June 2019 - In brief June 2019 - In Brief

For links to resources, clinical updates and more, visit news.wapha.org.au

17 October 2019

Eating disorders: Theimplications of starvationand importance of nutritionalrehabilitationDr Anthea Fursland (Associate Director andConsultant Clinical Psychologist) and Dr Lisa Miller,(Psychiatrist and Medical Director) at the WAEating Disorders Outreach & Consultation Service.

Since shame often hinders people from seekinghelp and early intervention is known to improveprognosis, all patients should be asked abouttheir eating habits and whether they purge,binge and/or severely restrict their food. Ascreening tool such as the SCOFF can helpidentify disordered behaviours and cognitions.Trustworthy psychoeducation, such as handouts

Medicare changes and evidence-basedtreatmentsFrom 1 November 2019, Medicarereimbursement will be increased for people withsevere eating disorders. Dietitians will be able toprovide up to 20 sessions per year andpsychologists up to 40 sessions. (To obtainbeyond 20 mental health sessions, the individualwill need to be assessed by a psychiatrist orpaediatrician).  Whilst assertively addressing nutritionalrehabilitation goals with people experiencingeating disorders can be challenging, it is alsocritical to recovery i.e. just talking to someoneabout their eating disorder, without changingthe behaviour is unlikely to be helpful. Thereforeit is important that GPs refer their patients topsychologists and dietitians who offer evidence-based treatment, which involves:

A focus on the current eating disorderEarly changeReducing eating disorder behaviours(restriction, binge eating, purging, drivenexercise)Weekly weighingWeight regain for those needing it

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"...just talking to someoneabout their eating disorder,without changing thebehaviour, is unlikely to behelpful."

In Brief

provided by the Centre for ClinicalInterventions,  is helpful in explaining suchconcepts as the need for regular eating, thedangers of purging and the effects of starvation.

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Increasingly, eating disorders are understood asneurobiological disorders, sitting at the interfaceof physical and mental health. Emergingevidence suggests early intervention, includingassertive nutritional rehabilitation andstructured psychological support with amultidisciplinary plan for relapse prevention, cansignificantly improve prognosis. Severe malnutrition and 'starvation syndrome 'can be experienced in people at any weight,resulting in physical and cognitive effectsincluding poor insight regarding nutritional andmedical risk. Severely malnourished individualsare unlikely to be able to reverse starvation ontheir own. Sometimes people with high risk medicalcomplications or recurrent presentations mayrequire inpatient admission to enable nutritionalrehabilitation/weight gain to a level sufficient forbrain recovery from malnutrition. Otherwise, thiswill continue to drive cognitions and impairengagement with psychological treatments,perpetuating the cycle of weight loss andreadmission. Access in Perth to publicpsychological services and private day programsfor people with eating disorders requires a BMI>16 kg/m, and BMI ≥17kg/m is associated withimproved ability to benefit from outpatienttreatment. Prevalence, screening and early interventionEating disorders are not rare. A longitudinalstudy from WA showed that by the age of 17,15.2% of females have a diagnosable eatingdisorder.

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Clinical UpdatesP e r t h M e a s l e s A l e r t Dr Paul Effler, A/Director, CommunicableDisease Control Directorate has recently advisedthat visitors and residents of the Perthmetropolitan area may have been exposed tomeasles and more cases may occur over thecoming weeks. There are now 19 confirmedmeasles cases in the Perth metropolitan areasince mid September, with the number of casesin WA this year now reaching 45. Over the pastfive years there has been eight to 43 casesreported in WA each year. All suspected or confirmed cases are to benotified immediately to the CommunicableDisease Control Directorate on 9222 0255 (93280553 A/H) or to the local Public Health Unit inregional areas. GPs are also advised to:

Consider measles in a febrile patient with acompatible clinical pictureTreat suspected measles cases withimmediate isolation with airborne precautionsBe alert for further locally acquired cases ofmeaslesOffer the MMR vaccine to people aged 53years and under who do not havedocumented evidence of two doses of MMR(see 'Immunisation – Adult' HealthPathway.)

Signs and symptomsPatients with measles usually look and feel veryunwell. Prodrome generally consists of two to four days of fever and malaise, AND oneor more of:

CoughCoryzaConjunctivitis or Koplik spots on buccalmucosa (not commonly observed).

This is followed by the onset of a rash two toseven days after prodrome, usuallycharacterised by:

Fever present at time of rash onset Commencing on face/head then descending Maculopapular, becoming confluent.

Infection and prevention controlPatients with symptoms and signs consistentwith measles should be:

Identified promptly at receptionFitted with a surgical maskIsolated in a room (negative pressure, whereavailable) separate from other patients, withthe door shut.

