Molecular pathology combines molecular analysis with traditional morphology and immunohistochemistry to understand disease at its most fundamental level. The field continues to evolve as new discoveries enter clinical practice.
Through molecular pathology, our knowledge of genetic mutations and targeted therapies has expanded. It is now rare for a tumour report to omit genetic findings. This discipline, while distant from daily clinical work, underpins treatment algorithms and prognostic models.
The ten hallmarks of cancer include: genome instability and mutation, resistance to cell death, sustained proliferative signalling, evasion of growth suppressors, replicative immortality, angiogenesis, invasion and metastasis, altered metabolism, tumour-promoting inflammation, and immune evasion.
Normal DNA contains proto-oncogenes that promote growth and tumour suppressor genes that restrain it. When balanced, they regulate healthy proliferation. Mutations in either disturb this balance, driving uncontrolled growth.
Germline mutations are inherited and present in every cell, while somatic mutations are acquired, often influenced by smoking, ultraviolet exposure, or diet. When proto-oncogenes mutate, they become oncogenes.
The RAS and BRAF oncogenes are key in molecular pathology. RAS controls upstream signalling that triggers cell growth, differentiation, and survival. Mutated RAS genes cause constant activation, leading to excessive signalling. The three RAS genes, HRAS, KRAS, and NRAS, are found in 20 to 25 percent of all human tumours and in 90 percent of pancreatic cancers. The BRAF gene, on chromosome 7, regulates downstream signalling and cell growth. BRAF mutations occur in about 10 percent of colorectal cancers, up to 50 percent of papillary thyroid cancers, and 27 to 67 percent of melanomas.
Other oncogenes include MYC, EGFR, and HER2. HER2 amplification is seen in some breast and ovarian cancers. These findings are vital as targeted treatments, such as JAK inhibitors and monoclonal antibodies, act on these pathways. A single mutation can activate an oncogene.
Tumour suppressor genes perform repair functions including correcting DNA mismatches, regulating the cell cycle, and promoting apoptosis. As telomeres shorten with age, mismatch repair errors increase. Mutated genes lose this ability, causing abnormal protein synthesis. Reports often describe mismatch repair proficient (no mutation) or mismatch repair deficient (mutation present), particularly in colon cancer.
Key tumour suppressor genes include BRCA1, BRCA2, and the Lynch syndrome genes MLH1, MSH2, MSH6, and PMS2. When mutated, they increase the risk of breast, ovarian, prostate, colon, uterine, and pancreatic cancers. While often inherited, mutations can also arise spontaneously or through epigenetic silencing. Each gene has two copies; both must be affected before suppression is lost. This two-hit hypothesis, proposed by Knudson in 1971, explains tumour development with ageing.
Methylation, sometimes noted in reports, refers to chemical modification of CpG (cytosine-phosphate-guanine) sites within a gene, often influenced by epigenetic factors. Abnormal methylation disrupts DNA repair, leading to failed tumour suppression.
This is a brief overview of a complex and evolving field.
Joining me is Dr Pranav Dorwal, Molecular and Anatomical Pathologist at Monash Health, also working in Diagnostic Genomics. Dr Dorwal is an examiner for molecular pathology, researcher, and author of over 60 publications. He has held positions at MD Anderson Cancer Center (Houston, USA) and Memorial Sloan Kettering Cancer Center (New York, USA), completed a fellowship at ANU Canberra, and received the Chancellor’s Gold Medal for Clinical Pathology.
Please welcome Dr Pranav Dorwal to the podcast.
References:
Dr Pranav Dorwal – www.monashhealth.org | www.genomicdiagnostics.com.au
Oncology at a Glance, Graham Dark, Wiley-Blackwell
www.pmc.ncbi.nlm.nih.gov
Each year in Australia, there are about 1,800 new diagnoses of ovarian cancer and over 1,000 deaths, making ovarian cancer the fifth most common cause of death from cancer in women. The lifetime risk is about 1.6%, increasing to 5% if a first-degree relative is affected, and 45% and 25% respectively if the BRCA1 or BRCA2 mutation is present.
The median age of diagnosis is 63 years, with two-thirds of patients diagnosed at 55 years or older.
Histologically, tumour cells may arise from the outer epithelial lining cells of the ovary (60%), the germ cells (30%), or sex cord stromal cells (8%). Epithelial tumours of the high-grade serous type are now thought to spread to the ovarian surface after arising from secretory cells at the fimbria of the fallopian tubes, acquiring a TP53 mutation there before metastasising to the ovary as clinically evident ovarian cancer.
Serous carcinomas represent the vast majority of primary malignant ovarian tumours (75%–80%) and are composed of columnar cells with cilia. These tumours are subdivided into high-grade and low-grade serous carcinomas, which has particular relevance for BRCA-associated ovarian tumours.
As with many internal diseases, clinical presentation may be late, with vague pelvic discomfort giving way to pain and bloating, followed by more systemic symptoms as the disease advances.
The tumour marker CA 125 may only be elevated 50% of the time in early disease, rising to 80% in advanced cancer; however, false positives may occur with benign ovarian disease, leiomyomas, and endometriosis. As with tumour markers used in the follow-up of other cancers, its utility in screening and early diagnosis is limited.
The disease is advanced in 75% of cases at the time of diagnosis. Five-year survival is about 41% when local spread is detected, reducing to 30% or less with distant metastases, compared to 89% survival or above with early detection when the disease is localised.
Given the importance of this condition, I was curious to consult Professor Thomas Jobling once more on current practices of surveillance, approaches to detection and management, and how to manage risk in first-degree relatives. How should we approach an ovarian cyst found incidentally during abdominal imaging? What symptoms should we, as clinicians, be mindful of in triggering our suspicion to investigate further?
I know you will find this conversation with Professor Thomas Jobling interesting. Tom is a gynaecological oncologist, ex-AFL footballer, and medical researcher with a highly respected reputation in Melbourne and internationally. He has extensive experience with minimally invasive surgery, including robotic surgery, for gynaecologic cancer. His main research area is ovarian cancer, for which he received an Order of Australia Medal in 2017, and he is currently Head of Gynaecological Health and VMO at Peter MacCallum Hospital.
