more_vertAbout 50 years ago, the enigma of Hodgkin’s lymphoma was depicted as the Hodgkin maze in two editorials in The Lancet.1,2 The uncertainties of the time were expressed through two questions: “Infection or neoplasm?” and “One entity or two (or more)?”.2 Subsequently, advances in cell biology and molecular pathology provided answers to these questions. Substantial evidence now indicates that classical Hodgkin’s lymphoma is a distinct neoplastic entity, with heterogeneous pathological features, which might be associated with Epstein-Barr virus infection.
Preference: Plastic Surgery
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Code Green
BY DR TESSA KENNEDY, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING
When we talk about sustainability in health we are usually talking about spending and workforce. But what of the physical environment?
Existing AMA policy acknowledges that: “Human health is ultimately dependent on the health of the planet and its ecosystem. Climate policies can have public health benefits beyond their intended impact on the climate. These health benefits should be promoted as a public health opportunity, with significant potential to offset some costs associated with addressing climate change.”
Yet the health sector itself contributes around seven per cent of all greenhouse gas emissions. Our own resource rich settings create an enormous amount of plastic and other waste which take a direct toll on patient health and our environment. The way we run our hospitals is also increasingly unsustainable from an environmental perspective.
Health facilities and workers should promote a holistic approach to health, including its social and environmental determinants. We are increasingly acknowledging this: hospitals are non-smoking areas, because tobacco is a significant risk to health. There have been efforts to improve food options and exclude sugar sweetened beverages from hospital canteens because obesity is a significant risk to health.
Yet every time I place a cannula, suture a chest drain, resuscitate a baby, I generate a large amount of disposable, non biodegradeable waste, including plastics and instruments that have barely touched a patient. When I wash my hands tens of times a day, paper towels are co-mingled with nonrecyclable rubbish. Many of us will drive to work because of lack of public transport options to suburban hospitals, especially when working shifts, and a lack of showering and changing facilities required to encourage active self-transport options like cycling or jogging.
Disposable coffee cups, choice of volatile anaesthetic gases, computers and lights left on overnight – there are many environment degrading and wasteful practices that would take little effort to change.
Nonetheless, I’m sure like me, many of you have felt like the threat of climate change is more of an existential one than of direct relevance to your every day. Even with good intentions it just feels too big, too far beyond our reach to change. Like any efforts we make are just a drop in a warming ocean.
But what if we could see the impact of our actions in the community we treat? To measure the impact of our efforts to change in terms of patient outcomes and cost savings that could be reinvested in our insatiable health budget? It would be a lot easier to stay motivated.
Luckily, we not only have a fantastic opportunity of many low hanging fruit to improve sustainability due to the current lack of priority it is afforded, but a proven model of how to go about achieving change from the UK NHS Sustainable Development Unit. This dedicated unit has coordinated research, policy and action to improve the sustainability of health care. They succeeded in cutting NHS greenhouse gas emissions by 11 per cent between 2007 and 2017, despite an 18 per cent increase in health service activity.
If we are sincere in acknowledging climate change and environmental degradation as one of the most significant threats to human health in our time, we must acknowledge our part in addressing it in how we work. As Associate Professor Forbes McGain of the University of Sydney and Doctors for the Environment Australia has said: “The [Australian] health-care system can’t become low carbon and low waste without leadership, incentives and direction.”
Being aware of the environmental impact of our work practices and changing our individual actions are a great way to bring the issue front of mind and help start a conversation with others. But to achieve sizeable change we need to issue a triage category upgrade for environmental sustainability, and we need the whole system to respond.
So, bring your Keep Cup. But also ask the coffee shop whether they would give discounts to everyone who brings one. Choose the instruments that go back to the sterilizer, not into the sharps bin. But also question whether the marginal cost saving of procuring single use plastic items offsets the clinical waste disposal and other environmental costs. Factor environmental impact into your choices and practices at work every day, and write to your chief executive to ask them to do the same. Improve patient outcomes locally, globally, and save money doing so – it’s a no-brainer.
The science is clear – we’ve been issued a Code Green. And if we are serious about safeguarding human health, we must respond.
GPs to retain access to MBS item 30202
Following representations from the AMA, it has now been confirmed by the Department of Health that GPs will not be precluded from accessing MBS item 30202.
