The Medical Link Issue 150

medical link THE OFFICIAL PUBLICATION OF THE GOLD COAST MEDICAL ASSOCIATION INC.

Celebrating 150 Issues of The Medical Link Magazine

ISSUE 150 | MAY – JUNE 2024

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THE MEDICAL LINK •

Contents 06 A Message From the GCMA President Prof Philip Morris AM EDITORIALS 08 Preventing Suicide: A Lifeline of Hope Prof Philip Morris AM 12 Babies Safety Guaranteed as RSV Rollout Commences AMA Queensland 14 GP Trainees Need Assistance: AMA Queensland Budget Submission 2024-25 AMA Queensland 16

Driving Decisions: A 5-Year Retrospective Analysis of Cognitive Testing in Fitness to Drive Assessment Jody E. Foxall, Sai H. Win, Julian J. Foxall

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Australasian Surgeons’ Attitudes to the Removal of the Pathological but Asymptomatic Gallbladder Mr Jack McKevitt, A/Prof David Cavalucci, A/Prof Nicholas O’Rourke

28 Business Succession Planning Now Can Avoid Disaster Later Avant Law

medicallink.com.au • 5

• THE MEDICAL LINK

A Message from the GCMA President Prof Philip Morris AM, President GCMA MB BS BSc PhD FAChAM (RACP) FRANZCP FPOA FFP ABPN info@drphilipmorris.com | 0422 545 753 | www.drphilipmorris.com

Dear GCMA colleagues,

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his is the 150th edition of The Medical Link! Our medical magazine has been an essential vehicle for maintaining the identity of the Gold Coast Medical Association and linking us to our members, other health professionals and organisations, and to our patients. It is read by doctors, reception and practice staff, journalists, and patients (often while in the waiting room!). It provides local and national information on pressing health matters and is a place where advertisers can promote their services to the health public. I am very proud of our The Medical Link. Congratulations to their team on this important milestone.

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am still hearing positive feedback from our Sunset Dinner Cruise on 24 February. I am so pleased the 70 members and friends who attended had such a good time. I hope the GCMA can put on another social event of similar success later in the year.

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n 21 March we restarted our monthly Thursday evening clinical meetings. The meeting was sponsored by South Coast Radiology and covered new developments in cardiac imaging. The function was well attended at Bumbles Cafe, Budds Beach, Surfers Paradise. Our Thursday evening meetings will continue through the year. Our GCMA Annual General Meeting will likely be in July.

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he GCMA has been active in advocating for our members and their patients this year. We submitted a series of questions and comments to the Commonwealth government Inquiry into the Covid-19 Pandemic Response as well as suggesting terms of reference for a proposed Senate led Royal Commission into the same topic. The GCMA submitted comment and questions to the Senate Inquiry into Unexplained Excess Deaths in Australia. This Inquiry is about to begin. We hope some explanations will come forward as to why so many excess (non-Covid-19) deaths have followed the pandemic.

THE GCMA PRESIDENT'S REPORT •

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e encourage all GCMA members to write articles or advertorials for The Medical Link. Contact admin@themedicallink.com.au to contribute.

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e are always looking to expand our membership. I encourage you to invite your doctor colleagues to join the GCMA. It is very easy to do. Just go to the GCMA website (www.gcma.org.au) and click through to the ‘Become a member’ page to join. The registration page can take credit card payments. The $150 annual membership is extremely good value. It covers regular evening meetings where salient updates on clinical and professional matters are presented as well as

We are always looking to expand our membership. I encourage you to invite your doctor colleagues to join the GCMA.

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a two-course meal and complimentary beverage, and the opportunity to interact with colleagues from all professional disciplines.

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ollowing this report I have included an article on Preventing Suicide. I asked ChatGPT to help me with this. I hope you read it and please send me any suggestions to my email address.

Yours sincerely, Prof Philip Morris AM President GCMA

"Preventing suicide is a collective responsibility that requires a comprehensive and compassionate approach."

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THE MEDICAL LINK •

Preventing Suicide: A Lifeline of Hope Prof Philip Morris AM, President GCMA MB BS BSc PhD FAChAM (RACP) FRANZCP FPOA FFP ABPN info@drphilipmorris.com | 0422 545 753 | www.drphilipmorris.com

Introduction Suicide is a deeply troubling and complex issue that affects individuals, families, and communities across the globe.

It is a leading cause of death worldwide, and its impact reaches far beyond the statistics. Preventing suicide requires a multifaceted approach that encompasses awareness, education, support, and mental health services. In this essay, we will explore some of the most important ways to prevent suicide and provide a lifeline of hope to those in need.

Raising Awareness Raising awareness about suicide is the first step in prevention. People need to understand the signs and risk factors associated with suicide. This knowledge enables individuals to recognize when someone they care about might be struggling and in need of help. Public awareness campaigns, school programs, and community initiatives can all play a vital role in spreading information about suicide prevention.

Reducing Stigma Stigma remains a significant barrier to seeking help for mental health issues and suicidal thoughts. Society must work to break down the stigma surrounding mental health and encourage open, non-judgmental conversations about it.

People should feel comfortable discussing their struggles and seeking professional assistance without fear of discrimination or social exclusion.

Promoting Mental Health

Preventing suicide begins with promoting mental health and well-being. This involves providing resources and support for individuals to develop resilience and coping skills. Schools, workplaces, and communities can create environments that prioritize mental health, offering tools and strategies to manage stress, anxiety, and depression effectively.

Identifying Warning Signs Recognizing the warning signs of suicidal ideation is crucial. These signs may include sudden changes in behavior, expressions of hopelessness, withdrawal from social activities, giving away belongings, or talking about death. Training programs for educators, healthcare professionals, and community members can help improve the ability to identify these signs and intervene appropriately.

Accessible Mental Healthcare One of the most critical elements in preventing suicide is ensuring that mental health care is accessible and affordable for everyone. This includes not only treatment for existing conditions but also timely access to crisis intervention services. Governments, insurance providers, and healthcare organizations must work together to remove barriers to mental health care.

Support Systems Strong support systems are vital for suicide prevention. Friends and family members play a crucial role in offering emotional support to individuals in crisis. Creating a safe space for open

communication and actively listening to those who are struggling can make a world of difference. Support groups and helplines also offer valuable assistance for individuals in need.

Crisis Intervention

Immediate intervention during a crisis is often required to prevent suicide attempts. Hotlines, crisis centers, and emergency services provide vital support to individuals in acute distress. Ensuring these resources are readily available and well-publicized can save lives.

Education & Training Educating the public and professionals about suicide prevention is an ongoing effort. Mental health first aid training programs can equip individuals with the skills to provide initial assistance to someone in crisis and connect them with appropriate resources. Schools and workplaces should consider implementing such training to create a more supportive environment.

Conclusion Preventing suicide is a collective responsibility that requires a comprehensive and compassionate approach. By raising awareness, reducing stigma, promoting mental health, identifying warning signs, providing accessible care, nurturing support systems, and offering crisis intervention, we can create a lifeline of hope for those struggling with suicidal thoughts. Together, we can work towards a world where every individual feels valued, heard, and supported, and where suicide is a preventable tragedy of the past.

Advertising in The Medical Link If you would like to advertise your products or services, positions vacant, rooms for rent etc. in The Medical Link, please feel free to contact us at admin@themedicallink.com.au.

