physiological measurement of ventilatory function. A key differentiating factor between useful and questionable results is the spirometry operator who ideally is someone knowledgeable and skilled in: • All curves from same individual during a single testing session Technically acceptable curve curve 1

Technically unacceptable curves curve 2

curve 3

• interpreting the flow-volume curve (F-V curve) to identify subject technique errors • correcting any subject technique errors

• equipment quality control procedures. These essentials impact on the accuracy of results that in turn can influence clinical interpretation and ultimately, diagnostic and management decisions. The following notes are designed to assist those involved.

Common misconceptions affecting accuracy and confidence in spirometry Volume [L]

* Maximal effort: - smooth rapid rise to peak flow - shape of peak flow is ‘peaky’

* Submaximal effort: - slow rise to peak - peak flow is rounded

* Submaximal effort: - slow rise to peak - peak flow mis-shapen

* N o interruption to flow during the blow from peak to end

* Incomplete FVC due to early termination of blow

* Tongue obstruction of mouthpiece during the blow * Incomplete FVC due to early termination of blow

* C omplete FVC as no early termination of blow

Curve 3 is a prime example of a curve where the results are likely to be of little clinical value. Curve 2 is the type commonly seen that is mistakenly accepted when it provides reduced clinical utility compared to curve 1.

Dr Simon Turner MBBS, FRANZCOG, FRCOG

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

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

Dr Julia Barton MBBS, FRANZCOG

Dr Bill Patton MBBch, BAO, DCG, DRCOG, MRCOG, MRCPI, FACGO,

Dr Zhuoming Ch u MBBS, PhD, FRANZCOG

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• applying international guidelines for correct test performance,

• reporting results correctly

FloW [L/s]

C L I N I C A L

U

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Three blows is all it takes. Correct practice delivers three technically acceptable F-V curves but it is uncommon for a patient to produce these (repeatable) results in three attempts only. Routinely, between five-to-eight attempts are required, with training prompts, before someone ‘hits their correct technique stride’. A standard baseline pre-bronchodilator spirometry session of 8 attempts takes approximately 12-15 mins. You just look at the numbers. FEV1, FVC, and the ratio (FER) are highly effort-dependent measurements, so subject technique is critical. The only objective means available to assess subject technique is examination of the F-V curve. Numerical results derived from a technically acceptable F-V curve reflect ‘real’ ventilatory function (rather than predominantly reflecting subject technique). Report the highest numbers. Often, the highest values for FEV1 and FVC come from the poorest technical quality F-V curve and therefore do not reflect ‘true’ ventilatory function. Correct practice is to report the highest FEV1 and FVC from a set of three technically acceptable and repeatable curves obtained, not the highest values from any curve. Spirometry software automatically always chooses the right results. Technical acceptability is assessed by the operator, not the software. If software auto-selection of results is overridden by the operator, who takes on curve reading responsibility, this prevents incorrect and potentially misleading data being reported. Annual calibration of a spirometer is sufficient quality control. Most spirometers have the overall limits of accurate measurement set by the manufacturer. However, routine calibration checking in the clinic confirms ongoing measurement accuracy i.e. the spirometer remains within the calibration ranges set by the manufacturer. Using a 3L certified calibration syringe, cal-checking is as frequent as spirometry is performed in the clinic. n

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C L I N I C A L U

A

lthough psoriasis can be very severe, most patients have mild and localised disease for which topical treatment is the mainstay of therapy. The chosen agent will differ from site to site: some preparations are unsuitable for use on the face or in the flexures; and hairy areas need specially formulated preparations like gels or lotions. Vehicles are important in topical therapy – more scale and cracking in psoriasis indicates greasier preparations should be used.

Prescribing considerations There are numerous topical drugs for psoriasis and the prescriber should not get fixated on topical corticosteroids alone. Some patients are corticosteroid-phobic, leading to poor compliance, and strong topical costicosteroids are to be avoided on the face and in flexures because they can cause atrophy and telangiectasia. Many topical psoriasis medications, including PBS-subsidised medications, are supplied in small pack sizes. Patients with significant skin areas affected by psoriasis will need Authority Scripts written for increased quantities adequate to treat the condition satisfactorily. This saves on doctor visits and repeat prescriptions. Below are listed suggested authority quantities of various preparations. See MIMS for criteria and restrictions.