In response to questions from the AMA, the DoH has stated that the MBS Taskforce response to the recommendations of the Dermatology, Allergy and Immunology Clinical Committee had been misreported in the Taskforce’s finding on the website. The reported change to MBS item 30202 would have seen GPs, the predominant users, excluded from claiming the cryotherapy item for removing malignant neoplasms.
The Clinical Committee recommended that the descriptor for MBS item 30202 be amended to replace “specialist” with “Australian Medical Council (AMC) recognised dermatologist”. It was also recommended that the Department of Health should monitor high-volume users to ensure that providers were requesting the appropriate pathology tests to confirm malignancy. At no point was it recommended that GPs be excluded from claiming the item.
However, the material that was released was inconsistent with this and suggested that the MBS Taskforce had recommended to Government that the descriptor be amended to restrict the use of this item to AMC recognised dermatologists and plastic surgeons to support appropriate use of the item and improve patient safety.
The DoH has now acknowledged the concerns raised by the AMA about the potential impact of the change and has confirmed an error was made during the publication of the taskforce’s findings. This will be corrected and amendments to the item descriptors will ensure GPs retain access to this item.
Many GPs, particularly those in rural areas, will be relieved that appropriate patient treatment will not have to be delayed for an unnecessary specialist referral.
MICHELLE GRYBAITIS
[Perspectives] Medical 3D printing and the physician-artist
It was psychologically impossible to prepare for the first patient I met who had catastrophic facial deformity. Medical training helped me respond to his sensory defects: sight, sound, smell, and taste. However, when one person meets another, we connect via, and then later recognise, one another’s face. When I met that first patient—one of many wounded soldiers with severe facial injuries—I was challenged to help artfully repair the damage. Had the injury occurred in the mid-20th century, surgery would have been greatly limited by the paucity of options in plastic surgery.
Additional research funding for rare cancers
The Federal Government has announced a $69 million boost to help medical researchers in their fight against rare cancers and rare diseases.
The funding is aimed at assisting patients who often have few options and poor life expectancy.
Health Minister Greg Hunt said the Government was committed to investing in research to find the answers to these challenges.
“This is a significant boost on the $13 million that was originally flagged when we called for applications and reflects the incredibly high calibre of medical research that is happening right here in Australia,” Mr Hunt said.
The new funding includes more than $26 million for 19 research projects as part of the landmark Medical Research Future Fund’s Rare Cancers, Rare Diseases and Unmet Needs Clinical Trials Program.
These projects will undertake clinical trials for devastating conditions like acute lymphoblastic leukaemia in infants, aplastic anaemia, multiple sclerosis and Huntington’s disease.
Researchers at the University of New South Wales will test a vaccine to target glioblastoma, a lethal brain cancer and the most frequent cause of cancer deaths in children and young people.
Another clinical trial at the University of Queensland will evaluate the benefits of medicinal cannabis for people with advanced cancer, and define the role of the drug for patients with cancer in palliative care.
Monash University is researching a new preventive treatment for graft versus host disease following a bone marrow transplant which could halve instances of the life-threatening complication, while a trial by the University of Western Australia to simultaneously compare a range of cystic fibrosis treatments may lead to improved care for this complex disease.
Other trials will explore the effectiveness and safety of aspirin compared to heparin to treat blood clots and test a new triple therapy regimen to target rare viral-driven brain lymphomas.
Prior to this announcement, rare and less common cancers received 12 per cent of the cancer research dollar, despite accounting for over 50 per cent of cancer deaths.
Details of the rare cancer projects that have received funding can be found here: www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-hunt008.htm
MEREDITH HORNE
AMA shines in Australia Day Honours
Former Australian Medical Association President Dr Mukesh Haikerwal has been awarded the highest honour in this year’s Australia Day awards by being named a Companion of the Order of Australia (AC).
He is accompanied by the current Editor-in-Chief of the Medical Journal of Australia, Laureate Professor Nick Talley, as well as longstanding member Professor Jeffrey Rosenfeld – who both also received the AC.
The trio top a long and impressive list of AMA members to receive Australia Day Honours this year.
AMA Federal Councillor, Associate Professor Julian Rait, received the Medal of the Order (OAM).
A host of other members honoured in the awards are listed below.