Please welcome Professor Jobling to the podcast.
References:
Professor Tom Jobling: reception_tjobling@bigpond.com.au
Ovarian Cancer: Cancer Australia
Pathobiology of Ovarian Carcinomas, Chinese Journal of Cancer, 2016 Jan; 34
Ovarian Cancer Research Alliance: https://ocrahope.org/
Mobile anesthesia is a unique concept in Australia closely related to office-based surgery (OBS) a term used internationally for any surgical or invasive procedure performed outside hospitals with these procedures taking place in private practices or ambulatory surgery centers and often involves various levels of anesthesia, including general anesthesia, moderate sedation or deep sedation. In Australia mobile anesthesia has become particularly relevant in dental treatments and radiological procedures and allows hospital quality anaesthesia to be provided in non-hospital settings such as dental offices. This approach enables a broader range of procedures to be safely performed outside traditional hospital environments.
The growth of mobile anesthesia has been driven by convenience and efficiency, cost effectiveness, technological advancements and patient demand. An area of particular interest relates to the positive impact mobile anesthesia can offer special needs patients who often face challenges in accessing dental care. In Australia approximately 1 in six people live with disability, some with severe and profound disabilities and mobile anesthesia is helping to break down the barriers to treatment for such patients.
The state of Victoria regulated mobile anesthesia services in 2018 and there are now 29 mobile anesthesia businesses operating in the state. Anesthesia related mortality rates in Victoria are low for mobile delivered anaesthetics at about 3.29 deaths per million people per year matching national averages.
Given this evolving area of practice, I was curious to expand my knowledge concerning mobile anaesthesia by inviting anesthetist and Associate Professor David Canty to the podcast. David is the academic director of ultrasound simulation at the university of Melbourne and Adjunct Associate Professor in the Department of Medicine and Nursing at Monash University. He works as an anesthetist across multiple forms of complex surgeries and is the medical director of a mobile anesthesia company working with dentists in Victoria. His passion for mobile anesthesia is quite palpable, please welcome David to the podcast.
References :
Dr David Canty: www.sleepdentistry.com.au
Mobile Health Services: Department of Health ,Victoria. www.health.vic.gov.au
Mobile Anaesthesia: https://pmc.ncbi.nlm.nih.gov
On a recent vacation to Exmouth on Western Australia’s far North coast, home to the amazing Ningaloo National Park, I had the pleasure of meeting Anaesthetist and outdoor adventurer Dr Neil Banham.
I discovered that when Neil wasn’t kiteboarding, his daytime job was Director of Hyperbaric Medicine at Fiona Stanley Hospital in Perth.
Our conversation exposed my deep ignorance of the potential use of HBOT beyond the management of air and gas embolism and piqued my interest in the various conditions that ay assis
Hyperbaric Oxygen Treatment (HBOT) exposes an individual to near 100% oxygen inside a treatment chamber at pressures higher than sea level. For clinical purposes, the pressure must equal or exceed 1.4 atmospheres absolute (ATA). Most HBOT in Australasia is performed at 2 ATA.
HBOT was first used in the early 20th century and by the US Navy in the 1940s to treat decompression sickness (“the bends”). In the 1960s it was used for carbon monoxide poisoning, and its use has since expanded. There are currently 15 approved indications accepted by the Undersea and Hyperbaric Medical Society. These fall under urgent and non-urgent conditions, and the Medicare Benefits Schedule includes specific item numbers for many of them.
Urgent conditions include: air embolism, central retinal artery occlusion, carbon monoxide poisoning, clostridial myonecrosis (gas gangrene), compromised surgical grafts and flaps, crush injuries and compartment syndromes, acute arterial insufficiency, decompression sickness, intracranial abscess, necrotizing soft tissue infections, exceptional blood loss anaemia, specific acute thermal burns, and idiopathic sudden sensorineural hearing loss.
Non-urgent conditions include delayed radiation injuries (soft tissue or osteoradionecrosis). HBOT for radiation cystitis has proven effective in over 80% of cases in published literature. A typical course is 30 sessions (2.5 hours per day, five days a week for six weeks) – a significant commitment. HBOT is also indicated for radiation proctitis, chronic refractory osteomyelitis, and some problematic wounds such as grade 3–4 diabetic foot ulcers.
There is growing interest in its application in inflammatory bowel disease, including ulcerative colitis and Crohn’s disease. A recent systematic review and meta-analysis of 118 patients treated with HBOT for perianal fistulizing Crohn’s demonstrated clinical response and remission rates of 75% and 55% respectively, warranting further consideration. Several studies also show improvements using HBOT as adjunctive therapy for hospitalised ulcerative colitis flares, and its role here will be watched with interest.
Contraindications include untreated pneumothorax, uncontrolled hypertension, congestive cardiac failure with ejection fraction below 35%, claustrophobia, congenital spherocytosis, uncontrolled diabetes, chronic sinus conditions, and advanced emphysema (“blue bloater”). Other factors include avoiding disulfiram, which blocks superoxide dismutase, and doxorubicin.
As in every field of medicine, delving into specialty subjects highlights deep knowledge and expertise. With curiosity at a high, I was privileged to hold this conversation with Neil about practical issues of HBOT, how it works, and its value across many indications. There is much to learn and reflect on in relation to the clinical problems we face.
Please welcome Neil to the podcast.
References:
Dr Neil Banham: FSH.Hyperbaric@health.wa.gov.au
Role of hyperbaric oxygen therapy in patients with inflammatory bowel disease: Kaur et al. www.co-gastroenterology.com
Hyperbaric oxygen therapy for refractory perianal Crohn’s disease: Tome et al, Gastroenterology & Hepatology, Vol 20, Issue 4, April 2024
Hyperbaric Patient Selection: DuBose et al: StatPearls, July 31, 2023. www.ncbi.nlm.gov/books
Cancer is one of the biggest health challenges worldwide. In 2021, about 15% of all deaths were cancer-related. In Australia, there are approximately 624 cases of cancer per 100,000 people, an incidence which has increased by about 7 % over 20 years, with an estimated 43 % of people being diagnosed by the age of 85 years. On a positive note, improved oncological medicine and care have reduced mortality by about 25 % which is very reassuring. The top ten cancers diagnosed in Australia, starting with the most common, are Prostate Cancer, followed by Breast Cancer, Melanoma, Colorectal Cancer, Lung Cancer, Non-Hodgkin Lymphoma, Kidney Cancer, Pancreatic Cancer, Thyroid Cancer and Uterine Cancer. From this group, deaths are more common with Lung Cancer, followed by Colorectal cancer and then Pancreatic and Breast cancer.