By Dr Chris Quirk, Dermatologist, Dermatology Specialist Group Ardross. Tel 9314 9900

• Calcipotriol /betamethasone dipropionate gel (DaivobetTM gel) OR • Calcipotriol scalp solution (DaivonexTM) PBS 30mls Rx1 (Authority 90mls Rx5 ) OR • Mometasone lotion (NovasoneTM, EloconTM) PBS 30mls no repeat (Authority 90mls Rx5) OR • Exorex lotionTM (coal tar) PBS 100mls Rx2. In all cases, use an appropriate shampoo in the morning, with daily use preferred. Antiscale, tar shampoos: Nutragena T TM gel, Ionil TTM shampoo, SebitarTM shampoo. Anti dandruff shampoos: Zinc pyridinethione preparations e.g DangardTM, ZP11TM, CedelTM

NovasoneTM, AdvantanTM) PBS 15g, Authority 150g Rx5 OR Extemporaneous preparations: • Dithranol 0.1%, salicylic acid 5% in emulsifying ointment (care needed as this can stain or burn) - apply overnight then wash off. PBS 200mls Rx1. • LPC 10% salicylic acid, 5% glycerin, 10% in sorbolene. PBS 100g Rx 1

Tachyphylaxis can see a drop off in efficacy of topical corticosteroids used long term. This can be avoided by alternating treatments e.g. for scalp psoriasis calcipotriol lotion applied at night weekdays and a topical steroid lotion (e.g. DiprosoneTM, NovasoneTM) applied at night during the weekend.

Palms and soles Similar treatments to trunk and limbs but hyperkeratosis can be more pronounced so potent keratolytic preparations are useful, such as:

Flexural psoriasis

• Lactic acid cream (QV Heel balmTM) OR

This usually involves axillae, submammary fat folds, or the groin (where secondary fungus or Candida may need to be excluded).

• Salicylic acid 6-8% in white soft paraffin (extemp) PBS 100g Rx1

• 1% hydrocortisone ointment/cream.

• Urea cream (Eulactol Heel balmTM) OR

• Clobetasol butyrate cream/ointment (EumovateTM).

Scalp psoriasis Thick scale prevents the penetration of active ingredients in preparations. Removing scale with an extemporaneous preparation for a few days or weeks, allows one to switch to more pleasant preparations for maintenance, as illustrated here. Remove scale with extemporaneous mixtures; PBS quantities cream/ointment 100g Rx1 or lotion 200mls Rx1. Examples: • Salicylic acid 4%, sulfur 4% in emulsifying ointment OR • Liquor picis carbonis (LPC) 10% in ointment base OR • Ung cocois co (30% coconut oil, 6.25% LPC, 4% acid sal, 2% sulfur in emulsifying ointment) Rub in, leave for a few hours – shampoo out. As soon as thick scale lifts, switch to maintenance:

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• Betamethasone valerate cream/ointment 0.02% (Celestone MTM, Betnovate 1/5TM ) or equivalents. Note: adding an anti-Candida cream like miconazole or clotrimazole can be useful.

Facial psoriasis Strong topical costicosteroids on the face can cause atrophy, telangiectasia and perioral dermatitis. However, severe facial psoriasis may warrant strong topical steroids from time to time. For maintenance, mostly try to use: • 1% Hydrocortisone OR

• Clobetasol butyrate (EumovateTM).

Plaques on trunk or limbs

• Calcipotriol cream (DaivonexTM) PBS 30g Rx1 OR • Calcipotriol + betamethasone dipropionate ointment (DaivobetTM) PBS 30g Rx1, Authority 150g Rx5 (see MIMS) OR • Half strength topical steroids (e.g. DiprosoneTM, Cortival1/2TM, EloconTM,

Psoriasis affected nails This is common. Fungal fingernail infections are very uncommon and although Candida is frequently cultured from dystrophic nails, it is mostly a secondary invader. Topical antifungals have little role in treating dystrophic fingernails. Calcipotriol lotion (DaivonexTM) OR Mometasone lotion (NovasoneTM, EloconTM) Apply to the nail bed (under the nail) and to the matrix area (base of nail) twice daily. Severe nail psoriasis often requires systemic therapy with methotrexate or acitretin. n