AMA President Dr Michael Gannon said the accolades were all well-deserved and made he made special mention of those receiving the highest Australia Day Honours.
“They have dedicated their lives and careers to helping others through their various roles as clinicians, researchers, teachers, authors, administrators, or government advisers – and importantly as leaders in their local communities,” Dr Gannon said.
“On behalf of the AMA, I pay tribute to all the doctors and other health professionals who were honoured today for their passion for their profession and their dedication to their patients and their communities.
“The great thing about the Honours is that they acknowledge achievement at the international, national, and local level, and they recognise excellence across all avenues of human endeavour.
“Doctors from many diverse backgrounds have been recognised and honoured again this year.
“There are pioneering surgeons and researchers, legends across many specialties, public health advocates, researchers, administrators, teachers, and GPs and family doctors who have devoted their lives to serving their local communities.
“The AMA congratulates all the doctors and other health advocates whose work has been acknowledged.
“We are, of course, especially proud of AMA members who are among the 75 people honoured in the medicine category.”
Dr Haikerwal, who was awarded the Officer in the Order of Australia (AO) in 2011, said this further honour was “truly mind-blowing” and another life-changing moment.
“To be honoured on Australia Day at the highest level in the Order of Australia is beyond imagination, beyond my wildest dreams and extremely humbling,” Dr Haikerwal said.
“For me to be in a position in my life and career to receive such an honour has only been made possible due to the unflinching support and unremitting encouragement of my closest circle, the people who have been with me through every step of endeavour, adversity, achievement, and success.”
CHRIS JOHNSON
AMA MEMBERS IN RECEIPT OF HONOURS
COMPANION (AC) IN THE GENERAL DIVISION
Dr Mukesh Chandra HAIKERWAL AO
Altona North Vic 3025
For eminent service to medical governance, administration, and technology, and to medicine, through leadership roles with a range of organisations, to education and the not-for-profit sector, and to the community of western Melbourne.
Professor Jeffrey Victor ROSENFELD AM
Caulfield North, Vic
For eminent service to medicine, particularly to the discipline of neurosurgery, as an academic and clinician, to medical research and professional organisations, and to the health and welfare of current and former defence force members.
Professor Nicholas Joseph TALLEY
Black Hill, NSW
For eminent service to medical research, and to education in the field of gastroenterology and epidemiology, as an academic, author and administrator at the national and international level, and to health and scientific associations.
OFFICER (AO) IN THE GENERAL DIVISION
Emeritus Professor David John AMES
East Kew, Vic
For distinguished service to psychiatry, particularly in the area of dementia and the mental health of older persons, as an academic, author and practitioner, and as an adviser to professional bodies.
Dr Peggy BROWN
Sanctuary Cove, Qld
For distinguished service to medical administration in the area of mental health through leadership roles at the state and national level, to the discipline of psychiatry, to education, and to health care standards.
Professor Creswell John EASTMAN AM
St Leonards, NSW
For distinguished service to medicine, particularly to the discipline of pathology, through leadership roles, to medical education, and as a contributor to international public health projects.
Professor Suzanne Marie GARLAND
Docklands, Vic
For distinguished service to medicine in the field of clinical microbiology, particularly to infectious diseases in reproductive and neonatal health as a physician, administrator, researcher and author, and to professional medical organisations.
Dr Paul John HEMMING
Queenscliff, Vic
For distinguished service to higher education administration, to medicine through contributions to a range of professional medical associations, and to the community of central Victoria, particularly as a general practitioner.
Professor Anthony David HOLMES
Melbourne, Vic
For distinguished service to medicine, particularly to reconstructive and craniofacial surgery, as a leader, clinician and educator, and to professional medical associations.
Dr Diana Elaine O’HALLORAN
Glenorie, NSW
For distinguished service to medicine in the field of general practice through policy development, health system reform and the establishment of new models of service and care.
MEMBER (AM) IN THE GENERAL DIVISION
Dr Michael Charles BELLEMORE
Croydon, NSW
For significant service to medicine in the field of paediatric orthopaedics as a surgeon, to medical education, and to professional medical societies.
Dr Colin Ross CHILVERS
Launceston, Tas
For significant service to medicine in the field of anaesthesia as a clinician, to medical education in Tasmania, and to professional societies.