Advertising of medical services in The Medical Link should comply with the same advertising guidelines released in the Medical Board of Australia Code of Conduct: Be factual and verifiable | Not include testimonials | Only make justifiable claims regarding quality and outcomes | Not raise unrealistic expectation | Not offer inducements | Not make unfair or inaccurate comparisons between your services and those of colleagues The Medical Link is designed and published by Swan Management Services. It is the advertiser’s responsibility to ensure that advertisements comply with the Trade Practices Act 1947 as amended. All advertisements are published on the condition that the advertiser indemnifies the publisher and its servants against all claims, suits, actions, loss and/ or damages as a result of anything published on the advertiser’s behalf.

DISCLAIMER: The contents of articles and opinions published are not necessarily held by the publisher, editor or the Gold Coast Medical Association. No responsibility is accepted by the publisher, editor or Gold Coast Medical Association for the accuracy of information contained in any opinion, information, editorial or advertisement contained in this publication and readers should rely upon their own enquiries in making decisions touching own interest. Unless specifically stated, products and services advertised or otherwise appearing in The Medical Link are not endorsed by the publisher, editor or the Gold Coast Medical Association.

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MEDICAL EDITORIAL COMMITTEE

Philip Morris, Geoff Adsett, Stephen Withers, John Kearney, Maria Coliat

GCMA MEMBERS gcma.org.au

GCMA EXECUTIVE COMMITTEE

President Prof Philip Morris 5531 4838 Vice-President Dr Maria Coliat 5571 7233 Secretary Prof Philip Morris 5531 4838 Immediate Past President Dr Sonu Haikerwal 5564 6255 Treasurer Dr Geoff Adsett 5578 6866 Specialist Representative Prof John Kearney 5519 8319 GP Representative Dr Katrina McLean 5564 6501 Academic Representative Prof Gordon Wright 5595 4414

Keeping the Medical Community Informed The Medical Link enriches the Gold Coast medical community by uniting the voice of its doctors.

Here you will find insightful stories and the latest trends in field research conducted abroad, and of course, right here on the Gold Coast. Keep informed of new health services, developments in the medical profession, and general interest items.

We invite you to submit your company updates, new recruits and promotions to the following email: admin@themedicallink.com.au And if you would like to advertise your products or services, positions vacant, rooms for rent etc. in The Medical Link, please feel free to contact us admin@themedicallink.com.au.

"RSV is extremely common among babies with 65 per cent of infants suffering from the virus within their first year of life."

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Babies Safety Guaranteed as RSV Rollout Commences AMA Queensland Media Release, 16 April 2024 media@amaq.com.au

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ueensland’s rollout of free Respiratory Syncytial Virus (RSV) immunisation is now underway. The program will protect our most vulnerable from the common yet often severe disease, with all eligible babies born after 1 February 2024 able to be immunised.

AMA Queensland welcomed the news of the free RSV immunisation program and is pleased to see newborns are now able to be immunised prior to discharge from hospital.

“RSV is extremely common among babies with 65 per cent of infants suffering from the virus within their first year of life,” AMA Queensland President Dr Maria Boulton said.

“In the first three months of this year we have already seen over 7,000 cases of RSV, which is double the number of cases from the same period in 2023.

“We have been watching the number of RSV cases increase at an alarming rate, so this rollout could not have come at a more crucial time.

“Providing free access to this immunisation for those at highest risk of severe disease from RSV will change the trajectory of the overwhelming number of hospitalisations and protect our most vulnerable.

“No parent wants to see their child unwell, especially not with respiratory symptoms that can impact their ability to

breathe freely.

“This vaccine will provide immediate protection against RSV that will last for at least 150 days and protect babies throughout the peak season.

“The monoclonal antibody has been proven to reduce the risk of hospitalisation by 80 per cent, meaning that if your baby does contract the virus, they are much less likely to exhibit some of the extreme and unpleasant symptoms.

“Ensuring your baby is immunised will reduce the spread of the otherwise highly contagious virus.

“We encourage all parents of young children to take advantage of this free program and have their eligible child vaccinated against RSV. “The second phase of the program planned to commence in late April will initially target babies three months and younger and vulnerable infants with certain complex medical conditions up to eight months.

“We are waiting further advice pending vaccine supplies to determine any further eligibility for the rollout.”

Background •

Infants and young children including newborns, Aboriginal and Torres Strait Islander infants and infants with certain complex

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medical conditions born from 1 February 2024 will be eligible for the free vaccine from late April 2024.

The program will use the monoclonal antibody product nirsevimab which was approved by the Therapeutic Good Administration (TGA) in November 2023.

AMA Queensland is aware nirsevimab is in very limited supply.

Primary care providers will be able to order the vaccine from the Queensland Health Immunisation Program (QHIP) from 22 April 2024 through a fortnightly special-order process to manage supply.

This process will require providers to identify the approximate numbers of eligible patients they will immunise over the coming fortnight. Further clinical guidance for suppliers can be found via the QPRSVP Program webpage.

The program will end on 31 January 2025.

Contact AMA Queensland Media +61 419 735 641 media@amaq.com.au amaq.com.au

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• THE MEDICAL LINK

GP Trainees Need Assistance AMA Queensland Budget Submission 2024-25 AMA Queensland Media Release, 15 April 2024 media@amaq.com.au

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MA Queensland is urging the Queensland Government to follow the lead of Tasmania and Victoria and offer financial incentives for doctors to train as GPs to head off a looming workforce crisis.

The call is made in the AMA Queensland Budget Submission 202425.

“We are heading towards a cliff in our general practice workforce,” AMA Queensland President Dr Maria Boulton said.

“Forty years ago, about 50 per cent of medical school graduates chose general practice as their specialty. Today it is less than 15 per cent.

“Those GPs who trained in the 1980s are now planning to move to part-time work or retire, and we do not have the new workforce to replace them.

“At the same time, we are seeing greater demand for GPs as Queenslanders are living longer with more chronic conditions that GPs are experts in treating.

“GPs are the highest trained general medical practitioners. It can take up to 15 years to train and Fellow as a GP. “However, junior doctors who choose general practice face a substantial pay cut in their training years compared to their colleagues. They also lose access to leave entitlements that hospital doctors get.

“At the same time, there is increasing competition from other states and territories for healthcare workers.

“The Victorian Government has ad-

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40 years ago, about 50% of medical school graduates chose general practice as their specialty. Today it is less than 15%.

Those GPs who trained in the 1980s are now planning to move to part-time work or retire, and we do not have the new workforce to replace them.

dressed the need to train more GPs with $40,000 grants to trainee doctors who enrol in a general practice training course.

“The newly re-elected Tasmanian Government has promised to pick up HECS/HELP debt of up to $100,000 to attract 40 new GPs to work in rural and regional areas.

“We need the Queensland Government to do the same and compensate junior doctors who make a huge financial sacrifice to train as GPs. Many junior doctors want to become GPs but the costs stop them following their dream.

“We must do everything we can to increase the number of graduates choosing general practice so all Queenslanders have access to best practice primary care and preventative health.

“GPs keep people well and out of hospital. They are the first port of call for people with mental health concerns.

In rural areas they provide antenatal care, anaesthetics and more.

“It is a wonderful career and such a privilege to care for multiple generations of the same family.