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P D A T E

Treatment of localised psoriasis


C L I N I C A L

A

n unprecedented global increase in allergic disease is most apparent in ‘westernised’ regions but also evident in the more populous developing regions that are undergoing rapid economic transition. Already, about 30-40% of the world’s population is affected by one or more allergic conditions, including food allergies, eczema, allergic rhinitis and asthma 1, with enormous personal and social costs. In Australia alone, allergies cost an estimated $7.8b in 2007 2.The greatest burden of this ‘epidemic’ is borne by young children, who account for the most dramatic increase in disease. As they reach adulthood, the burden of allergic diseases is expected to increase even more. Many of these conditions can be serious and life threatening. This makes allergy a major public health problem requiring continuous efforts towards prevention and optimal treatment.

Food allergy, the ‘second wave’

vulnerable to modern environmental changes.

Food allergy is a substantial and evolving public health issue, only recently emerging over the last 10-15 years as a ‘second wave’ of the allergy epidemic 3. In a bizarre and puzzling twist, the very fact that this new epidemic has lagged decades behind the original epidemic of asthma and allergic rhinitis with inhalant sensitization, raises a series of new and intriguing questions.

Moreover, the appearance of immune disorders (such as food allergy and eczema) within months of life indicates significant effects in early life when the immune system is developing.

In Australia, new data show that almost 20% of infants have sensitisation to foods by 1 year of age and more than 10% have challengeproven IgE-mediated food allergy 4. There has been more than a 10-fold increase in specialist referrals for food allergy, coupled with more than a 5-fold increase in the number of hospital referrals for food-related anaphylaxis, the most severe and potentially life-threatening form of IgE-mediated food allergy reaction 5. Of further concern, this new generation appears less likely to outgrow food allergy than their predecessors, with long-term implications for disease burden.

Why is this happening? Allergic disease has been clearly linked to modern lifestyle changes. And this appears to be part of a much larger picture. A dramatic rise in virtually all immune diseases is clear evidence that the immune system is highly

Candidate factors under investigation include changing dietary patterns (more inflammatory dietary profiles), changing behaviour (more sedentary activities and ‘screen-time’ i.e. vitamin D insufficiency), changing intestinal commensal bacteria and a range of environmental pollutants. It is not known whether the rise in food allergy is a harbinger of earlier and more severe effects of these progressive environmental changes or whether additional or unrelated lifestyle factors are implicated.

Where is research heading? New studies suggest that these environmental factors can produce epigenetic changes in gene expression and disease risk that may be potentially heritable across generations6. This new field of investigation provides new explanations for the complex geneenvironmental interactions that underpin many modern diseases.

Resources for clinicians The Australasian Society of Clinical

By A/Prof Susan Prescott, Paediatric Immunologist & Allergist.

Immunology and Allergy website (www. allergy.org.au) is a valuable resource for both practitioners and patients. It includes the latest information, action plans, position statements and specific advice for common allergic problems. 1. World Allergy Organization (WAO) White Book on Allergy. Editored by Ruby Pawankar, Giorgio Walter Canonica, Stephen T. Holgate and Richard F. Lockey. Milwaukee, Wisconsin: World Allergy Organization (www.worldallergy.org), 2011. 2. The economic impact of allergic disease in Australia: not to be sneezed at. Report by Access Economics Pty Ltd for the Australasian Society of Clinical Immunology and Allergy (ASCIA). 2007. 3. Prescott SL, Allen KA. Food Allergy: Riding the second wave of the allergy epidemic. Paediatric Allergy Immunology. 2011; 22:155–60. 4. Osborne NJ, Koplin JJ, Martin PE, Gurrin LC, Lowe AJ, Matheson MC, et al. Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants. J Allergy Clin Immunol 2011; 127:668-76. 5. Mullins RJ. Paediatric food allergy trends in a community-based specialist allergy practice, 19952006. Med J Aust 2007; 186:618-21. 6. Martino D, Prescott SL. Silent mysteries: epigenetic paradigms could hold the key to conquering the epidemic of allergy and immune disease. Allergy 2010; 65(1):7-15. n