Associate Professor Peter HAERTSCH OAM
Breakfast Point, NSW
For significant service to medicine in the field of plastic and reconstructive surgery as a clinician and administrator, and to medical education.
Professor Ian Godfrey HAMMOND
Subiaco, WA
For significant service to medicine in the field of gynaecological oncology as a clinician, to cancer support and palliative care, and to professional groups.
Dr Philip Haywood HOUSE
WA
For significant service to medicine as an ophthalmologist, to eye surgery foundations, and to the international community of Timor Leste.
Adjunct Professor John William KELLY
Vic
For significant service to medicine through the management and treatment of melanoma, as a clinician and administrator, and to education.
Dr Marcus Welby SKINNER
West Hobart, Tas
For significant service to medicine in the field of anaesthesiology and perioperative medicine as a clinician, and to professional societies.
Professor Mark Peter UMSTAD
South Yarra, Vic
For significant service to medicine in the field of obstetrics, particularly complex pregnancies, as a clinician, consultant and academic.
Professor Barbara S WORKMAN
East Hawthorn, Vic
For significant service to geriatric and rehabilitation medicine, as a clinician and academic, and to the provision of aged care services.
MEDAL (OAM) IN THE GENERAL DIVISION
Professor William Robert ADAM PSM
Vic
For service to medical education, particularly to rural health.
Dr Marjorie Winifred CROSS
Bungendore, NSW
For service to medicine, particularly to doctors in rural areas.
Associate Professor Mark Andrew DAVIES
Maroubra, NSW
For service to medicine, particularly to neurosurgery.
Dr David William GREEN
Coombabah, Qld
For service to emergency medicine, and to professional organisations.
Dr Barry Peter HICKEY
Ascot, Qld
For service to thoracic medicine.
Dr Fred Nickolas NASSER
Strathfield, NSW
For service to medicine in the field of cardiology, and to the community.
Dr Ralph Leslie PETERS
New Norfolk, Tas
For service to medicine, and to the community of the Derwent Valley.
Associate Professor Julian Lockhart RAIT
Camberwell, Vic
For service to ophthalmology, and to the development of overseas aid.
Mr James Mohan SAVUNDRA
South Perth, WA
For service to medicine in the fields of plastic and reconstructive surgery.
Dr Chin Huat TAN
Glendalough, WA
For service to the Chinese community of Western Australia.
Dr Karen Susan WAYNE
Toorak, Vic
For service to the community of Victoria through a range of organisations.
Dr Anthony Paul WELDON
Melbourne, Vic
For service to the community, and to paediatric medicine.
PUBLIC SERVICE MEDAL (PSM)
Dr Sharon KELLY
Yeronga, Qld
For outstanding public service to the health sector in Queensland.
Professor Maria CROTTY
Kent Town, SA
For outstanding public service in the rehabilitation sector in South Australia.
Medicare Benefits Schedule Review update
The MBS Review Taskforce continues its work into 2018, with the next round of public consultations expected for release in February.
In the meantime, a number of clinical committees have yet to begin. The Department of Health’s MBS Review team is currently accepting nominations from medical practitioners with the relevant background to participate on the following reviews:
Aboriginal and Torres Strait Islander Health, Neurology, Pain Management, Urology, Allied Health, Colorectal Surgery, Consultation Services, General Surgery, Mental Health Services, Nurse Practitioner & Participating Midwife, Ophthalmology, Optometry, Oral & Maxillofacial Surgery, Paediatric Surgery, Plastic & Reconstructive Surgery, Thoracic Surgery, Vascular Surgery
The MBS Review Taskforce also has an interest in participants (both specialists and consultant physicians) for the review of specialist consultation items.
The success of the MBS reviews is contingent on the reviews being clinician-led and the AMA encourages medical practitioners with the relevant skillset to consider nominating to the clinical committees. Follow the online links to learn more about the individual items under review by each committee.
For more information or to submit a nomination, contact the MBS Review team.
The AMA’s approach has always been to defer recommendations relating to specialty items to the relevant Colleges, Associations and Societies (CAS) and comment on the broader policy. As such, the AMA does not have direct representation on individual clinical committees but supports the commitment made by members who do contribute their expertise to the review.