“We need to ensure that we have GPs in all communities. This requires long-term sustainable solutions that keep general practices viable in our regional communities, not Band-aid fixes that outsource GPs’ work to less-trained healthcare workers, putting patient care at risk.

“The Queensland Government is piloting a single employer model for GP

Registrars and we will be monitoring this closely to see if it delivers better outcomes for trainee GPs. “We welcome the Queensland Government’s commitment to funding training for 50 GPs to upskill in obstetrics and anaesthetics, which will help retain our GP workforce in regional areas.

“However, this is an election year and we will be watching closely the promises and policies from all sides.

“This is a critical budget for Queensland’s healthcare system and we must see substantial investments in our workforce.”

The AMA Queensland Budget Submission 2024-25 is available here.

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increase the number of GP trainee enrolments in 2024 and 2025.

The Tasmanian Government has promised to pay up to $100,000 of student debt for 40 GPs who relocate to regional areas.

Under AMA Queensland’s proposal, 400 trainees would be offered a top-up payment for

first-year trainees of $30,000 and $10,000 to support the costs of exams during GP training.

Contact AMA Queensland Media +61 419 735 641 media@amaq.com.au amaq.com.au

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The 2023 Medical Deans Survey found general practice was the preferred future specialty for 13 per cent of medical students.

A medical graduate –who has most likely also completed an undergraduate degree before their medical degree - can enter community GP training after two years of hospital training.

The base salary for a GP Registrar with two years of hospital training is well below the base salary for their colleagues who remain in the hospital system.

The Victorian Government is offering GP Trainee Grants of $40,000 grants over two years to

medicallink.com.au • 15

Driving Decisions: A 5-Year Retrospective Analysis of Cognitive Testing in Fitness to Drive Assessment Jody E. Foxall, Sai H. Win, Julian J. Foxall 1.Oceania University of Medicine, Sydney, AUS 2. General Practice, Boorowa Medical Centre, Boorowa, AUS 3. Engineering, Oxford University, Sydney, AUS Corresponding author: Jody E. Foxall, jody.foxall@oum.edu.ws

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Abstract Introduction

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ith an ageing population, assessing fitness-to-drive in older adults has become increasingly important.

Cognitive impairment is a significant risk factor for unsafe driving and cognitive testing has been proposed as a tool to evaluate fitness to drive in this population. However, the utilization of cognitive testing in patients presenting for fitness to drive among older adults is not well established.

Objectives

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his study aimed to investigate the utilization of cognitive testing in older adult patients presenting for their Assessing Fitness-To-Drive assessment in a rural location.

Methods

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retrospective analysis of patient records from a purposive sampling of 254 patients presenting to a rural medical facility specialising in older adult care was conducted. Data on patient demographics, medical history, cognitive testing, and government-mandated fitness-to-drive assessments were collected and analysed.

Results

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he results of this study indicate a concerning under-diagnosis of cognitive decline in the sample population.

The sample data shows less prevalence than in the Australian Bureau of Statistics Data for the 75-79 age group, 2.9% vs 5.3%, and the 80-84 age group, 5.6% vs 8.0%, while the 85 and over age group the Sample Data shows 23.8% vs 19.8%.

The results also identified potential barriers to cognitive testing in this context.

Conclusion

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his five-year retrospective study revealed a prevalence of under-testing for cognitive decline among elderly patients seeking fitness-to-drive assessment in a sample from a rural general practice compared to the general population.

This could potentially impact road safety as elderly drivers with cognitive decline are not being identified by the system.

Introduction

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t is widely accepted that as people age their cognitive abilities can decline which can potentially affect their ability to drive safely (Pond & McNeil, 2023) [1]. In New South Wales and Victoria, all drivers aged 75 and over must undergo the Assessing Fitness to Drive (AFTD) assessment yearly to ensure that they are still capable of driving safely. This assessment covers vision, hearing, cardiovascular system, diabetes, musculoskeletal/neurological system, psychological health, sleep disorders, substance misuse and medications. Cognition falls within the psychological health section as a subheading and is reported by the health professional as either normal or abnormal (Assessing Fitness to Drive for Commercial and Private Vehicle Drivers 2022 EDITION Medical Standards for Licensing and Clinical Management Guidelines, n.d.) [2].

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he questionnaires are standardised throughout the states with brief descriptions of the patient's medical conditions and perceived potential safety issues reported by the clinician completing the survey. Although there are guidelines for the standards to be achieved for various components of the assessment, there is no mandate on how the assessment should be conducted. Typically, these assessments are conducted by healthcare professionals, including general practitioners (GPs), occupational therapists, neurologists, and specialists in rehabilitation medicine and geriatrics. In a vast majority of cases, the survey will have been completed by GPs who are most accessible to patients.

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n comparison to the general population, elderly patients seeking AFTD assessments in this rural general practice setting in New South Wales (NSW), exhibit a higher prevalence of under-diagnosis for cognitive decline. This could contribute to a potential risk to road safety, as elderly drivers with undetected cognitive decline may continue to operate vehicles without appropriate intervention. A survey of the GPs working at this rural practice showcased that a formal cognitive test was usually not completed during medical assessment for fitness to drive. Of the four clinicians surveyed, the main reason for not completing the test was due to time constraints and lack of a mandate.

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dditionally, it is hypothesized that the implementation of improved cognitive assessment protocols for elderly patients undergoing AFTD evaluations will lead to more accurate detection of cognitive decline, thereby reducing risks associated with undiagnosed cognitive impairment in elderly drivers.

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his study raises the question of whether there should there be a requirement in Australia for compulsory, precise and dependable cognitive assessments to assist in the early identification of cognitive decline among elderly drivers.

Materials & Methods

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comprehensive search was conducted using electronic databases including PubMed, Psych Info and Google Scholar to identify studies published between 2000 and 2023. The search keywords included older adults, cognitive decline, driving performance, assessment tools and interventions. Only those published in English and focusing on older adult populations aged 65 and above were included for the study as outlined below. The scope of the journal articles was not limited to Australia; it encompassed content from Canada, Japan, the United Kingdom, and the United States of America.

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Study Design

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his single-centre retrospective study reviewed the medical records of elderly patients who presented over a fiveyear period for an AFTD assessment at a rural GP clinic in NSW. Purposive sampling of data was analysed and compared to the Australian Bureau of Statistics (ABS) data.

Ethics Approval was provided by the Oceania University of Medicine Human Ethics Committee.

(Ethics approval number OUMHREC23_012)

Data Collection & Assessment Criteria

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ata were collected using Medical Director – Clinical (cloud-based clinical and practise management software), of patients 75 years old and over presenting to a single rural general practice in NSW. The data was collected over five-year period from 01/01/2018 – 31/12/2022.

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he data collected included demographic information, medical history, results of cognitive screening tests i.e.

Mini Mental Status Exam (MMSE), and final assessment outcomes. All data has been de-identified and permission to collect and use data was given.

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tatistical analysis of the relevant data was done using Excel Spreadsheet Software, and the sample data was normalised and compared to the Australian Bureau of Statistics data 44300DO080_2018 Survey of Disability, Ageing and Carers: Dementia in Australia (Australian Bureau of Statistics, n.d.)[3].

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nclusion criteria consisted of patients aged 75 and older, male or female, with or without a pre-existing diagnosis of cognitive decline or dementia and all those patients that are required by law to have a AFTD assessment completed by their GP at a rural medical centre in NSW.