Update: Indemnity for Retirement Many doctors are happily practising as they head towards retirement, blissfully unaware of professional indemnity insurance requirements designed to keep them out of trouble. How does it work these days? This update builds on the advice published in Medical Forum a year ago. First, if you hang up the stethoscope for between 3 and 12 months, insurers may give you a reduced premium for the period of nonpractice, but you will have to continue Medical Board registration under the Limited-Public Interest (Occasional Practice) category, which allows you to provide services such as writing scripts and making referrals, without payment. This category of registration will be available till September 2013. If you decide to hang up your stethoscope permanently and cease all practice, then unless you are age 65 or over, you could have

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up to a three-year wait before the federal government’s Run Off Cover Scheme (ROCS) kicks in. ROCS would cover your past private practice for free. During that time you can drop Medical Board registration or take out Occasional Practice registration. Either way, you will need to maintain professional indemnity insurance for the period of time before become eligible for ROCS. If you wish to continue providing gratuitous services after retirement for no payment your insurer may be able to offer a Gratuitous Services policy which would cover you for undertaking volunteer or charitable work as well as continuing to write scripts and undertaking referrals. There are a few add-ons for unusual circumstances. If you go overseas you still have to maintain Australian insurance for past events not yet reported. If you cease all remunerated practice due to maternity or disability, ROCS is available immediately. l 37

U P D A T E

Understanding the allergy epidemic


Evaluation and management of postmenopausal uterine bleeding M

enopause is defined by 12 months of amenorrhea after the final menstrual period. It reflects complete, or near complete cessation of ovarian oestrogen secretion. Postmenopausal bleeding (PMB) refers to any uterine bleeding in a menopausal woman outside the expected bleeding that happens with sequential Hormone Replacement Therapy (HRT).

Aetiology Abnormal bleeding noted in the genital area is usually attributed to an intrauterine source, but may actually arise from the cervix, vagina, vulva, or fallopian tubes, or be related to ovarian pathology. Bleeding from nongynaecologic sites such as the urethra, bladder and bowel could be mistaken for genital tract bleeding. Anticoagulant therapy can sometimes be responsible.

women without any uterine bleeding, have not been established. The American College of Obstetricians & Gynaecologists recommends endometrial biopsy, if the endometrial thickness is >11mm in the absence of any abnormal uterine bleeding. This is based on a well-designed decision analysis calculation, estimating the risk of endometrial cancer as 6.7% for postmenopausal women without uterine bleeding who had an endometrial thickness >11 mm, which is similar to that in postmenopausal women with bleeding and endometrial thickness of >5mm; the risk of endometrial cancer was less than 0.002% at endometrial thickness of <11mm2.

Hysteroscopy. Hysteroscopy provides direct visualisation of the endometrial cavity, thereby allowing targeted biopsy or excision of lesions identified during the procedure. Saline infusion sonography (sonohysterography). This imaging technique in which TVUS is performed after sterile saline is instilled into the endometrial cavity is useful in delineation of endometrial polyps or small submucous fibroids.

Women on HRT

Pathology Atrophy

58%

Polyps

12%

Endometrial cancer

10%

Endometrial hyperplasia

10%

Hormonal effect

7%

Cervical cancer

1%

Other

2%

Diagnostic Evaluation1 The primary goal is to exclude malignancy. Adenocarcinoma of the endometrium is the most common genital cancer in women over age 45. Obese, nulliparous, diabetic women over age 70, with abnormal uterine bleeding, have an 87% risk of complex hyperplasia and endometrial cancer compared to 3% in women without these characteristics. History and physical examination. Details of the bleeding episode(s) and Pap smear history are relevant along with a detailed medical history. It is important to elicit the risk factors for endometrial cancer like nulliparity, diabetes, obesity and the use of tamoxifen. In addition to a systemic examination, thorough physical examination of the external and internal anatomy of the female genital tract is important. Cervical cytology. All women need cervical cancer screening as part of the evaluation of abnormal bleeding Endometrial evaluation (see Chart). Evaluation of the endometrium is the key component in the diagnostic evaluation of women with postmenopausal bleeding. Endometrial sampling is the gold standard for diagnostic evaluation of women with abnormal uterine bleeding in whom endometrial hyperplasia or carcinoma is a possibility. Trans Vaginal Ultrasound Scan (TVUS) is an acceptable alternative initial test in postmenopausal women who cannot tolerate Pipelle Endometrial biopsy, or who need evaluation of the adnexae.