Often, a primary practitioner will make the diagnosis or suspect changes in his/her patient that lead to a diagnosis being established. Whilst most treatment regimens are initiated by Oncologists, radiotherapists or Surgeons, the primary practitioner is very frequently saddled with managing many of the day-to-day issues arising from therapy and the emotional trauma associated with cancer treatment. I was interested to explore oncology in general practice more with my colleague, Oncologist Dr Michael Fernando, who generously joins us today on the podcast. Michael is beginning his journey in medicine and brings a huge amount of compassion, maturity and enthusiasm with him. He also jointly runs a podcast called Oncology for the Inquisitive Mind, which has been very well received, and I strongly recommend it to you.
Please welcome Michael to the conversation.
References.
Dr Michael Fernando. Epping Specialist Group. www.eppingspecialistgroup.com
Oncology for the Inquisitive Mind: podcasts.apple.com
Uterine cancer is the fifth most common cancer in females and the most common cancer of the female genital tract in Australia, with about 3,300 cases annually and 660 deaths. The major prevalence is in women between 50 and 70 years, and the quoted major risk factors include: early onset menarche and late menopause, obesity, nulliparity, unopposed oestrogen treatments, polycystic ovaries with prolonged anovulation, extended use of tamoxifen for breast cancer treatment and Lynch syndrome, which confers a 30 % lifetime incidence. Presenting with abnormal PV bleeding or prolonged post-menopausal bleeding, other presentations may include dyspareunia, pelvic pressure, weight loss, anaemia and in later stages, possibly pelvic pain. Whilst a PAP smear will frequently be negative, pelvic imaging revealing a suspicious endometrium and subsequently hysteroscopy and biopsy guide the diagnosis. Patients with more than 50 % myometrial invasion have a six-to-seven-fold higher prevalence of pelvic lymph node metastases and advanced surgical stage compared with women with less than 50 % invasion. With current management the five-year survival has improved over the past 40 years to 83 %.
In contrast to endometrial cancer, which has seen an increasing incidence since 1982 of about 0.9 % per year, Cervical cancer prevalence has reduced from 14 per 100,000 in 1982 to 7 per 100,000 in 2017, influenced by the introduction of the HPV vaccine Gardesil in 2007. Gardesil 9 is the HPV vaccine used in Australia’s National HPV Vaccination Program, providing 100 % protection against HPV strains 6,11,16,18,31,33,45,52 and 58, which are known to cause genital warts and cervical and other HPV -related cancers. Types 16 and 18 cause most of the HPV -associated cancers. This vaccine is recommended for all children aged 12 to 13 years and is free for all Australians aged 12 to 25 years. The vaccine is estimated to prevent up to 90% of cervical cancers and 96% of anal cancers.
I was fortunate in this podcast to have a conversation with Professor Thomas Jobling regarding the risks and management of endometrial and cervical cancer. Tom is a gynaecological oncologist, ex-AFL footballer and medical researcher with a very respected reputation in Melbourne and internationally. He has extensive experience with minimally invasive surgery, including robotic surgery, for gynaecologic cancer. His main research area is ovarian cancer for which he received an Order of Australia Medal in 2017, and he is currently Head of Gynaecological Health and VMO at Peter MacCallum Hospital.
Please welcome Professor Jobling to the podcast.
References :
Professor Tom Jobling: reception_tjobling@bigpond.com.au
Endometrial Cancer Treatment-NCI
Endometrial Cancer-Cancer Australia
The pace of modern life may not give many of us the time to stop, rest and recover with a good night’s sleep, yet sleep is as important for good health as diet and exercise. Regular healthy sleep improves brain performance, mood and health. Poor sleep hygiene is associated with increased risk of heart disease, stroke, obesity, impaired immune and cognitive function.
Sleep consists of two distinct states as shown by EEG: REM sleep (rapid eye movement sleep), where dreaming occurs, and non-REM sleep, which is divided into 4 stages. Sleep is cyclical, with four or five REM periods during the night, accounting for about 1/4 of total sleep. Initial REM periods are shorter than later ones. During REM sleep, information is believed to be cemented into memory.
Stage 4 sleep is the deepest, during which blood pressure, heart rate and breathing slow, muscles relax, and both growth and repair processes are believed to occur. Stage 4 usually occurs in the first several hours of sleep. Variations in sleep may be due to shift work, travel or individual patterns. Creativity and responsiveness to unfamiliar situations are impaired by sleep loss.
Alcohol, smoking and stimulants such as caffeine, cold remedies and cocaine can reduce sleep time. Benzodiazepines tend to increase total sleep time with variable effects on non-REM sleep. Antidepressants tend to decrease REM sleep, with rebound on withdrawal in the form of nightmares.
For most adults, 7–9 hours of uninterrupted sleep is recommended — a little less for older adults and more (8–11 hours) for teenagers, with even more needed for infants and toddlers. Sleep dysfunction is common and includes short sleep (less than 6 hours for under 65s, or 5 hours for older adults), long sleep (longer than recommended), poor sleep quality (frequent waking, difficulty falling asleep), and disorders such as sleep apnoea, restless leg syndrome and insomnia.
Doctor-diagnosed sleep disorders affect about 1 in 5 adults, and 48% of adult Australians report at least two sleep-related problems. Up to 19% report not getting enough sleep. Shift workers (around 16% of the Australian workforce) are at higher risk, with 1 in 3 experiencing sleep disorders, including falling asleep at work and having a 60% higher risk of accidents compared to non-shift workers.
An Australian survey of 1,050 adults revealed that sleeping pills were being used by 37%, 14% were using melatonin, and the majority were taking a range of hypnotics, including benzodiazepines and non-benzodiazepine products (e.g. Zopiclone from the cyclopyrrolone group or orexin receptor antagonists).