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xclusion criteria – Patients over the age of 75 years who have not presented to the practice within the specified time frame were excluded, not all residents of this rural location were present at this practice as there are two medical practices in this town and not all patients over the age of 75 years hold a driver’s license.

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he rural town where the practice is located has a population of approximately 2,000. It is a farming community, and the demographics indicate that many of the inhabitants were of Anglo-Saxon descent. Over recent years, an influx of migrants to the area for retirement and work has increased the population from approximately 1,100 to the current level.

Results

patients identified to have cognitive decline in a sample size of 254 patients.

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he study then compared the data obtained from the Australian Bureau of Statistics for cognitive decline in the elderly population (ABS.gov.au 2018) [3], 75 and over.

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hile the overall prevalence of cognitive decline by age group between the Sample and the ABS data is similar, 10.2% vs 10.3% respectively, the prevalence in the different age groups showed larger differences *(Table 2). The Sample data showed less prevalence than in the ABS data for the 75-79 age group, 2.9% vs 5.3%, and 80- 84 age group, 5.6% vs 8.0%, while the 85 and over age group the Sample showed 23.8% vs 19.8% in the ABS data.

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f the 254 patients attending the practice who identified as being 75 and above, 167 patients (65.7%) presented to the GP clinic for the AFTD assessment and were deemed fit to drive.

ormalising the Sample data for the ABS age groups showed the Sample cognitive decline at 9.4% vs the 10.3% in the ABS data. Again, the two younger age groups had a lower prevalence in the Sample than in the ABS data, while the 85 and over age group had a higher prevalence.

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Data Analysis

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fter assessment by a Geriatrician, 26 of the 254 patients were found to have cognitive decline, dementia, or Alzheimer’s. This information was recorded in their patient file via a letter informing the GP of the diagnosis. As a side note, a total of 6 patients were shown to have been prescribed an NMDA receptor antagonist (Memantine) or cholinesterase inhibitor (Donepezil) to aid in cognition as per the specialists' request.

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patients had both the AFTD test and were diagnosed with either cognitive decline, dementia, or Alzheimer’s

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ased on the raw Sample data collected, as shown in Table 1, the percentage of patients with cognitive decline was 10.2% (notwithstanding age breakdown).

The breakdown of patient numbers by age was 3 (75- 79) (2.9%), 4 (80-84) (5.6%), and 19 (85 and over) (23.8%) for

he incidence of cognitive decline diagnosis increases with age, as would be expected. For the normalised data set, 1.2% of the patients in the 75-79 age group, and 6.9% of the patients in the 85 and over age group had a cognitive decline diagnosis.

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he Sample data in Table 2 showed a smaller number of cognitive decline diagnoses in the younger age groups, 75-79 and 80-84, than in the ABS data, pointing to a potential under testing of the Sample population. These two age groups were also the most likely to have had the AFTD test and were permitted to drive. Note that while only 48.8% of patients in the 85 and over age group are permitted to drive, 7.7% of those patients had been permitted to drive via the AFTD test as well as having been diagnosed with cognitive decline.

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he Sample data showed that the incidence of patients who have had the AFTD test and were thus permitted to drive declined with age: 30.5% of the 75 and over patients were in the 75-79 age group, while only 14.2% of the 75 and over patients are in the 85 and over age group, as shown in Table 3.

T

able 3 shows in more detail the breakdown of the Sample data, normalised to the ABS population by age groups. The Age Group distribution is similar between the Sample and ABS data. For the patients that were permitted to drive that also had been diagnosed with cognitive decline, there were 1.2% in the 80-84 age group of the total permitted to drive, this amounted to 5.6% of the 80-84 age group itself. Similarly, the 2.1% in the 85-89 age group of the total permitted to drive amounted to 16.9% of the 84-89 age group itself.

Discussion

T

he aim of this study was to investigate whether there was significant underdiagnoses of cognitive decline in a rural general practice by patients presenting to their GP for their annual Assessing Fitness-to-Drive (AFTD) paperwork.

T

he AFTD assessment covers vision, hearing, cardiovascular system, diabetes, musculoskeletal, neurological system, psychological health, sleep disorders, substance misuse and medications.

C

ognition falls within the psychological health section as a subheading and is reported by the health professional as either normal or abnormal. GPs who fill out the questionnaire for their patients are required to be familiar with the patient and vice versa.

C

urrently, there is no mandatory cognitive testing for elderly patients who present for completion of their AFTD questionnaire.

O

ur findings showed there was a lower incidence of cognitive decline in the Sample data compared to the ABS data especially in the two younger age groups, in which the incidence of cognitive decline in the Sample data was 55% of that in the ABS statistics for the 75-79 age group, and 69% for the 80-89 age group.

T

he results indicate that there was an underdiagnosis of cognitive decline among elderly patients in the study location, compared to the data provided by the ABS. Whilst there may be several reasons for the discrepancy, the most notable is likely due to the lack of mandatory cognitive testing during the consultation with the GP.

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• THE MEDICAL LINK

A

s there is a lack of mandatory screening (and the keyword is mandatory) of cognitive ability during AFTD assessment for older drivers, missing an early diagnosis of cognitive decline could potentially have a negative impact on road safety. Many older drivers develop slower reaction times and have difficulty with decision-making and impaired judgement which could increase their risk of being involved in a car accident (Shen et al., 2020)[9].

M I

t must be acknowledged this study has limitations. Firstly, the retrospective design relied on medical records and may have been subject to incomplete or missing data. Additionally, the study was conducted at a single rural clinic, which limits the extrapolation of the findings to other settings. The location of this clinic may have GPs who perform differently during assessments to their peers in other regions due to limited resources.

O

ther potential reasons for these discrepancies may be due to, but not limited to, patients being able to mask their cognitive decline in areas they are familiar with or lack of time during the consultation with the GP.

W

hile GPs have access to multiple tools to test their patients for cognitive decline as reported by Wallis, et al.

[4] time constraints and patient familiarity can lead to these tools not being used to accurately to assess the cognition of elderly patients.

T

his could potentially allow the patients to mask their level of cognitive decline when they present for renewal of their AFTD assessment. The study by Kay Margaret Jones et al., 2012 [5] found elderly patients may mask their medical

20 • Issue 150

and cognitive conditions for fear of losing their driver's licence and therefore their independence. Patients who are familiar with the doctor and their environment can mask their level of cognitive decline with learned responses such as repeating stories and questions which are familiar to the patient and the doctor. It is therefore possible for the doctor to assume that the patient is aware and orientated to time, space and person from such interaction (How Seniors Hide Their Dementia Symptoms | Heather Glen | HG Senior Living, n.d.)[6]. ne of the tools that is readily available to the GP is the Mini Mental Status Exam (MMSE) which can be used to assess 6 areas of mental abilities, including orientation to time and place, attention/concentration, short-term memory (recall), language skills, visuospatial abilities, and the ability to understand and follow instructions. All the parameters are essential for the safe operation of a vehicle. It is scored out of 30, with a score below 24 suggesting significant cognitive impairment. The MMSE takes 10-15 minutes to administer (Dementia Australia, 2015)[7]. The application of a formal assessment of cognition using several established tests bypasses familiarity and masking (Silverberg et al., 2011)[8].

O

andatory screening for cognitive ability as part of the AFTD assessment could help identify sooner older drivers who may be at increased risk of being involved in an accident, ensuring they receive appropriate support, monitoring, or restrictions on their driving (Charlton et al., 2021)[10].