By Dr Mini Zachariah, Consultant Obstetrician & Gynaecologist, KEMH & Mercy Medical Centre

Bleeding is common when hormone therapy is initiated and should decrease over time. If it does not, or if it becomes heavier, or bleeding occurs after a long period of no bleeding, then a biopsy is indicated.

However, there is an increased risk of endometrial cancer in women with endometrial fluid and endometrial thickness of >3mm. Hence, endometrial sampling is recommended.

Ultrasound scan does not appear to be a useful screening tool for women on Hormone Replacement Therapy since endometrial thickness thresholds are not very well established for such women; hence endometrial sampling is still the gold standard to exclude endometrial hyperplasia and/or carcinoma.

Management In postmenopausal women, uterine bleeding is usually light and self-limited. Exclusion of cancer is the main objective; therefore, treatment is usually unnecessary once cancer or endometrial hyperplasia have been excluded.

Women on Tamoxifen Tamoxifen is known to cause thickening and cystic changes of the endometrium on TVUS. There is no clear cut-off for normal versus pathological endometrial thickness in these women. Endometrial biopsy is recommended in the event of any abnormal bleeding, as Tamoxifen causes a slight increase in endometrial cancer risk (roughly 1/1000).

If a benign lesion is diagnosed, it can be treated, as appropriate, if symptoms are bothersome. Polyps can be removed if indicated. Bothersome bleeding due to genital tract atrophy can be managed by a short course of local oestrogen. Women diagnosed with malignant lesions are evaluated and referred to Gynaecology Oncology Service.

Asymptomatic women with endometrial thickening or fluid

References

Thickened endometrium or fluid within the endometrial cavity can be an incidental finding on TVUS performed for indications other than PMB.

1. www.uptodate.com. The evaluation and management of uterine bleeding in postmenopausal women. 2. Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol 2004; 24: 558.

The criteria for a thickened endometrium alone, necessitating intervention in postmenopausal PMB TVUS <4mm ET No recurrence of bleeding.

Reassure

Pipelle Endometrial Biopsy

>4mm ET Suboptimal view of Endometrium. Diffuse or focal echogenicity. Recurrent bleeding.

Endometrial Biopsy

Benign histology. No recurrence of bleeding.

Patient unable to tolerate. Cervical stenosis. Insufficient sample or non diagnostic histology. Recurrent bleeding.

Reassure

TVUS+/Hysteroscopy + D&C

PMB – Postmenopausal bleeding; ET – Endometrial Thickness; TVUS – Trans Vaginal Ultrasound Scan; D&C – Dilatation & Curettage

Mercy Hospital Mount Lawley, Thirlmere Road, Mount Lawley 6050 • Tel 08 9370 9222 • Fax 08 9370 9488 • Email: hospital@mercycare.com.au 38

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DonateLife Network Working to improve organ and tissue donation rates. The DonateLife Network has been created across Australia with the focus on achieving continued and sustained growth in organ and tissue donation rates and an increase in the number of life-saving transplants. The DonateLife WA team, as part of the DonateLife Network, has grown to include 11 new doctors and nurses across nine hospitals in WA.

Organ donation teams in major hospitals These hospital-based teams have been created across the three tertiary hospitals together with PMH, Rockingham Health Service, Joondalup Health Campus, St John of God Murdoch and Subiaco, and The Mount Hospital. The clinical staff members are in addition to the DonateLife WA donor coordinators who administer the organ and tissue donation process. This specialist workforce of doctors, donor coordinators, and nurses has been working to ensure donation is a routine part of end-of-life patient care and that every potential donor is identified and donation is discussed in a sensitive and respectful way with the family. WA is also working with the Australian Organ and Tissue Authority to establish a best practice model for “family conversations”.

Recently, intensive care specialists completed a survey to assist DonateLife WA to determine attitudes and approaches to end-of-life conversations. The information from this survey will be vital in determining whether a national communication model can be implemented.