I wondered if this high level of prescribing indicates that our general approach to advising patients on sleep should change in favour of promoting more natural ways of achieving sleep hygiene. To satisfy my curiosity and gain insights into healthy sleep patterns and how to achieve this naturally, we are joined by senior research scientist Josh Leota from Monash University’s School of Psychological Sciences.
Josh is actively involved in sleep research, especially regarding the effects of sleep on athletic performance, and is currently studying a cohort of elite female athletes competing locally and after travelling through time zones interstate. I was very pleased to welcome Josh to share smart insights into understanding sleep cycles, how poor sleep may impact health, and advice on achieving sleep without pharmacological assistance.
References:
Josh Leota, Research Fellow. School of Psychological Sciences, Monash University, 270 Ferntree Gully Rd, Notting Hill, Vic 3168
Sleep problems as a risk factor for chronic conditions: www.aihw.gov.au
Falls in the elderly are associated with significant morbidity and, after a serious fall, indeed predict the transition within a year of 10-15% of seniors to long-term care facilities. Additionally, the one-year and three-year mortality for seniors is 16.4 % and 40.5% following a report of more than one fall in the past 3 months (about double the average). When a hip fracture complicates the fall, the all-cause mortality is three times higher than for the average population and as high as 27% in one year in some studies.
Many factors are at play in the deterioration of senior patients experiencing falls and mobility decline. Faltering stability may arise from inadvertent overmedicating with hypotensive agents and beta-blockers, or the consequences of previous cerebrovascular accidents, Parkinson's disease and myopathies. Excluding these more overt and obvious conditions, one of the greatest determinants of falls is toe strength. Toe strength affects stability, which is a problem in an estimated 1:4 people over the age of 65 years.
The problem of falls relating to toe strength, foot proprioception and distal muscular control piqued my interest and led to a curiosity to explore this issue further with expert physiotherapist Allan Abbott. Allan is known for pushing the boundaries of knowledge and learning, and for providing a fresh perspective on many functional issues affecting us that one may not have considered previously in any detail. In an earlier podcast, Allan helped us explore breathing techniques designed to enhance physiologic function, and I would commend these episodes, including 139,140, as well as 153 and 154, to you.
The concept of dying from the feet up warrants careful examination and thorough understanding. Hopefully, after listening to this podcast, you will believe, as I do, that we could all benefit from the ideas Allan explores.
I was keen to learn more about the major factors contributing to foot problems, the exercises we should be considering and recommending as well as performing regularly ourselves to improve toe strength, balance and dexterity. The role of footwear and how one may select “good” foot support in terms of orthotics is also of significant importance and interest.
If you are interested in improving foot function and limiting morbidity both for your patients and yourself, please join me with Allan as he navigates this fascinating topic.
References:
Mr Allan Abbott - Physiotherapists http://www.healthinnovations.net.com/
The prognosis of falls in elderly people living at home: Donald et al. Age and Ageing. Vol 28. March 1999.
Mortality and cause of death in hip fracture patients aged 65 or older - a population-based study
Panuka et al.BMC Muskuloskeletal Disorders. May 20, 2011
Older adults and balance problems. Sep 2022. www.nia.nih.gov
The Greek messenger Pheidippides famously ran 42 kilometres from Marathon to Athens delivering news of victory in battle before dropping dead, still a young man. Pheidippides was undoubtedly fit and an accomplished runner as he had been a Greek herald messenger his entire life. Was his untimely death due to excessive exercising or unforeseen preexisting cardiac risk factors? This stand-out story mirrors the sad death last year of champion athlete and Queensland iron man Dean Mercer, aged 47 years, from an acute cardiac event after an early morning swim session. Was his death a consequence of his extraordinary training schedule or preexisting cardiac disease? The famous Australian Carney sisters were both forced to retire from world triathlon competition and their elite standing with life-threatening cardiac disease, similar to world champion triathlete Greg Welch. Notable athletes such as American marathon runner Ryan Shay succumbed from a fatal cardiac event at 28 years during Olympic Marathon trials and athlete authors Christopher McDougall known for his book ‘Born to Run’ died alone on a trail run in New Mexico aged 58 years similar to Jim Fixx who wrote ‘The Complete Book of Running’ and died in 1984 at the age of 52 from an acute cardiac event. These notable cases raise questions about the insidious impact of elite endurance sport and volume exercise and raise concerns about cardiac rhythm disturbances and coronary arterial plaque rupture, as well as chronic inflammation in a condition some refer to as “Athletes’ Heart”.
As compelling as this diagnosis may seem, the proposed condition “Athletes’ Heart”, however, is not widely accepted and indeed, quoting Andre La Gerche, who is an expert sports cardiologist at the Baker Heart and Diabetes Institute, there is no proven link between endurance sport and sudden death. To the contrary, Athletes live longer. Endurance athletes and gold medallists live the longest; however, endurance athletes are about 2-5 % more likely than the general population to develop heart problems, including rhythm disorders such as Atrial Fibrillation”.
Dr La Gerche urges us to remember the importance of separating public health from individual risk and reminds us that exercise in all forms reduces the risk of cardiovascular disease and diabetes and extends life. Any individual can have a heart attack; there are 20,000 deaths from heart disease per year in Australia -one every 10 minutes. Common things happen commonly, and about 1 per 100,000 people die of heart attacks during marathons; no conclusion can be drawn as a preexisting condition in such cases was likely.
The question remains whether moderate exercise should be the goal with caution for those entering elite high-volume endurance training regimes. As noted, studies are progressing, but to answer some of these questions, I was joined by cardiologist Dr Maria Brosnan. Maria is an elite athlete herself, having competed widely, and has a strong interest in arrhythmias as well as cardiac physiology in elite athletes. She works at St Vincent's Heart Centre and The Baker Institute as well as the National Centre for Sport Cardiology. She serves as a consultant for Tennis Australia, The AFL draft, Rowing Australia and several professional cycling teams. Please welcome her to the podcast.