I

n rural communities, private motor vehicles are often the primary mode of transportation for older adults, as public transportation options can be limited or non-existent (Nutley 2003) [11 ]. This reliance on motor vehicles has both positive and negative effects on the health and well-being of older adults.

O

n the positive side, driving is a key aspect of independence for many older adults, allowing them to maintain their autonomy and engage in various activities. (Rosenfeld et al., 2022)[12 ] Motor vehicles can provide older adults with greater mobility and freedom by allowing them to access essential services such as medical care, grocery stores and social activities. This in turn can help reduce social isolation and improve overall quality of life (Lin & Cui, 2021)[13].

T

he potentially negative consequences of motor vehicle reliance in rural communities is that older drivers who experience declines in physical and cognitive abilities are at increased risk of accidents and injuries (Doi et al., 2020)[14].

Road safety research indicates that there is a significantly higher risk of death or injury due to crashes on rural or remote

roads (Safety Tips for Minimising the Risks of Driving on Rural and Remote Roads, n.d.)[15 ].

A

nother negative aspect is telling a patient they are unfit to continue to drive. Lee and Molnar (2017)[16], state it is one of the more challenging aspects of patient care. As there is currently no gold standard test or scale to determine driving fitness, many clinicians do not feel comfortable making a recommendation for their patients to stop driving. (Pauldurai & Gudlavalleti, 2021)[17].

T

his study highlights the importance of addressing the cognitive decline in elderly drivers and emphasises the need for healthcare providers to prioritise cognitive assessments during fitness to drive evaluations. By enhancing testing protocols and increasing awareness of the importance of cognitive health in driving safety, we can work towards improving road safety for everyone. Future research should consider larger sample sizes and multicentre studies to better understand the prevalence of undiagnosed cognitive decline among elderly drivers seeking fitness-to-drive assessments.

References

T T

his study underscores the need for improved cognitive assessment protocols for elderly patients undergoing fitness-to-drive evaluations, emphasising the importance of accurate testing to address potential risks associated with undetected cognitive decline in elderly drivers.

2020,

10.3390/ijerph17238886

1.

Pond, D., & McNeil, K. (2023). Clinical approach to driving and the older person. AJGP, 52(8), 512–515. https:// doi.org/10.31128/ajgp-01-23-6693

10. Charlton JL, Di Stefano M, Dow J, et al.: Influence of chronic illness on crash involvement of motor vehicle drivers.

Monash University Accident Research Centre, Melbourne, Australia; 2021.

2.

Austroads; National Transport Commission: Assessing fitness to drive for commercial and private vehicle drivers medical standards for licensing and clinical management guidelines. Sydney: Austroads. 2022,

11. Nutley, S: Indicators of transport and accessibility problems in rural Australia. Journal of Transport Geography. 2003, 11:5571.

10.1016/s0966-6923(02)00052-2

3.

Disability, Ageing and Carers, Australia: Summary of Findings, 2018 | Australian Bureau of Statistics data 44300DO080_2018 Survey of Disability, Ageing and Carers: Dementia in Australia. (2020). Accessed: September: http://www.abs.gov.au.

4.

Wallis, K.A., Matthews, J. and Spurling: G.K: Assessing fitness to drive in older people: the need for an evidence‐based toolkit in general practice. The. Medical Journal of Australia, [online] 212, pp.396398.e1.

2020, 10.5694/mja2.50588

5.

Kay Margaret Jones, Sian Rouse-Watson, Beveridge, A.A., Sims, J. and Schattner, P: Fitness to drive - GP perspectives of assessing older and functionally impaired patients. Australian Family Physician. 2012, 41:235-9.

6.

Conclusions his five-year retrospective study revealed a prevalence of under-testing of cognitive decline among elderly patients seeking a fitness-to-drive assessment in this rural general practice.

8886.

How Seniors Hide Their Dementia Symptoms | Heather Glen | HG Senior Living. (n.d.). www.hgseniorliving.com. https:// www.hgseniorliving.com/blog/how-seniors-hide-their-dementiasymptoms.

7.

Dementia Australia. (2015, December 21). Cognitive screening and assessment. Dementia.org.au. https:// www.dementia.org.au/information/ for-health-professionals/clinical-resources/cognitive-screening-and-assessment

8.

Silverberg, N. B., Ryan, L. M., Carrillo, M. C., Sperling, R., Petersen, R. C., Posner, H. B., Snyder, P. J., Hilsabeck, R., Gallagher, M., Raber, J., Rizzo, A., Possin, K., King, J., Kaye, J., Ott, B. R., Albert, M. S., Wagster, M. V., Schinka, J. A., Cullum, C. M., & Farias, S. T. (2011). Assessment of cognition in early dementia. Alzheimer’s & Dementia, 7(3), e60–e76. https:// doi.org/10.1016/j.jalz.2011.05.001

9.

Shen Y, Zahoor O, Tan X, et al.: Assessing Fitness-To-Drive among Older Drivers: A Comparative Analysis of Potential Alternatives to on-Road Driving Test. International Journal of Environmental Research and Public Health, 17,

12. Rosenfeld, M., Goverover, Y., & Weiss, P: Self-awareness predicts fitness to drive among adults referred to occupational therapy evaluation. Frontiers in Rehabilitation Sciences, 3.

2022, 3: 10.3389/fresc.2022.1005025 13. Lin, D., & Cui, J.: Transport and Mobility Needs for an Ageing Society from a Policy Perspective: Review and Implications. International Journal of Environmental Research and Public Health.

2021. 18(22):10.3390/ijerph182211802 14. Doi T, Ishii H, Tsutsumimoto K, et al.: Car Accidents Associated with Physical Frailty and Cognitive Impairment. Gerontology.

2019, 66:624-630. 10.1159/000508823 15. Safety tips for minimising the risks of driving on rural and remote roads. https:// www.hpw.qld.gov.au/__data/assets/pdf_ file/0025/9736/ruralremotedriving.pdf.

16. Lee, L, & Molnar, F: Driving and dementia: Efficient approach to driving safety concerns in family practice. Canadian Family Physician. 2017, 63:27-31.

17. Pauldurai, J., & Gudlavalleti, A. (2021).

Cognitive Decline and Driving Evaluation In The Elderly. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/ books/NBK569418/

medicallink.com.au • 21

Australasian Surgeons’ Attitudes to the Removal of the Pathological but Asymptomatic Gallbladder Jack McKevitt Medical Student, Pharmacist (B.Pharm Hons) jack.mckevitt@oum.edu.ws A/Prof David Cavallucci Professor (Associate), HPB Surgeon, MBBS, FRACS Hepatopancreatobiliary Fellowship reception@brisbanehpb.com.au A/Prof Nicholas O’Rourke Professor (Associate), HPB Surgeon, MBBS, FRACS Hepatopancreatobiliary Fellowship reception@brisbanehpb.com.au

22 • Issue 150

FEATURE STORY •

Abstract

Introduction

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G

ackground: Gallbladder cancer, a hepatobiliary malignancy, often develops without symptoms and has a high likelihood of early metastatic spread. Despite not being classified as a genetic condition, there is substantial evidence of familial associations. A history of gallstones is the most significant risk factor for gallbladder cancer. In Australasia, there is a significant variation in surgical opinions regarding the removal of asymptomatic gallbladders in individuals with a family history of gallbladder cancer.

