Special delivery Managing the vaccine roll out - Australian ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
medicSA
FEBRUARY 2021 VOLUME 34 NUMBER 1
Special delivery
Managing the vaccine
roll‑out
THE ‘RIGHTS’ APPROACH TO AGED CARE • HONOURING 2020 GRADUATES
medicSA | 1
GROUND-BREAKING CANCER FINDINGS • TREATING EATING DISORDERS
You’ve read
10 times your 120 years’ experience
helping medical
professionals
weight in Medico-legal advice
24/7 emergency
support
journals for
Risk education
learn to manage
your risk
this career.
Earn Qantas Points1
on your MIGA
insurance
It deserves With 120 years as a specialist
insurer to the medical profession,
expert protect yourself with the experts
in medical indemnity insurance. 2
protection. For a competitive quote,
call 1800 777 156 or visit
www.miga.com.au
The experts in medical and
professional indemnity insurance.
Doctors, Eligible Midwives, Healthcare Companies, Medical Students
A business must be a Qantas Business Rewards Member and an individual must be a Qantas Frequent Flyer Member to earn Qantas Points with MIGA. Qantas Points are offered under the MIGA Terms and Conditions (www.miga.com.au/qantas-tc).
Qantas Business Rewards Members and Qantas Frequent Flyer Members will earn 1 Qantas Point for every eligible $1 spent (GST exclusive) on payments to MIGA for Eligible Products. Eligible Products are Insurance for Doctors: Medical Indemnity
Insurance Policy, Eligible Midwives in Private Practice: Professional Indemnity Insurance Policy, Healthcare Companies: Professional Indemnity Insurance Policy. Eligible spend with MIGA is calculated on the total of the base premium and membership
fee (where applicable) and after any government rebate, subsidies and risk management discount, excluding charges such as GST, Stamp Duty and ROCS. Qantas Points will be credited to the relevant Qantas account after receipt of payment for
an Eligible Product and in any event within 30 days of payment by You. Any claims in relation to Qantas Points under this offer must be made directly to MIGA by calling National Free Call 1800 777 156 or emailing clientservices@miga.com.au
Insurance policies available through MIGA are underwritten by Medical Insurance Australia Pty Ltd (AFSL 255906). Membership services are provided by Medical Defence Association of South Australia Ltd. Before you make any decisions
about any of our policies, please read our Product Disclosure Statement and Policy Wording and consider if it is appropriate for you. Call MIGA for a copy or visit our website at www.miga.com.au © MIGA March 2019
SIMPLE_DJ_MIGA019
2 | medicSA
Contents
Australian Medical Association 5 President’s message
(South Australia) Inc.
7 Easy does it – ePrescriptions help doctors and patients
Level 1, 175 Fullarton Road,
Dulwich SA 5065 8 The rights stuff – a human rights approach to caring
PO Box 134 North Adelaide SA 5006 for the aged
Telephone: (08) 8361 0100
11 Correct dose – planning and managing the
Facsimile: (08) 8361 0199
COVID-19 vaccine roll-out
Email: medicsa@amasa.org.au
Website: www.amasa.org.au 15 Puffs of smoke – the AMA’s campaign against vaping
Executive contacts
16 A light-bulb moment – new discoveries in breast
President
cancer treatment
Dr Chris Moy: president@amasa.org.au
medicSA 19 Finest moments – AMA(SA) Australia Day Honours
Editorial recipients
Editor: Dr Philip Harding 20 Early diagnosis – the continuing questions
Managing Editor: Karen Phillips surrounding eating disorders
Advertising
medicSA@amasa.org.au
22 On the record – Dr Chris Moy provides a
My Health Record update
Production
Typeset and printed for the AMA(SA) by 26 End of an era – 2020 Medical School graduates
Douglas Press Pty Ltd.
30 From the top – introducing our new student
ISSN 1447-9255 (Print)
societies’ presidents
ISSN 2209-0096 (Digital)
Cover artwork 33 Centre of care - doctors' key role in
iStock – peterschreiber.media. 'home hospital' program
Disclaimer
Neither the Australian Medical Association
(South Australia) Inc nor any of its servants
and agents will have any liability in any way
arising from information or advice that is
18
contained in medicSA. The statements
or opinions that are expressed in the
magazine reflect the views of the authors
and do not represent the official policy of
the Australian Medical Association (South
Australia) unless this is so stated. Although
all accepted advertising material is
expected to conform to ethical standards,
such acceptance does not imply
endorsement by the magazine.
All matter in the magazine is covered by
copyright, and must not be reproduced,
stored in a retrieval system, or transmitted
in any form by electronic or mechanical
means, photocopying, or recording,
without written permission.
South Australia’s 2021 Rhodes Scholar and AMA(SA) member Dr Sarah
Images are reproduced with permission Short has travelled a long way in her professional and personal life – and
under limited license. has recently added competing in triathlons to an already awe-inspiring list
of achievements.
medicSA | 3
Is your practice protected?