Only staff who are immune to measles shouldattend the patient and airborne precautionsshould be used, including the wearing ofappropriate PPE. All equipment in contact withthe patient should be single use or reprocessedbefore use on another patient.

The examination room should also be left vacantfor at least 30 minutes after the patient has leftand all touched surfaces thoroughly cleaned. Visit the Department of Health website todownload a series of posters to display at thefront door of general practices and in clinicalareas. Laboratory testingFormal diagnosis should be supported by thefollowing patient testing:

Throat or nose swab, or nasopharyngealswab or aspirate, for measles PCR, in viraltransport medium Urine for measles PCRSerology for measles IgG and IgM.

N e w T e l e h e a l t h M B S i t e m sFrom 1 November 2019, there will be 12 newMedicare Benefits Schedule (MBS) items fortelehealth video consultations with patientsliving in rural and remote areas. The new itemswill be available to GPs and non-specialistmedical practitioners, and can be used forpatients who:

Are living in a Modified Monash Model (MMM)6 or 7 area (use the online Health WorkforceLocator to search the MMM map);Have had three face-to-face professionalattendances in the preceding 12 months fromthe practitioner who will provide thetelehealth service; and At the time of the consultation, are at least 15kilometres by road from the practitioner.

To find out more, read the factsheets availablefrom MBS Online. More information aboutTelehealth consulting can be found on the

E x p r e s s i o n s o fI n t e r e s t – M e n t a l H e a l t hN e t w o r k C l i n i c a l C o - L e a dThe Mental Health Commission, in partnershipwith the Department of Health, is seekingExpressions of Interest from suitably qualifiedindividuals for the position of Clinical Co-Leadfor the Mental Health Network. The Clinical Co-Lead will work together with the Community Co-Lead to provide leadership and direction to theMental Health Network. To apply, complete theapplication requirements and email toMHNetwork@mhc.wa.gov.au by 4pm Friday, 18October 2019. For more information, contactAssistant Director, Planning, Policy andStrategy, Ms Renae Hodgson on 6553 0412 oremail renae.hodgson@mhc.wa.gov.au

'Telehealth' HealthPathway.

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V i e w i n g d i a g n o s t i c t e s t i n gn o w e a s i e r t h r o u g h M yH e a l t h R e c o r dTo better support clinical decision making, MyHealth Record has recently upgraded theviewing of pathology and diagnostic imaging.The upgrade's enhanced clinical workflowcapabilities will better enable GPs to easilyidentify and group together relevant tests andresults, keep track of tests from multipleproviders, and allow patient test results to bemonitored over time. Visit the Australian DigitalHealth website for more information.

S i l v e r B o o k - n e w a g e d c a r eg u i d eThe RACGP has recently published a newedition of the RACGP aged care clinical guide(Silver Book). The fifth edition provides GPs withup-to-date information on the complex care ofolder people, with the first section nowaccessible online. It is designed to assist inclinical decision-making by presenting asnapshot view of the diagnosis andmanagement of a range of clinical conditions.Practitioners in this area may also wish to view 

C o p i n g w i t h s e l f - h a r mr e s o u r c e f o r G P s a n dp a t i e n t sA new youth mental health resource, Copingwith self-harm: A guide for parents and carers,has been developed by the Orygen NationalCentre of Excellence in Youth Mental Health withfunding support from the Perth South SuicidePrevention Trial led by WA Primary HealthAlliance. The guide provides practicalinformation for parents and carers but is also auseful resource for GPs to reference and provideshould they see presentation in their practice. There is also a 'Deliberate Self Harm'HealthPathway.

S e c o n d r o u n d o f G PU r g e n t C a r e a p p l i c a t i o n sn o w o p e nApplications have now opened for practiceswishing to join the GP Urgent Care NetworkPilot. Click here for more information onessential criteria and how to access theapplication form. Any questions about theapplication or the Pilot can be emailed tourgentcare@wapha.org.au Applications close 31October 2019.