Methods: The study, “Australasian Surgeons’ Attitudes to the Removal of the Pathological but Asymptomatic Gallbladder,” aimed to engage Hepatopancreatobiliary surgeons who are members of the Australasian Association of Hepatopancreatobiliary Surgery (AANZHPBA). A seven-question survey was disseminated to all members, with an expected sample size of 50.

Results: A survey conducted over 53 days (08/08/2022 to 30/09/2022) with 73 out of 150 Australasian Surgeons revealed universal agreement on non-removal of gallbladder polyps, regardless of size or number. However, opinions diverged significantly regarding removal based on risk factors such as family history, polyp size, or stone size. Notably, in the case of asymptomatic gallstones in a patient with a first-degree relative who has had gallbladder cancer, a majority (59%) would opt for removal, supporting the research team’s primary hypothesis that there is a significant disparity in the removal of a gallbladder in patients with a family history of gallbladder cancer.

Conclusion: This study advances understanding of Australasian surgeons’ views on managing asymptomatic gallbladders. It highlights the need for guidelines to standardise practices and enhance patient care. Despite its significance, the findings are limited by a small sample size and need further validation. This research lays a foundation for future studies and guideline development in this area.

allbladder cancer, a type of hepatobiliary malignancy, originates from the mucosal lining of the gallbladder. It often develops without symptoms and has a high likelihood of early metastatic spread(1,2). Despite not being classified as a genetic condition, there is substantial evidence of familial associations. Up to 25% of patients diagnosed with gallbladder cancer have a positive family history, especially among first-degree relatives(3).

G

allbladder polyps, often detected in adults through trans-abdominal ultrasound (TAUS), pose a significant clinical challenge. Despite their frequent occurrence, they rarely progress to gallbladder cancer. However, the importance of early detection of this malignancy is paramount due to its poor prognosis, highlighting the complexity of managing gallbladder polyps(4,5). Gallbladder adenocarcinoma, akin to all forms of cancer, typically stems from an extended period of chronic inflammation in the gallbladder that interferes with normal cell growth and signalling. This inflammation is frequently attributed to the buildup of gallstones, or cholelithiasis, which generally precedes gallbladder cancer by around two decades. A history of gallstones is the most significant risk factor for gallbladder cancer, with a relative risk (RR) of 4.9(6). It's projected that 85% of individuals who develop gallbladder cancer have cholelithiasis(3).

A

lthough gallstones are strongly associated with the origin of gallbladder cancer, their role as a direct cause remains ambiguous. The dominant theory proposes that chronic irritation from gallstones and the local production of carcinogens such as secondary bile acids lead to sequential development of metaplasia/hyperplasia, dysplasia, and eventually carcinoma(7). The risk for gallbladder cancer escalates with the size of the gallstones. However, the recent rise in gallbladder cancer cases among individuals under 45 challenges the belief that

gallstones are the exclusive cause. Other notable risk factors encompass age, obesity, genetic predisposition, exposure to mutagens in the workplace, and ongoing infections(3).

I

n Australasia, there is a significant variation in surgical opinions regarding the removal of asymptomatic gallbladders in individuals with a family history of gallbladder cancer. This variation is likely due to the absence of Australasian guidelines on this topic. Many Australian Hepato-Pancreato-Biliary (HPB) specialists currently follow guidelines from countries like the USA and the UK, which have established protocols(8).

However, these guidelines from the USA and UK only provide a loose framework for the scenarios proposed in this study, and they do not offer guidance on how to manage a patient who has a gallstone and a relative with a history of gallbladder cancer.

T

herefore, to promote safe medical practices and reduce divergent opinions, it is crucial to develop a set of Australasian guidelines. The research team constructed a list of questions that encompassed the range of opinions on this topic. The aim was to create and distribute a concise seven-question survey to the members of the Australia and Aotearoa New Zealand Hepatic, Pancreatic and Biliary Association (AANZHPBA). The responses were analysed and used to formulate preliminary guidelines for the removal of the pathological but asymptomatic gallbladders in individuals with a family history of gallbladder cancer. The purpose of this research is to determine the attitudes of Australasian Surgeons towards the removal of the pathological but asymptomatic gallbladder in individuals with polyps or stones. This study also aims to contribute to the creation of a set of Australasian guidelines to improve consistency among surgeons and enhance patient care and safety. In this research, the research team’s primary hypothesis is that we anticipate a significant disparity in the removal of a gallbladder in patients

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• THE MEDICAL LINK

with a family history of gallbladder cancer. Furthermore, the team’s secondary hypothesis predicts that most of the survey respondents, who are HPB Surgeons, would choose to remove a gallbladder polyp that is larger than 6mm.

ture of this study, we anticipated that not all AANZHPBA members would participate, setting the expected sample size at 50. Participation was entirely voluntary, with no obligation for AANZHPBA members to complete the survey.

Purpose & Hypothesis

Materials

T

D

he purpose of this research is to determine the attitudes of Australasian Surgeons towards the removal of the pathological but asymptomatic gallbladder in individuals with polyps or stones.

This study also aims to contribute to the creation of a set of Australasian guidelines to improve consistency among surgeons and enhance patient care and safety. In this research, the research team’s primary hypothesis is that we anticipate a significant disparity in the removal of a gallbladder in patients with a family history of gallbladder cancer. Furthermore, the team’s secondary hypothesis predicts that most of the survey respondents, who are HPB Surgeons, would choose to remove a gallbladder polyp that is larger than 6mm.

Materials & Method Method

T

he study, titled " Australasian Surgeons’ Attitudes to the Removal of the Pathological but Asymptomatic Gallbladder," was designed to engage the entire cohort of approximately 150 surgeons who are members of the Australasian Association of Hepatopancreatobiliary Surgery (AANZHPBA) (9).

Sample/Participants

T

he population being sampled comprised of Hepatopancreatobiliary surgeons, all of whom were members of the AANZHPBA. The sampling method involved disseminating a survey to all members of the AANZHPBA, thereby ensuring that all responses met the inclusion criteria. Given the preliminary na-

24 • Issue 150

ata was collected through responses to a seven-question survey in a yesor-no format. The survey was developed by the research team and distributed via Google Forms. The survey data will be provided in the appendix of this paper.

Ethics Approval

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his study has received approval from the AANZHPBA Ethics Committee. Data will be securely stored within the Royal Brisbane Women’s Hospital (RBWH) premises in an encrypted database. To maintain anonymity, no data will be transferred to a study team member’s personal computer or taken off-site, in compliance with current private data handling protocols in Queensland, Australia. Additional information, including email communication, is available upon request from the reviewer.

Method/Procedure

T

he survey was distributed to the members of the AANZHPBA via email communication. The data was gathered from respondents who answered the preformulated yes-or-no questions. The data was then transferred from the survey hosting website to a Microsoft Excel spreadsheet for analysis. The percentage of yes or no responses and visually represented in bar graph format.

Both the survey and the Excel spreadsheet were password-protected to ensure data security. The survey was open from 08/08/2022 to 30/09/2022 totalling a duration of 53 days.

A

ll responses were anonymised for privacy, and the collected data was securely stored, and password protected.

This ensured the ethical handling of the data and the privacy of the participants.

Survey Questionnaire Would you (yes or no) recommend the removal of an asymptomatic gallbladder in the following scenarios?