Interventions having a positive effect In 2010, the first full year of the DonateLife Network implementation, 309 organ donors saved and improved the lives of 931 Australians; which was the highest donation rate since national records began. This is a 25% increase on the 2009 outcome of 247

organ donors. The continued growth in 2011 builds upon the increase in national donation rates with 201 organ donors so far this year compared to 174 organ donors at July 2010. In WA the number of organs transplanted has increased by 29% from 2009. In fact, the organ and tissue donation rate in the last three years has been increasing with 19 organ donors in 2009 and 22 organ donors in 2010. So far this year there have been 20 people who, with the consent of their families, became organ donors giving 57 people life-saving transplants. On top of this, 39 donors in WA donated tissues including bones, corneas and heart valves.

How to encourage registration Organ Donation Facts

• Organ donation is the ultimate gift

• Each organ donor can save up to 7 lives • Family discussion is essential • Age and health status are not necessarily barriers

• All major religions support donation

• Having lived in the UK does not stop you from being an organ donor. • Call 9222 0222 for further info

Registration for organ and tissue donation can be done via the national register administered by Medicare Australia on which there are almost 700,000 Western Australians registered. For those who registered through their driver’s licences, their details have been transferred onto the national register. Currently national registration forms are sent out with each driver’s licence renewal. If you would like further information or if you are a doctor who is interested in working with our hospital teams, please contact Dr Kevin Yuen, State Medical Director at DonateLife WA on 9222 0222 or visit www.donatelife.gov.au.

A better heart is now online. From research and consultation to surgery and recovery, Perth Cardiovascular Institute offers complete care and convenience. To make our services even more convenient we’ve got a healthy new website. See for yourself, visit perthcardio.com.au to find out more.

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15/02/11 5:03 PM

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Yachting By Tellisha Dunlop

Sailing a small boat that far across a big ocean and going to these amazing places … it was the experience of a lifetime!

Race to

Paradise!

Rockingham registrar Dr Shane Leavy has been sailing since he was a child, so when the first Fremantle to Bali regatta in 14 years took place this year (to commemorate the 30th anniversary of the first Fremantle to Bali race), he was keen to be involved. One of the five-man crew on the yacht Farr Lap of Sydney (named after the designer Bruce Farr), Shane persuaded his land lubber GP father Dr Richard Leavy to come along for the adventure, although it didn’t take much to convince his boss, Dr Stephen Granger – himself a keen sailor – to join the crew. Theirs was one of 22 crews competing for line honours in the gruelling nautical marathon. “It opens your eyes. Sailing a small boat that far across a big ocean and going

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to these amazing places … it was the experience of a lifetime!” Shane said. But it wasn’t all smooth sailing. “Unfortunately, we were smashing into the wind for the first few days. And then coming into Bali after being out at sea for twelve days, the winds turned against us.” “It was full on, just being woken up every few hours. We were all exhausted when we got to Bali. But now, Dad can’t wait for the next one. He loved it.

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(L to R) Russell McGovern, Dr Richard Leavy, Tanya Berthoud, Dr Shane Leavy and Dr Stephen Grainger [Photo: Bernie Kaaks] Travelling around the Indonesian islands [after the race] was another adventure in itself.” The biggest challenge they faced on their odyssey was when they discovered a hole in the boat and had to stop in Exmouth for 24 hours.

Shane also had the responsibility of being one of the race doctors on the voyage. He said that although there were few catastrophes, one of the crew members from the eventual winner yacht Limit needed hospitalisation with broken ribs and a punctured lung.

“We didn’t know where the water was coming from, so we didn’t know if we were sinking or not. But it turned out to be a really small leak. It was just so much water coming over the boat on those first few days.”

“They had to pull into Geraldton to let the guy off. He was hit by the boom, thrown across the deck, and landed on a winch. He was lucky they didn’t keep going for the whole trip.”

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The Arts By Tellisha Dunlop

The

Madness

of being creative

Many times throughout history, artistic expression and mental illness have gone hand in hand. Artistic WA medicos speculate on the connection. Is creativity linked to certain types of mental illness? The topic has been circling parlours and lecture halls for hundreds of years. Inspired by former Freo footballer Heath Black’s comment in our August edition (Back from the Brink) – “If I was medicated [for bipolar disorder] like I am now, would I have been any good at playing AFL footy?” – Medical Forum picked the brains of medicos involved in artistic pursuits to get their view on what fuelled the fires of creation.

she said. She cited painter Lucien Freud and philosopher Frances Bacon as famous examples.