Eating disorders (cont)

A focus on eating regularly and reducing foodavoidance by exposure to food and eating. The local Women's Health and Family ServicesEating Disorders Resources Directory, whichlists practitioners with expertise in this area, canbe accessed via the 'Eating DisordersSpecialised Assessment' HealthPathway. The two most widely used evidence-basedpsychological treatments are:

Family Based Treatment (FBT) – foradolescents with anorexia nervosaCognitive Behaviour Therapy (CBT) – for all

diagnoses and all ages from adolescence Although the onset of anorexia nervosa andbulimia nervosa is usually in the teen years,binge eating disorder can develop at any age,and affects men in equal numbers. Patientspresenting in later life may have tried manytreatments, but the evidence suggests thatevidence-based approaches can still work withthis older group and that even longstandingeating disorders can be treated successfully. Eating disorders are complex in nature, causeenormous distress to patients and their families,and carry a large burden of care. Because ofthis, it is critical to screen for eating disorders,intervene early and refer appropriately, plusprovide regular medical monitoring. The WAEating Disorders Outreach & ConsultationService (WAEDOCS) is available to supportclinicians throughout the state and can bereached on 1300 620 208. WAEDOCS has also

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created clinical guidelines to facilitate bestpractice care.

More information can also be found in therecently completed 'Eating Disorders'HealthPathway. References:

Keys, A. The Biology of Human Starvation. Minneapolis, MN: University ofMinnesota Press; 1950.Wade, T., Allen, A., Crosby,R., Fairburn, C., Fursland, A., Hay, P., McIntosh, V.,Touyz, S., Schmidt, U., Treasure, J. & Byrne, S. (2017) Trajectory of weightchange over the first 13 sessions of outpatient therapy for anorexia nervosaand relationship to outcome, International Conference on Eating Disorders,PragueAllen, KL, Oddy, WH, Byrne, SM & Crosby, RD (2013) DS M-IV-TR and DSM-5Eating Disorders in Adolescents: Prevalence, Stability, and PsychosocialCorrelates in a Population-based Sample of Male and Female Adolescents.Journal Abnormal Psychology. 122 (3) 720-732

4. Raykos, B., Erceg-Hurn, D., McEvoy, P., Fursland, A. & Waller, G. (2018) Severeand enduring anorexia nervosa? Illness severity and duration are unrelated tooutcomes from enhanced cognitive behaviour therapy. Journal Consulting &Clinical Psychology. 86, 8; 702-7095. Eddy, KT, Tabri, N, Thomas, JT, Murray, HB..& Franko (2016) Recovery fromAnorexia Nervosa and Bulimia Nervosa at 22-year follow-up. J Clinical Psychiatry

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the suite of 'Older Adults’ Health' HealthPathways.

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Visit wapha.org.au/events more information on GP education events or to register.

Education Events

H e a l t h P a t h w a y s W A G PE d u c a t i o n E v e n t a tR o c k i n g h a m G e n e r a l H o s p i t a l :L i n k i n g P r i m a r y t o T e r t i a r yC a r e P L U S C P R R e f r e s h e r Presented by Rockingham Peel Group and RockinghamGeneral Hospital in partnership with WA PrimaryHealth Alliance; HealthPathways WA, this full dayevent will cover a variety of topics and also provide GPswith an opportunity to connect with local serviceproviders. Education sessions include:

Syphilis and STIs by Dr Lewis MarshallAllied Health & NDIS by Belinda Whitworth & MarkBurrowsAged Care Transition by Deb JonesDementia by Dr Nisha Antony Menorrhagia & Urinary Incontinence by Dr YadavYogenderEndocrinology by Dr Krish ChikkaveerappaPaediatric ADHD by Dr Colin Derrick

Presentations will be followed by an optional one hourCPR session at a cost of $99 for RACGP members and$121 for non-members. Date: Saturday 9 November Time: 8:30 AM - 3:30PMVenue: Rockingham General Hospital

Education Centre Lecture Theatre Elanora Dr, Cooloongup 6168

Accreditation: 40 Cat 1 RACGP QI&CPD and 30 ACRRM PRDP points. Registration and more information : https://waproject.healthpathways.org.au/Events/RGHGPEventNov2019.aspx

For more information on upcoming GP educationevents or to register, visitwapha.org.au/events

GP & Practice Team: Advanced Care Planning Education Event - GreenwoodWA Primary Health Alliance Saturday 26 October 

TADPole: Treating Alcohol and Other Drugs in Primary CareWA Primary Health Alliance Saturday 16 November

Australasian Doctors' Health ConferenceRural Health WestFriday 22 - Saturday 23 November

ARMED - Annual Review of Metabolism,Endocrinology and DiabetesFSH, Diabetes WA and WA Primary HealthAlliance; HealthPathways WASaturday 2 November

Chronic Pain Management WebinarECU & WA Primary Health Alliance Monday 21, Thursday 24 October 

TADPole: The 'Heartsink' Consultation-Managing Complex NeedsECU and WA Primary Health AllianceSaturday 19 October

RACGP GP 19 Conference RACGP Thursday 24 to Saturday 26 October