Through feedback mechanisms involving the CAS, a member-based AMA Working Group and the Medical Practice Committee, the AMA has responded to every single MBS review consultation – raising issues from across our membership, while stressing where systematic improvements need to be made. The AMA Secretariat and the President have done this through direct representations with the Health Minister, the Department of Health and in writing to the Chair of MBS Review Taskforce.
Recent submissions highlighted a number clear deficiencies and significant variations in the MBS review process, signalling a need for absolute transparency from the Taskforce and leadership on the clinical committees through early engagement of the relevant CAS.
This year, the AMA will continue to press Government to ensure the reviews result in sensible reinvestment into the MBS while protecting clinical decision making. It is therefore crucial that each committee has the input of practicing clinicians and consistent, practical advice from the CAS.
The AMA continues to monitor the reviews with interest and update members along the way. The profession and the wider CAS are encouraged to do the same by engaging early with the clinical committees and public consultations. The full schedule of MBS reviews can be found on the Department of Health website: http://www.health.gov.au/internet/main/publishing.nsf/content/MBSR-about
For more information on AMA’s advocacy with the MBS reviews, contact Eliisa Fok
Senior Policy Adviser, Medical Practice efok@ama.com.au
Eliisa Fok
AMA Senior Policy Adviser
Recall: APO-Metformin XR 1000 mg tablets
Recall – risk of injury due to potential contamination with plastic fragment
Results of study show first effective intervention against dementia
Researchers in the United States have released a study showing effective intervention aimed at significantly reducing the risk of dementia.
The findings, first released in the peer-reviewed journal Alzheimer’s & Dementia: Translational Research & Clinical Interventions, were published mid-November following a 10-year study.
It is the first randomised controlled trial to show an intervention effective at lowering the risk of dementia.
According to the article, Speed of Processing Training Results in Lower Risk of Dementia, a computerised brain exercise licenced exclusively by Posit Science, markedly reduced the risk of dementia among older adults over the decade of the study.
Posit Science makes of the online and app brain training platform known as BrainHQ.
The article reports on the latest results from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Study, funded by the National Institutes of Health. That study followed 2,802 healthy older adults for 10 years, as they aged from an average of 74 to 84.
The ACTIVE Study looked at the impact on aging of different types of cognitive training by randomising participants into a control group and three intervention arms:
1) a memory group receiving classroom instruction on memory strategies;
2) a reasoning group receiving classroom instruction on reasoning strategies; and
3) a speed of processing group receiving individualised computerised brain training in a classroom setting.
Participants in the cognitive training groups were asked to engage in a total of 10 sessions of training of about an hour each and conducted over the first five weeks of the study.
All participants were assessed on a number of cognitive and functional measures at the beginning of the study, after the first six weeks, and at the end of years 1, 2, 3, 5 and 10.
Subsets of each intervention group also received four additional booster training sessions in the weeks before the assessments at the end of years 1 and 3.
At the end of 10 years, researchers found no significant difference in incidence of dementia for the strategy-based memory or reasoning training groups, as compared to the control group. However, the speed of processing group engaged in computerized brain training showed a significant reduction in incidence of dementia – with a 29 percent reduction in the hazard of dementia.
“Relatively small amounts of training resulted in a decrease in risk of dementia over the 10-year period of 29 percent, as compared to the control,” said Dr Jerri Edwards, lead author of the article and a Professor at the University of South Florida, College of Medicine.
“And, when we looked at dose-response, we saw that those who trained more got more protective benefit.”
To place the size and importance of this protective effect in context, the researchers quantitatively compared the risk reduction for dementia from the computerised brain training to the risk reduction for major cardiovascular events, (such as heart failure, heart disease and stroke) yielded by blood pressure medications, and found that this non-pharmacological intervention had a two to four times greater protective effect against its targeted disease condition.
“No health professional would suggest that any person with hypertension forego the protection offered by prescribed blood pressure medication,” said Dr Henry Mahncke, CEO of Posit Science.
“We expect these results will cause the medical community to take a much closer look at the many protective benefits of these exercises in both older and clinical populations.”