References:
D Maria Brosnan: St Vincent’s Heart Centre, www.stvheart.com and nationalsportscardiology.com
Competitive Sports and the Heart: Benefit or Risk ?. https://pmc.ncbi.nih.gov
Athletes and Heart Disease: Why Does It Happen? www.mountelizabeth.com
Artificial intelligence is a wide-ranging branch of computer science concerned with building smart machines capable of performing tasks that typically require human intelligence. It is widely accepted that artificial intelligence computer systems will be used extensively in Medical Sciences. Common applications are likely to include illness diagnosis, end-to-end drug discovery and development, improving communication between physicians and patients, transcribing medical documents, including history note taking and writing prescriptions. It is probable that as technology advances, doctors and allied health professionals will be replaced in certain roles by artificial intelligence computers.
Artificial intelligence is not new and has been an important enabler within the technology industry, built into our handheld phone computer devices, enabling new business innovation, including web search content recommendations, product recommendations, targeted advertising and autonomously driven vehicles. Humans reap the benefits of artificial intelligence systems every day.
In medical practice, there are many advantages offered from embracing artificial intelligence, with the expectation that diagnostic accuracy and patient care will be the beneficiaries, whilst providing an excellent second opinion or co-collaborator with the physician, increasing medical efficiency and confidence in applying treatment strategies.
I was curious to learn more about the likely trends this technology might bring to health management and was fortunate to meet Anders Sorman- Nilsson at a recent medical conference where he provided our audience with a thought-provoking, entertaining and informative lecture on the future, including the possible integration of AI in medicine. As a global futurist and innovative strategist, Anders gave us a wonderful glimpse into a new world.
Anders has degrees in both law and political science as well as an EMBA, has keynoted at TED X in the United States and Australia and shared the stage with Hillary Clinton. He was nominated to the World Economic Forum's young global leaders in 2015 and has authored 3 books, including Seamless, Thinque Funky and Digilogue, as well as contributing to After Shock, edited by John Schroeter. Noting how meticulously researched and energetic his lecture was at our conference, I could strongly recommend Anders to anyone seeking an excellent keynote speaker who will provoke searching questions and prompt some deep thinking, possibly inspiring a new and creative approach to how you conduct business and prepare for the future.
In this podcast, I was keen to explore the possible place of artificial intelligence in medicine, including how it could impact diagnostic assistance, drug discovery, provide virtual health assistance, enhance personalised medicine, as well as improve robot-assisted surgery. Other areas of interest extend to its place in influencing medical education and training, clinical trial optimisation, natural language processing for health records and how it may assist in both the sequencing of genomes and coping strategies for those requiring mental health support. It was a great privilege to speak to Anders today. Please welcome him to the podcast.
References:
Anders Sorman-Nilsson found at: anderssorman-nilsson.com
Artificial Intelligence: How is it Changing Medical Science and Its Future? Basu et al. https://www.ncbi.nlm.nih.gov
Good oral health is fundamental to overall health and well-being, and a person's quality of life is compromised without it. By Oral health, we are referring to the condition of a person's teeth and gums, as well as the health of the muscles and bones in their mouth. Tooth decay, gum disease and tooth loss affect many Australian children and adults and contribute 4.5% of all the burden that non-fatal diseases place on the community. Most oral health conditions are largely preventable, and it is estimated by the World Health Organization that oral diseases affect close to 3.5 billion people worldwide, with three out of four people affected living in middle-income countries. Many factors contribute to poor oral health, including consumption of sugar, tobacco and alcohol as well as a lack of good oral hygiene and regular dental checkups. Additionally, a lack of fluoridation in some water supplies and a lack of access and availability to dental care impact adversely. There are also recognised links between poor oral health and chronic diseases, including cardiovascular disease, cerebrovascular disease, diabetes, oral cancers, pulmonary conditions and adverse pregnancy outcomes. Socially disadvantaged and indigenous Australians are more likely than others to experience untreated dental and oral disease, which negatively impacts their health outcomes.
This important subject is certainly worthy of further discussion, and it was a pleasure to meet Dr Asef Anwar, a registered Dental Surgeon with a passion for oral medicine. He is a graduate of the University of Sydney Dental School and has degrees as a Bachelor of Medical Science as well as being a Doctor of Dental Medicine. He has worked across private practices in both New South Wales and Victoria and has special interests in complex Full Mouth Rehabilitation, Dental Implants, Oral Surgery and Cosmetic Dentistry. He is committed to continuing education and research and is extending his knowledge and studies as the Oral Medicine Registrar at the University of Melbourne. It was a real pleasure to conduct a conversation with him today on the subject of Oral Medicine, exploring its interface with the practice of general medicine. I was curious to learn more about the relationship between oral mucosal and dermatological conditions, oral manifestations of systemic conditions, orofacial pain management and oral cancers. Another area of interest I was keen to explore related to the treatment of obstructive sleep apnea with mandibular advancement and dental splints, as well as broaching the subject of dental implants. With these points in mind, please welcome Dr Asef Anwar to the podcast.
References :
Dr Asef Anwar, MBedSci, DMD, FRACDS, FICOI. https://www.drasef.com.au
Australian Institute of Health and Welfare. aihw.gov.au
Australian Dental Association. https://ada.org.au
Cardiovascular disease is a major cause of mortality in Australia, responsible for around one in four (24%) of all deaths. On average, around 120 people in Australia die from CVD each day - equivalent to one person every 12 minutes. 40% more men die from CVD compared to women. With these statistics in mind, it is perhaps as well that the field of cardiology appears to be galloping toward the future with exciting treatments to manage this substantial burden of disease. We are witnesses to the development of incredible percutaneous interventions, including coronary stenting, valve replacements and repairs, watchman devices, radio frequency ablations as well as enhanced diagnostic tools and pharmacologic choices. At times, I have found the pace of change difficult to stay current with and was interested in putting some questions forth to my colleague, Dr James Sapontis to clarify my understanding and build my knowledge base. I was curious about the protocols around dual platelet therapy and their combination with DOACS, a combination I have observed leading to increased occult and overt gastrointestinal bleeding and the escalating use of iron infusions to correct deficiency states and Capsule studies to determine oozing sites. I was also interested in the indication for the use of mitraclips, the place of B-type Natriuretic peptide test in the elucidation of heart failure, as well as many more developments that have solidified their place in the clinical world of cardiology.