1. Asymptomatic gallbladder stones in a well patient under 40?

2. Asymptomatic gallstones stones if there is gallbladder wall thickening greater than 5mm?

3. Asymptomatic gallstones in a patient with a first degree relative who has had gallbladder cancer?

4. Asymptomatic gallstones in a patient with a family history of any primary HPB malignancy?

5. Any gallbladder polyps (irrespective of size and/or quantity)?

6. Gallbladder polyps greater than 6mm?

7. Gallbladder polyps greater than 10mm?

Results

T

he survey was conducted from 08/08/2022 to 30/09/2022 (53 days) with a total of 73 Australasian Surgeons participating out of the 150 surveys distributed. The purpose of the research was to determine the attitudes of these surgeons towards the removal of the pathological but asymptomatic gallbladder in individuals with polyps or stones.

The results are represented by Table 1 and Figure 1 with an included written analysis below.

Result/Analysis

W

ould you recommend the removal of an asymptomatic gallbladder in the following scenarios?

Question 1: Asymptomatic gallblad-

FEATURE STORY •

in a patient with a family history of any primary HPB malignancy: Only 25% of the surgeons would opt for removal in this case, while 75% would not.

Question 5: Any gallbladder polyps (irrespective of size and/or quantity): None (0%) of the surgeons would opt for removal, indicating a consensus that size and/or quantity of polyps is a significant factor in the decision.

Question 6: Gallbladder polyps greater than 6-9mm: 29% of the surgeons would opt for removal, while 71% would not. This result partially supports the study team’s secondary hypothesis that most surgeons would choose to remove a gallbladder polyp that is larger than 6mm.

Question 7: Gallbladder polyps greater than 10mm: All surgeons (100.0%) would opt for removal, indicating a consensus that polyps of this size warrant removal.was to determine the attitudes of these surgeons towards the removal of the pathological but asymptomatic gallbladder in individuals with polyps or stones.

The results are represented by Table 1 and Figure 1 with an included written analysis below.

Discussion

G

der stones in a well patient under 40: Only 11% of the surgeons would opt for removal, while a significant majority (89%) would not.

Question 2: Asymptomatic gallstones stones if there is gallbladder wall thickening greater than 5mm: The responses were more divided in this scenario, with 42% opting for removal and 59% against it.

Question 3: Asymptomatic gallstones in a patient with a first degree relative who has had gallbladder cancer: In this case, a majority (59%) would opt for removal while 42% were against it, supporting the research team’s primary hypothesis that there is a significant disparity in the removal of a gallbladder in patients with a family history of gallbladder cancer.

Question 4: Asymptomatic gallstones

allbladder cancer, although uncommon, is the most prevalent form of cancer in the biliary tract, accounting for 80%–95% of these types of cancers(10).

The progression of this cancer often goes unnoticed, leading to a high fatality rate due to late-stage diagnosis(10). The prevalence of gallbladder cancer varies greatly based on geographic location and ethnicity, with a disproportionately high incidence among American Indians and in Southeast Asia(10).

T

he onset of gallbladder cancer results from a combination of inherent genetic susceptibility and exposure to environmental risk factors. One common genetic risk factor is the co-occurrence of gallstone disease and gallbladder cancer.

Having a family history of gallbladder

medicallink.com.au • 25

• THE MEDICAL LINK

disease also increases the risk of developing gallbladder cancer(11).

T

his study titled “Australasian Surgeons’ Attitudes to the Removal of the Pathological but Asymptomatic Gallbladder”, aimed to elucidate the perspectives of Australasian surgeons on the management of asymptomatic gallbladders in individuals with polyps or stones. The survey findings (see Table 1) revealed a majority consensus (58.9%) among surgeons favouring the removal of an asymptomatic gallbladder in patients with a first-degree relative diagnosed with gallbladder cancer. Though a majority, the consensus was not unanimous, substantiating the primary hypothesis that a significant disparity exists in the surgical management of gallbladders in patients with a familial history of gallbladder cancer.

I

nterestingly, surgeons universally agree on the non-removal of gallbladder polyps, irrespective of their size or number.

This consensus, which underscores the significance of polyp size and quantity in surgical decisions, is not a novel concept.

It’s a viewpoint shared by most HPB surgeons globally. However, when it comes to questions 2-6 (see Figure 1), there’s a notable divergence in surgical opinions, especially regarding the removal of a gallbladder based on risk factors such as family history, polyp size, or stone size. This discrepancy highlights the urgent need for Australasian guidelines to manage asymptomatic gallbladders, standardise surgical practices, and ultimately improve patient care.

C

omparatively, the European guidelines provided by the study “Management and Follow-up of gallbladder polyps: Updated joint guidelines between ESGAR, EAES, EFISDS and ESGE” (8) offer a set of guidelines for the more common scenarios regarding gallbladder polyp and size. However, these guidelines do not specifically address the complex scenarios proposed in the Australasian study, particularly questions 2-6, most

26 • Issue 150

importantly question 3. This highlights the need for a set of Australasian guidelines.

G

allbladder cancer, while typically considered uncommon in the broader medical space, is the predominant form of cancer in the biliary tract. Its onset is a result of a combination of inherent genetic susceptibility and exposure to environmental risk factors. Traditional imaging techniques like ultrasonography, CT, and MRI can identify abnormalities in the gallbladder but often struggle to differentiate cancer from other conditions such as cholecystitis(11,12). In recent times, numerous nuclear scanning studies have been published to distinguish between benign and malignant polyps(11,12).

The effectiveness of dual-time-point (18) F-FDG PET in distinguishing malignant from benign gallbladder disease has been assessed. Delayed (18)F-FDG PET is more beneficial than early (18)F-FDG PET in evaluating malignant lesions due to increased lesion uptake and enhanced lesion-to-background contrast. However, this diagnostic method is not widely used, and the current recommended protocol includes guidelines, monitoring, and surgical intervention(11,12). While it is essential to develop guidelines for treating gallbladder polyps, alternative diagnostic methods for gallbladder cancer, such as FDG PET/CT, are showing potential. More research is required to enhance early detection and treatment of gallbladder cancer.

T

hese observations (see Figure 1) underscore the necessity for the development of Australasian guidelines pertaining to the management of pathological but asymptomatic gallbladders.

The establishment of such guidelines could foster the adoption of safe medical practices and mitigate divergent surgical opinions. Further investigations are warranted to explore the potential benefits and risks associated with the removal of pathological but asymptomatic gallbladders in diverse patient populations.

T

his study illuminates this previously unexplored scenario, particularly in the context of patients with an asymptomatic yet pathological gallbladder.

Drawing from the insights of this study, the research team proposes a set of preliminary guidelines, which are visually represented in a flow diagram (see Figure 2). It is noteworthy that Australia has not yet established nationwide guidelines on this subject. The findings from this study, along with those from the aforementioned study(8), could potentially lay the groundwork for the development of official guidelines in Australia.

Summary & Possible Recommendations

T

his study is intended to be a preliminary step in the development of a set of formal guidelines. The research team has devised an algorithm (see Figure 2) based on the data gathered from survey questions. This algorithm is structured as a flowchart of binary (yes or no) responses. A "no" response guides the user to the next question, ultimately leading them to a final answer and the recommended guideline to follow. The team acknowledge that there is always potential for enhancement in this flowchart, including the specific treatment protocol determined by the final answer. Nonetheless, this is merely an illustration of the potential benefits this algorithmic guideline could provide to HPB surgeons in Australia and New Zealand.