Famous examples

While Louise said mental illness by itself wasn’t the root of creativity, she saw a connection between highly creative people and those suffering from mental illness.

US Professor of Psychiatry Kay Redfield Jamison’s Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, which analyses whether psychological suffering is linked to artistic creativity and how bipolar disorder can run in artistic or high-achieving families, is probably the best known exploration of the subject. Jamison cites Lord Byron, Vincent Van Gough, and Virginia Woolf as examples of well-known artists touched by mental illness. “Yes [mental illness] certainly can [fuel creativity]. I think the two are inextricably linked,” said psychiatrist Dr Lynne Cunningham. “There are certainly plenty of creative people who don’t have mental illness, but there are also many people who’ve been creative who have also had mental illness. They’re not mutually exclusive, but there are certainly plenty of examples of people who have been very creative when they’ve been experiencing severe mental illness problems.”

Making the connection “Mental illness in itself is often a by-product of a society that has lost its connection with its soul,” said Louise Helfgott, a WA playwright and speaker on suicide, mental well-being, and the arts at this month’s Open Your Eyes conference.

“I do believe that in some forms of creativity you need to have a heightened level of sensitivity in order to be able to create effectively – and that very sensitivity is what could make people more vulnerable to a mental illness when other environmental factors might go wrong.” GP Dr Jenny Fay agrees that mental illness may fuel creativity. Jenny is also a musician, and last year, she coordinated an exhibition for neurosurgeon Prof Neville Knuckey’s paintings. “I think conditions like bipolar disorder and

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some of the post-traumatic stress disorders can have an outlet and will often lead to an increase in work output and creative output,” she said. “In a manic phase, especially, people with bipolar disorder will often be quite productive and really over the top and create different styles of artworks than what they would when they’re in their depressed phase.”

Medication issues Mood stabilising medication is a prickly issue for artists with bipolar disorder who creatively tap into their mania. “I think a lot of patients don’t like taking anti-depressant medications or treatments for bipolar, in particular, because they feel it will lessen their creative outlet,” Jenny said.

As both a psychiatrist and musician (Lynne plays the flute and the violin, and she is a member of the West Australian Doctors’ Orchestra), Lynne is familiar with all sides of the debate and knows of many people who fit the pattern. “There is a long list of people who had bipolar disorder – musicians, composers, and writers,”

Dr Lynne Cunningham: “Music is a huge part of my life”

Dr Jenny Fay

Lynne said there was a fine line to walk when medicating patients, especially those with bipolar disorder who are notorious for not taking medication as “they feel they’re not themselves”.

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“You have to juggle all the factors, all the time. It’s quite complex, you’re trying to keep them relatively well, but also functioning in a way that they’re happy with, because if they’re not happy, you can keep them from having any symptoms, but then if they’re not creative or doing what they want, you’re taking away their quality of life.”

Art as therapy There’s an argument for mental illness influencing creativity, but creative pursuits are often a form of expression or therapy for people with mental illness. Lynne pointed out that Graylands Hospital has an arts group for patients, and once a year, the group holds an exhibition to sell their work. Likewise, Melbourne’s vast Cunningham Dax Collection comprises 15,000 creative works by people touched by mental illness or emotional trauma, collected by Dr Eric Cunningham Dax between the 1950s and the 1980s.

Louise Helfgott

“I think it works both ways. Creativity helps people with mental illness, but I think that mental illness can lead to a creative outlet,” Jenny said. GP Dr Philip Wu agrees that it “works both ways”.

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“Yes, well often they use their art to express their internal feeling and mental well-being. For example, with bipolar disorder, people can create art that expresses the bipolar fluctuation in their mood,” he said. But Philip stresses that he views creativity more as a therapeutic treatment for his patients. “I see art as an expression of their talents. It’s also relaxing and therapeutic. I’ve dealt with patients with mental health issues and often those patients who practise art regularly (painting, music, etc.) actually manage their mental health much better. Their mood is better controlled if they practice art regularly.” On a personal level, both Jenny and Lynne find performing as musicians to be an integral and enjoyable part to their lifestyle. “It probably helps me in stress management and certainly in switching off from work, at times, which is a good thing,” Jenny said. Lynne echoed her sentiments. “My music is a huge part of my life. I don’t know where I would have been without it. I’ve certainly had times when I’ve felt terrible and the music has been the one thing that’s really made a huge difference to me,” Lynne said. Ed.Louise Helfgott will be speaking about mental illness and creativity at the Open Your Eyes conference in Geraldton, September 13-16. www.openyoureyes2011.com.au