Please join me with the ever-patient and erudite cardiologist James Sapontis as we explore these points in more detail.
References:
Dr James's Sapontis : www.jamessapontis.com
Cardiac Society of Australia and New Zealand. Guidelines for the management of antiplatelet therapy in patients with coronary stents undergoing non-cardiac surgery.
Royal Australian College of General Practitioners (RACGP)
https://www.racgp.org.au › afp CSANZ
https://www.csanz.edu.au
One in five people will develop heart failure in their lifetime. Half will have preserved ejection fraction- HFpEF, which is becoming increasingly prevalent, the other half have heart failure with reduced ejection fraction- so-called HFrEF.
Separate to these two entities an extreme form of heart failure is cardiogenic shock. This most commonly occurs after acute myocardial infarction (AMI) and complicates AMI’s in 5-10% of cases. Cardiogenic shock is a clinical syndrome characterised by decreased cardiac output resulting in end-organ hypoperfusion and tissue ischemia. Patients presenting with ST-elevation myocardial infarction (STEMI) are 2-fold more likely to present with cardiogenic shock than those presenting with a non-STEMI. Cardiogenic shock carries a poor prognosis and is the leading cause of death in patients with acute myocardial infarction. About 80% of patients with cardiogenic shock die despite optimal treatment, usually from complications including dysrhythmias, cardiac arrest, renal failure, ventricular aneurysm, stroke and thromboembolism.
Treatment modalities include medical resuscitation and pharmacologic management, primary percutaneous coronary intervention, urgent coronary artery bypass grafting and artificial circulatory support, drawing upon intra-aortic balloon pumps and extracorporeal membrane oxygenation (ECMO). Additionally, there are non-intra-aortic balloon pump percutaneous mechanical devices as well as cardiac transplantation to consider.
These treatments have reduced in hospital mortality yet, cardiogenic shock patients who survive to reach hospital discharge still have a higher rate of mortality post-discharge than uncomplicated AMI patients.
Some exciting new developments are afoot however with the recent introduction into clinical practice in Australia of the micro axial pump device. I was curious to learn more about this subject and new approach to management and was privileged to have this conversation on the subject with expert cardiologist Dr James Sapontis. James has been involved with some of the steering committees related to cardiogenic shock management and works actively as an interventionalist at many sites in Melbourne including St John of God Berwick and Victorian Heart Hospital. Please welcome James to the podcast.
References:
Dr James's Sapontis : www.jamessapontis.com
Vision Australia estimates there are 453,000 people in our country who are blind or have low vision. This number is predicted to grow to over 560,000 people by 2030. Low vision refers to the ability to see at only 6 meters what a normal vision could see at 60 meters. It also refers to a restricted peripheral vision narrower than 20 degrees in diameter. Such people need to use devices, technology and adaptive strategies to keep doing the things they enjoy. Conditions such as age-related macular degeneration, albinism, cataracts and glaucoma, are often responsible for low vision.
For those of us with relatively normal vision, it is easy to forget, ignore and misunderstand the challenges blind and vision-impaired people face daily. Apart from the obvious day-to-day challenges, blind and vision-impaired patients receiving medication have to cope with the difficulty of not seeing their prescription medication clearly, not recognising a pigmenting skin spot that may be melanoma or scaly lesion that could be neoplastic and have the significant emotional burden of isolation thrust upon them.
I was curious to understand some of these challenges by holding a conversation with the brilliant Mr. Murray Stewart. Murray is blind but has found his way to becoming a community leader, a podcaster, philanthropist, Myo therapist, athletics trainer for some of our future star athletes and managing director of Blind magic Communication. Murray Stewart hails from Australia’s’ red centre and is a true inspiration to all who meet him, please welcome him to the Podcast.
References:
Murray Stewart: Bridgeovermurray@bigpond.com
www.healthline.com
Helping our patients attain good health holistically consists of diagnosing and treating their organic diseases, assisting them in achieving a healthy mental and emotional state as well as providing education on the fundamentals of a balanced diet, sleep hygiene, supportive relationships and exercise.
With over 65% of Australians recognised as being either obese or overweight, promoting and detailing a practical exercise plan should be one of our key health objectives for patients coupled with healthy eating. Often a busy schedule, poor health and both a lack of confidence and motivation can make exercise challenging for our patients. Generally, the biggest barrier to establishing the important habit of exercise is a mental one. Whatever our patients’ age or level of fitness there are many steps we may lead patients along to make exercise less intimidating and painful and more fun and instinctive. We have to help our patients’ overcome excuses couched in terms such as ‘I hate exercising’, ‘I'm too busy’,’ I'm too tired’, ‘I'm too old’ or ‘I'm too fat’, ‘my health isn't good enough’, or ‘exercise is too painful and difficult and I'm just not athletic’.
Whilst going for a walk at any pace is better than sitting on the couch, the current recommendation for most adults is to exercise for at least 150 minutes at moderate activity per week and this may be achieved in many ways such as exercising for 30 minutes five times a week.
Thinking about intensity of exercise, low intensity activity is where one can easily talk in full sentences or sing during exercise, at moderate intensity one can speak in full sentences but not sing. At vigorous intensity exercise one is too breathless to even speak in full sentences.
It's important to recommend that patients start small with realistic chunks of time dedicated to exercise before slowly building momentum and a healthy habit. Personal trainers, exercise physiologists and exercise apps may all provide specialist assistance as well as further motivation whilst injecting fun and confidence into a routine. Group exercises can also be inspiring and hold individuals accountable to a routine exercise program. It is important to remember that whilst health gains from exercise provides excellent positive feedback to patients, as clinicians encouraging words and interval health checks including measurement of fitness parameters such as pulse and blood pressure as well as lipid profile can be immeasurably helpful in building a patient’s esteem.
In this podcast we hold a conversation with a brilliant man, a podcaster, philanthropist, Myo therapist, athletics trainer for some of our future star athletes who is also blind and managing director of Blind magic Communication. Murray Stewart hails from Australia’s’ deep heart and discusses in this podcast his approach to exercise and how he’s managed to motivate many of our young Australians of whom a significant number are indigenous on the athletics track of our own Alice Springs located in the deep red centre of Australia. Please welcome him to the Podcast.