The newly published results confirm and extend preliminary results first announced last year. Those results used a broader definition of dementia to reflect the under-reporting of dementia in the community. The preliminary results, indicating a 33 percent reduction in risk, relative to the control are contained in this report. However, to be more conservative, the authors now also include and highlight a narrower definition of dementia – restricted to reports of a dementia diagnosis or falling below a cut-point on a standard test. Even with the narrower definition, the effects are substantially similar, with a 29 percent reduction in dementia risk at any given point in time for the overall speed group as compared to the control.
Participants in the computerised brain training group were trained on a highly specific task designed to improve the speed and accuracy of visual attention, including both divided and selective attention. To perform the divided attention training task, a user identified an object (i.e., car or truck) at the center of gaze while at the same time locating a target in the periphery (i.e., car). As the user gets the answers correct, the speed of presentation becomes faster. In the more difficult training tasks, the target in the periphery is obscured by distracting objects.
“This study highlights that not all cognitive training is the same,” Dr Edwards said. “Plasticity-based, computerised, speed of processing training has differentiated itself based both on the data and on the neurophysiological model from which it was developed.”
CHRIS JOHNSON
Close the clean drinking water gap
BY AMA PRESIDENT DR MICHAEL GANNON
Safe drinking water is an indispensable human right. The leading national and international health bodies, such as the World Health Organization and the United Nations, all agree that safe drinking water is essential to sustain life, and a prequisite for the realisation of other human rights. The UN General Assembly explicitly recognises the human right to clean drinking water.
Having access to sufficient, safe, accessible and affordable drinking water is an important public health issue.
In developed nations such as Australia, it is often assumed that safe drinking water is accessible to all. However, this is not the case, particularly in many remote or very remote communities where artesian (bore) water is often the primary source of drinking and household water.
According to the Bureau of Statistics (2007), for discrete Indigenous communities the majority accessed bore water (58 per cent), while other sources of water included: town supply (19 per cent), river or reservoir (5 per cent), rain water tank (3 per cent), well or spring water (3 per cent), and other sources of water (2 per cent).
While the supply of potable water (defined as waterthat is safe to drink or to use for food preparation, without risk of health problems) impacts on all people living in remote areas of Australia, Aboriginal and Torres Strait Islander people are disproportionately affected.
Many Aboriginal and Torres Strait Islander people living remotely find it challenging to obtain water that is of sufficient quantity (and quality) to meet their needs.
In 2012, the Australian Bureau of Statistics estimated that there were more than 400 discrete Aboriginal communities across Australia, with the largest number in Western Australia. Data collected on over 270 remote WA communities indicated that the quality of drinking water did not meet the Australian standards, as outlined in the Australian Drinking Water Guidelines (ADWG), approximately 30 per cent of the time.
While the National Health and Medical Research Council (NHMRC) has responsibility for the ADWG, this is not a mandatory standard, with State and Territory Governments and local councils responsible for the implementation and monitoring of water quality and safety. Yet during the two year period 2012-2014, 80 per cent of remote Aboriginal communities in Western Australia failed to meet quality standard testing at least once.
There are obvious health consequences from drinking poor quality water. Some Aboriginal communities are known to have unsafe levels of chemical contaminants such as nitrates and uranium in the water. Nitrates and uranium occur naturally, and are common in the Goldfields and Pilbara regions.
‘Blue Baby Syndrome’ – where an infant’s skin shows a bluish colour and they can have trouble breathing – can be caused by excessive nitrates in the diet, which reduce the blood’s ability to carry oxygen. It can occur where prepared baby formula is made with well water. Water tested in over 270 remote communities in WA showed nitrate levels 10 times the recommended levels.
It is concerning that Aboriginal and Torres Strait Islander people living remotely often have no choice but to pay for safe drinking water. While the majority of us enjoy free, safe drinking water from the tap, those who can least afford it often have to pay just to ensure they are not drinking water sourced from rivers, streams, rivers, cisterns, poorly constructed wells, or water from an unsafe catchment.
The AMA is a member of the Close the Gap steering committee and the Public Health team has raised potable water as a Close the Gap target.
The solution may not just be in more bottled water. In communities without adequate recycling and waste disposal services, thousands of extra plastic water bottles create additional environmental problems.
Governments must invest in infrastructure, such as proper treatment facilities, water storage facilities and distribution systems to meet the changing demands of communities.
All Australians must have permanent and free access to safe water. It is a basic human right and it is difficult to understand how this hasn’t already been implemented and addressed.