Future Improvements

T

he survey data underscores several key issues that need to be addressed concerning the attitudes towards the removal of an asymptomatic but pathological gallbladder. However, there is still significant room for improvement.

I

n the future, a more granular approach to data variables could provide a more in-depth analysis of surgeons’ attitudes towards this procedure. Factors such as

FEATURE STORY •

the respondents’ gender, age, years of specialisation, and location (rural or urban) could be considered.

Limitations

T

he limitations of this research include a relatively small sample size, which may restrict the scope of data extrapolation. Therefore, any conclusions drawn from this study will require additional research for validation. Additionally, extending the research duration would enhance the overall validity of the results.

Conclusion

T

his investigation marks a significant stride towards understanding the

perspectives of Australasian surgeons on managing asymptomatic gallbladders, a complex issue that has not been specifically addressed in the context of individuals with a first-degree relative with gallbladder cancer or stones/polyps smaller than 6mm(8). The study underscores the need for Australasian guidelines that could standardise surgical practices and improve patient care. While the findings are significant, they are limited by a small sample size and require further research for validation. Serving as a cornerstone for future research and guideline development, this study fills this gap and provides a foundation for future research and guideline development in this area.

References 1.

Mukkamalla S, Kashyap S, Recio-Boiles

2.

3.

4.

5.

6.

A. Gallbladder Cancer Treasure Island: StatPearls Publishing; 2023.

Rakic M, Patrlj L, Kopljar M. Gallbladder cancer. Hepatobiliary Surgery and Nutrition. 2014 October; 3(5): 6-221.

Rawla P, Sunkara T, Thandra K. Epidemiology of gallbladder cancer. Clinical and Experimental Hepatology. 2019 May; 5(2): 93-102.

Andrén-Sandberg A. Diagnosis and Management of Gallbladder Polyps. North American Journal of Medical Sciences.

2012 May; 4(5): 203-211.

Park J, Hong S, Kim Y, Kim H, Kim H, Cho J. Long-term follow up of gallbladder polyps. Journal of Gastroenterology and Hepatology. 2002 January; 24(2): 219222.

Randi G, Franceschi S, La Vecchia C. Gallbladder cancer worldwide. International Journal Cancer. 2006; 118: 1591-1602.

A full list of references can be found in the digital version of this magazine at www.themedicallink. com.au.

medicallink.com.au • 27

• THE MEDICAL LINK

ADVERTORIAL

Business Succession Planning Now Can Avoid Disaster Later Michael Mobberley Senior Associate | Avant Law 1800 867 113 | www.avant.org.au

S

tarting or joining a medical practice as a principal is an exciting time for many doctors. It’s a time for new opportunity, career development and running your practice as you see best.

But for every new venture started, there are also those that come to an end.

And while everyone hopes that the end of a business is due to a well-earned retirement or planned sale, the reality is that for some, a sudden departure of a business partner may quickly throw a business into chaos.

As the scenario* below illustrates, things can quickly go from bad to worse if a proper succession plan is not in place.

The accident

D

octors Rocha, Mullins, Sanchez and Khan run a medical practice together. They are equal partners and have worked together for many years in business premises they co-own.

None of the doctors have plans to retire in the foreseeable future.

On a typical Wednesday morning, the practice receives a phone call. Dr Mullins has been involved in an accident and has passed away.

28 • Issue 150

The surviving doctors hold an emergency meeting to try and ensure Dr Mullins’ patients continue to be looked after.

A few weeks later, the doctors sit down to discuss what to do.

The issues

D

r Mullins’ family has called and asked when they should expect their share of the business to be paid out to them. Unfortunately, there is no documented valuation method or agreement as to how the business should be valued.

When discussions turn to revenue sharing, things get even more heated.

Dr Rocha says that everything should remain even, but Dr Sanchez argues she should be compensated for taking on the lion’s share of Dr Mullins’ patients.

After much back and forth, the remaining doctors finally agree on a valuation method and organise their accountant to prepare the valuation report.

While waiting on the report, significant tension remains between the doctors as they try to resolve the revenue issue and the conflict begins to impact the practice.

A new problem

W

hen the accountant returns with the business valuation, a new problem arises. The practice has been quite successful and along with an increase in property prices, Dr Mullins’ share has increased considerably.

The remaining doctors consider buying out Dr Mullins’ share. None of them have sufficient cash on hand to buy out the share. Dr Rocha’s recent divorce means his borrowing power has reduced considerably. Dr Sanchez has recently purchased a new investment property and the bank has turned her down for further finance. Dr Khan has some borrowing capacity but not enough to cover a full quarter share of the business.

They are yet to find another doctor who might be interested in joining their business structure in place of Dr Mullins.

Meanwhile, Dr Mullins’ family calls for an update on when they will receive their payment and threatens to force sale of the practice if they don’t receive something soon.

As disputes over revenue splitting continues, Dr Sanchez decides she no

longer wishes to remain in the practice.

With no alternatives available, the doctors start searching for a prospective buyer of the practice.

The alternative solution

T

he dilemmas faced by the doctors could have easily been avoided if a proper succession plan had been in place.

Rather than simply hoping for the best, a succession plan spells out in detail what should occur if you, or one of your business partners, should suddenly pass away or lose capacity. It can also help fund the buyout of an exiting partner so that you can continue practising, rather than worrying about how you will afford an unexpected purchase.

Features of a succession plan include an agreed business valuation formula and mechanisms for how an exiting doctor’s share of the business can be sold to a third party or purchased by the remaining doctors.

If the practice had also organised buy/ sell insurance, the family of the affected doctor could be paid out via insurance.

This allows the other doctors to continue

working without having to overextend themselves to finance the payout themselves.

Contact the experts

I

f your business has not considered its succession future, or you haven’t reviewed your structure in some time, now is the time to get organised.

If you have any questions, or would like more information about how we can assist your practice, please call 1800 867 113, or fill out the form at www.avantlaw. com.au/contact-us to organise a confidential discussion at a time that suits you.

Protect your practice

K

ey person insurance+ can provide your practice financial protection in several different ways, including mitigating revenue loss from the death, sickness, or invalidity of the key person, covering replacement costs, servicing debts, addressing goodwill write-downs, providing liquidity, and maintaining supplier relationships.

If you are thinking about taking out

key person insurance, book an appointment with Avant Life Insurance for advice tailored to your personal circumstances.

About the Author

M

ichael Mobberley is a Senior Associate in the estate planning and commercial law practices at Avant Law, based in Sydney. Michael is an accredited specialist in Wills & Estates and holds a Masters degree in Corporate, Commercial and Taxation Law. Michael provides advice to both individuals and businesses on a range of matters, as well as acting for clients in contested estate and family provision claims.

Disclaimer: The information in this article does not constitute legal advice or other professional advice and should not be relied upon as such. It is intended only to provide a summary and general overview on matters of interest and it is not intended to be comprehensive. You should seek legal or other professional advice before acting or relying on any of this content. The information in this article is current to 23 January 2024. Liability limited by a scheme approved under Professional Standards Legislation.

Legal practitioners employed by Avant Law Pty Limited are members of the scheme. © Avant Mutual Group Limited 2024

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