References:
Murray Stewart: Bridgeovermurray@bigpond.com
www.healthline.com
Obesity has become a major public health concern, with an estimated 34% of Australians classified as obese—defined as having a body mass index (BMI) of 30 kg/m² or more due to excess body fat. It is now the second leading risk factor for chronic disease in Australia, increasing the likelihood of developing type 2 diabetes, metabolic syndrome (including cirrhotic liver disease), osteoarthritis, and several types of cancer, as well as contributing to higher all-cause mortality.
While the pathophysiology of obesity is not yet fully understood, the primary goal of obesity management is to prevent and address obesity-related complications while improving overall quality of life. Standard treatment objectives include setting a weight loss target of approximately 10% for individuals with a BMI of 30–40 kg/m² and 15% for those with a BMI over 40 kg/m². This is initially achieved through dietary, exercise, and behavioural modifications before considering pharmacotherapy or bariatric surgery.
Dietary approaches that focus on calorie restriction are the most common first-line strategies for obesity management. These approaches emphasise consuming a wide variety of predominantly unprocessed foods while limiting high-calorie, nutrient-poor options such as sugar-dense foods, refined carbohydrates, and alcohol. Various low-carbohydrate, high-protein diets—such as the Atkins, Keto, and South Beach diets—have gained popularity over the years. However, studies have shown that low-calorie meal replacement diets are more effective for weight loss compared to conventional low-energy, food-based diets.
Calorie-restricted diets can be categorised based on daily calorie intake:
Low-energy diets (LEDs) allow for 1,000–1,500 calories per day.
Very-low-energy diets (VLEDs) restrict intake to 600–800 calories per day, with carbohydrate consumption limited to less than 50 grams per day.
Meal replacements serve as a behavioural strategy that promotes weight loss by reducing food choices while controlling intake. These products are typically high in protein, low in carbohydrates, and fortified with essential vitamins and minerals. They can be used to replace all daily meals or just one to two meals per day. While many meal replacement products are available on the market, many do not meet the recommended daily protein intake.
In this episode, we speak with Glennis Winnett from the nutrition company Formulite, which has developed a range of high-protein meal replacement products, including shakes, bars, recovery protein, and soup. Formulite offers Australia's only VLED programme that meets protein requirements with a three-product-per-day plan, supporting obese patients on their weight loss journey.
During our conversation, Glennis shares her motivation for developing the impressive Formulite product line and discusses how these meal replacements can be incorporated into effective dietary strategies for weight loss.
Please welcome Glennis to the episode!
References:
Min et al., The Effect of Meal Replacement on Weight Loss According to Calorie-Restriction Type and Proportion of Energy Intake: A Systematic Review of Randomised Controlled Trials. Journal of the Academy of Nutrition and Dietetics, 2021, Vol 121, Number 8.
Obesity, WHO, 30 June 2020.
The field of regenerative medicine is receiving significant interest with the objective of restoring damaged tissues to health using biological products, as well as influencing age-related decay.
The use of pluripotent stem cells has been studied for some years now with the hope of nurturing their undifferentiated state into specific cell types reflecting the target tissues requiring repair. Another approach has been to harness the biological properties of exosomes. Exosomes are nano-sized biovesicles released by all nucleated cells into surrounding body fluids upon fusion of tiny intracellular multivesicular bodies and the plasma membrane.
These small vesicles, measuring between 40 and 160 nanometers, were first identified in the late 1980s and initially were proposed as cellular waste resulting from cell damage or by-products of cell homeostasis with little or no effect on neighboring cells. This initial simple interpretation of their function has now been supplanted by new insights into their physiological roles. Exosomes carry a complex cargo of proteins, lipids, and nucleic acids and are now recognized as functional vesicles capable of delivering very important cargoes of information to target cells they encounter. This chemical messaging may ultimately reprogram the recipient cells remotely from their release and represent a novel mode of intercellular communication as well as playing a major role in many cellular processes such as immune response, signal transduction, and antigen presentation.
It is likely that the cargo of exosomes may differ significantly depending upon the function of the originating cell type and its current physiological state, including states of transformation, differentiation, stimulation, or stress.
A current line of study aims to determine whether active exosome cargo may offer prognostic information on a range of diseases such as chronic inflammation, cardiovascular and renal disease, neurodegenerative diseases, lipid metabolic disease, and tumors. Additionally, as exosomes are not immunogenic, they are being examined for their potential to actively deliver biological therapeutics across different biological barriers to target cells, including across the blood-brain barrier.
References:
Dr. Jeffrey Gross:www.ReCELLebrate.com
Stem Cells and Regenerative Medicine: From Molecular Biology to Clinical Applications. Academic Press. 2021.
Exosomes in Cell-to-Cell Communication and Regenerative Medicine. Theranostics. 2020.www.ncbi.nlm.nih.gov
The Role of Exosomes in Regenerative Medicine and Tissue Engineering. Frontiers in Bioengineering. 2019.www.frontiersin.org
In this episode, we delve into the critical issue of obesity and the transformative potential of bariatric surgery with Dr. Jason Winnett, a leading expert in weight loss treatments and Director of the Winnett Specialist Group in Melbourne. With obesity affecting 67% of Australians and posing severe health risks such as type 2 diabetes, heart disease, and cancer, Dr. Winnett explores how modern surgical techniques are offering hope to those struggling to achieve sustainable weight loss through traditional methods.
Dr. Winnett provides insights into the latest bariatric procedures, including gastric sleeve and mini-gastric bypass surgeries, highlighting their effectiveness in achieving long-term weight loss and managing chronic conditions. We also discuss pre-surgical pharmacological approaches, the role of multidisciplinary care, and the importance of managing potential nutritional deficiencies.
This episode offers a comprehensive overview of the advancements in bariatric surgery and its critical role in combating obesity. Tune in to learn from Dr. Winnett's decades of expertise and discover how these treatments are transforming lives.