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On the Grapevine By Dr Craig Drummond

Whisson Lake –

One Vineyard, One Variety Mark Whisson and Bruce Lake are certainly committed to Pinot Noir, the famous red grape of Burgundy. In 1985, they chose a high altitude vineyard site in the Piccadilly Valley, Adelaide Hills with it specifically in mind and planted it entirely to Pinot Noir. This was a brave undertaking given that they chose one of the most fastidious varieties to grow and most difficult wines to make. Furthermore, they have followed the true Burgundian philosophy of producing wines that reflect their ‘terroir’. This French term (which has no English translation) , encompasses all the environmental factors (soils, climate, altitude, aspect, geology etc.) that make that site unique and impart the particular characters to the wines coming from that site.

Many fine wine enthusiasts enjoy identifying the subtle nuances that differentiate the villages within Burgundy. Whisson Lake have taken this concept one step further by producing Pinot Noir in six styles, each made from fruit selected from different areas within their vineyard. Three of these wines were presented for tasting.  The 2010 “Le Gris de Noir” Pinot Noir is a style unfamiliar to many wine drinkers as it is a white wine produced from red grapes. A red wines colour comes from pigments in the grapes skin, so if the clear juice is separated immediately from skins at crushing, then the resulting wine is, in fact, white. This wine shows an attractive light gold colour with a hint of pink from skins. The aromas are initially restrained but open up in glass to reveal attractive ‘musky’ fruit. The palate is clean and linear with a fine acid focus giving a long finish. The fruit has been selected from an area of the vineyard that is shaded in the late afternoon and therefore  retains more acidity in the resultant wine. Invariably, I find that ‘blanc de noir’ wines still taste of red fruits, as indeed

this wine does. Fruit flavours come through late on the palate with Pinot›s red berry character evident. This is a robust wine (it has been fermented in new oak) with a firm ‘four square’ structure, quite unique in style, and is best consumed with food. Only 967 bottles have been produced from low fruit yields, so at $55 a bottle, it is, in fact, very reasonably priced. The 2010 “Black Label” Pinot Noir is from fruit selected in a high altitude, exposed area of the vineyard with resultant ripe fruit flavours yet with good acid retention. It is a product of a natural fermentation, which relies on the wild yeast present on the grapes and in the winery. Most Australian wine is produced in a more predictable controlled way using laboratory produced yeast cultures. The exciting thing about ‘wild ferments’ is that you can never predict what the final result will be – and vintage variation can be significant. This wine certainly has a ‘funky’ rustic character with complex strawberry and red plum aromas and smoky exotic red fruit flavours. This wine is drinking well now,

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

Q: 

Which Whisson Lake wine is actually a white wine produced from red grapes?

Answer:

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

Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, September 30, 2011. To enter the draw to win this month’s Doctors Dozen, return this completed coupon to ‘Medical Forum’s Doctors Dozen’, 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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and I feel needs to be consumed in the short to medium term. Again, a wine of low production levels, and priced at only $28, it is a bargain for all you Pinot freaks. An intriguing wine indeed is the 2010 “White Label” Pinot Noir, which was my pick of the range. Made from three carefully selected parcels of ripe complex fruit, it for me reflects what Pinot is about. It has aromas of spicy integrated dark cherry which lead on to a layered palate of complex interwoven flavours of Satsuma plum and black cherry, cinnamon spice, and an earthy underlying ‘forest floor’ character. This is a structural wine which should age over the next decade, taking on more of the earth and spice character. Only 1266 bottles have been produced, and are priced at $35. I admire what Whisson Lake are doing. They are producing unique traditionally-styled wines keeping production as natural as possible and using minimal sulphur additions. These are certainly wines that will interest any Pinot admirer. They can be purchased through www.whissonlake.com.au.

Enter here!... or you can enter online at www.MedicalHub.com.au! Name:

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Please send more information on Whisson Lake wine offers for Medical Forum readers. 

45

Medical Forum 09/11  

Western Australia's leading medical magazine

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