Resources and References:
* Winnett Specialist Group: winnettspecialistgroup.com.au
* Australian Institute of Health and Welfare: Impact of Overweight and Obesity as a Risk Factor for Chronic Conditions, 2017
* Australian Bariatric Surgery Registry, 2019
* Swedish Obesity Study: J Internal Medicine, 2013
* British Obesity and Metabolic Surgery Society Guidelines, 2020 Update
* RACGP Guide to Bariatric Metabolic Surgery, 2017
As a background to this podcast in 2021 there were 15 200 Australians with kidney failure receiving dialysis, a doubling of the number receiving dialysis from 2000 with a male-to-female ratio of approximately 2 to 1.
82% of these patients were receiving chronic haemodialysis all of whom required an arterio venous vascular shunt for access. A small proportion (18%) were being managed by peritoneal dialysis and in that year, there were 857 functioning kidney transplants. Of the haemodialysis patients 25% were being dialysed in hospital, 65 % in satellite centres and 9 % at home. Indigenous Australians representing 2.5 % of the population comprised 9% of patients commencing renal replacement therapy highlighting a very significant health burden for first nations people. The main indications for patients receiving dialysis included having severe renal failure with a GFR less than 15ml/min/1.75m2 accompanied by complications such as metabolic acidosis, hyperkalaemia, pericarditis, encephalopathy, intractable volume overload, anorexia with weight loss and lethargy, peripheral neuropathy, intractable gastrointestinal symptoms or having an e GFR of 5-9 ml/min or less despite being asymptomatic.
Vascular access for haemodialysis is accomplished by the creation of an arteriovenous fistula or use of a prosthetic graft with catheters providing temporary access only. As normal veins are not strong enough to cope with the high pump pressures and the rapid blood flow from a dialysis machine a native fistula joining vein to artery, normally in the forearm is created. As the fistula matures over 6 to 8 weeks the vein adapts and thickens leading to a stable fistula ready for use. Both immediate, early and late complications are described including infection, aneurysm, thrombosis and staphylococcal infection. Despite expert surgery up to 30% of fistulas are unusable. The Kidney Disease Outcome Quality Initiative (KDOGI) describes the Rule of 6 for fistulas comprising being: Ready for use 6 weeks or more after being formed, having a blood flow through the fistula of 600 ml/ min, a diameter of 6 mm accessible for 6 cm and at 6 mm depth.
To learn more about arteriovenous fistulas as well as the Do’s and Don’ts of fistula care in primary practice we welcome back Dr Ming Yii. Ming is a well-recognised expert in vascular surgery and is the director of vascular and transplant surgery at Monash Health and adjunct Senior lecturer with Monash University. Ming is also part of the Monash transplant team in kidney and pancreas transplantation and brings a wealth of knowledge and experience as well as an effusive personality to accompany his skills. In this episode he discusses his approach to fistula formation and for their ongoing management and care.
References:
Dr Ming Yii. mingyiivascular.com.au or admin@yiivascular surgery.com.au
Webster AC et al. Chronic Kidney Disease. Lancet .2017Mar 25;389 (10075):1238-52.
National Kidney Foundation: kidney.org
Show Notes: Snake Bite Envenomation in Australia with Dr Tim Jackson
Australia is home to many of the world’s most dangerous snake species so familiarity with snake bite management and understanding the clinical effects of snake bite is vital for Australian doctors, especially those with a rural practice. Each year in Australia there are about 1000 recorded snake bites but fortunately only 2-3 deaths, most of these relate to bites from the brown snake. This contrasts with a vastly higher number of reported deaths from snake bite in India and Africa contributing to a recorded 100 000 deaths from envenomation globally.
Australian snakes, also known as elapids, deliver a venom through their bite which predominantly exerts systemic effects. There are five major venom types for Australian snakes. Minor to moderate local effects may also be experienced depending on the snake genera.
Snake venom is a complex mixture of many components including peptides, enzymes, phospholipases, proteases, and others. The venoms may have a potent pro coagulant effect leading to venom induced consumptive coagulopathy which may ultimately lead to defective coagulation through consumption of clotting factors. D- Dimer levels will be high in such instances. A primary anticoagulant effect may occur without significant D-Dimer production but significant bleeding. Other effects include neurotoxicity where toxins have either pre or post synaptic targets. Early signs of developing paralysis such as ptosis need to be watched for closely in the hope of avoiding a neurotoxic flaccid paralysis that may require ventilation. Myotoxicity predominantly affects skeletal muscle and may lead to profound rhabdomyolysis with renal injury and intravascular haemolysis as associated sequelae.
Clinical diagnosis of envenomation may be based on a definite history of observed snake bite however more cryptic presentations where definite snake bite has not been observed may result in baffling systemic effects with minimal local evidence of a bite. It’s important to be aware of envenomation as a potential diagnosis in such cases.
Detecting coagulopathy is the most urgent investigation to consider after an Australian snake bite. A complete coagulation panel including D-Dimer assessment is essential, electrolyte, renal function and creatinine phosphokinase levels should also be checked. For a well patient these tests should be ordered at presentation, after removal of the first aid pressure bandage and then again at 6 and 12 hours post bite, assuming preceding tests have been normal. Evidence of envenomation requires stabilisation of the patient and administration of antivenom.
Australia is the only country with commercially available snake venom detection kits that may assist in the identification of venom that has been inoculated and provide a very helpful guide to the appropriate antivenom to administer. A polyvalent vaccine is also available for administration although larger in volume and associated with more side effects than the ‘monovalent ‘antivenoms correctly chosen from the kits mentioned above. Doses are the same for adults, children and the pregnant. Expert assistance from a toxicologist and intensivist should be sought early if troubling signs and symptoms of envenomation are observed.
In this episode we have a conversation with Dr Tim Jackson who is co-head of the Australian Venom Research Unit at Melbourne University and an evolutionary biologist. Tim brings a huge and enthusiastic wealth of knowledge to this discussion, and it was a real honour to invite him as an expert guest. Please welcome Tim to the podcast.
References:
Dr Tim Jackson - AVRU - Australian Venom Research Unit - Melbourne University
White, J.A Clinician’s Guide to Australian Venomous Bites and Stings, BioCSL, Melbourne 2013.
Preventing and managing snake bites. (PDF). Qld Govt. May 2018