Running a medical practice is as much about managing risk You’re covered for the legal costs to defend your practice against
as providing healthcare. When poor patient outcomes result patient loss or injury, employee disputes, privacy breaches and
from lapses in processes or staff error, it’s not only practitioners other exposures specific to medical practices.*
and your team at risk – the practice itself can be exposed to
You’ll also have the support of our medico-legal experts, who can
legal action.
advise you on preventing and managing risks, so you can focus
So, it’s important to protect your practice with the responsive on running a safe, successful practice.
cover, strong defence and expert advice offered by Avant Practice
Medical Indemnity Insurance. Protect your practice and your team with Avant Practice
Medical Indemnity Insurance.
Avant Practice Medical Indemnity Insurance
1800 128 268 avant.org.au/practices
IMPORTANT: *Cover is subject to the full terms, conditions, exclusions and sublimits set out in the Policy Wording and Policy Schedule. Practice Medical Indemnity Policy is issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The
information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details
including the terms, conditions, and exclusions that apply, please read and consider the policy wording which is available at avant.org.au or by contacting us on 1800 128 268. MJN220 01/21 (DT-1720)
4 | medicSA
REPORT
President’s
report
Dr Chris Moy
C
OVID-19 is certainly the gift that administer the COVID vaccine in congratulate joint AMA(SA) Student
keeps giving. Who in February the community. Medal winners Matilda Smale, who
2020 could have foretold that It has been somewhat concerning, was a valuable contributor to AMA(SA)
12 months later the world would therefore, to hear that some have Council as the Flinders representative
still be grappling with the devastating complained that we did not work hard in 2020, and Liam Ramsey, who wrote
impacts of COVID-19? That those of enough; that we have somehow ‘sold for medicSA as the Flinders Medical
us in Australia would have extremely them out’. To these, and others, can I Students’ Society President last
limited opportunities to leave – and be urge you to consider – for a community year. I am certain that Dr Smale and
happy about it? That South Australia which has felt widespread pain from Dr Ramsey will be strong advocates for
would be one of the few places in the the direct and indirect effects of
their colleagues as interns and in their
world where the vast majority of people the pandemic – that the COVID-19
future careers.
listen to science? vaccine roll-out is a time to look past
At ‘the other end’ of their careers
There has been and continues to our own needs and is our moment to
be so much to do. But I am extremely stand up. The profession has earned (usually!) are those AMA members who
proud of how doctors and the AMA have the thanks of the community for our received recognition in the Australia
‘stood up’ over the past year. Our work roles in combatting the virus to date – Day Honours last month. In 2020, we
has been incredibly important in so something that may be diminished if were proud to have our own member,
many spheres, and despite how many the community senses complaint and Dr James Muecke, named as Australian
times you’ve heard my voice on radio, self-interest among doctors, even if only of the Year, and watched as he used
only a fraction of our advocacy has hit from a few of us. The AMA will continue this invaluable platform to inform
the media. to work for doctors and patients to help and educate Australians about the
In recent weeks, the major topic in our Australia through this, and I hope all dangers of sugar. I’m very much looking
meetings with Australian Government doctors will understand their key role in forward to seeing the AMA building
officials has been the involvement the big picture of the vaccine roll-out. on and promoting the work James and
of GPs in the vaccine roll-out. Again, As March approaches, and we look others are doing.
I’m pleased that we have been able to forward to what we hope will be a time As I write this, the House of Assembly
open the eyes of the government to of less anxiety and greater certainty, is debating the Termination of
the key role that GPs should play. GPs please spare a kind thought for our Pregnancy Bill 2020, which was delayed
know their patients and their medical medical students. The time spent as a from early February to late this month.
backgrounds; the word of trusted university student is arduous enough
The AMA has been publicly supporting
GPs is likely to increase a patient’s in the calmest of times; throw in a
the Bill in its ambition to decriminalise
confidence in the vaccine’s safety. pandemic and it’s been a nightmare.
abortion in this state – the only one in
With the appropriate support, GPs can One of the impacts has been on the
Australia where abortion remains in the
adapt their practices to ensure vaccines normal rites of passage from medical
are delivered across the country, in a school to internship. As you’ll see on criminal code. I am sure there will be
COVID-safe manner, while continuing page 26, AMA(SA) has had to postpone more to say in the next issue of medicSA.
to provide usual care to their patients. the announcement of our 2020 Adelaide In the meantime, we begin the
It should have been a no-brainer, but Medical School Student Medal winner vaccine roll-out. It will be challenging
it wasn’t. due to pandemic restrictions on public – but I am very confident that together
And as a result of our work, GPs gatherings. But we were very glad that we can perform our expected role in
have been allocated an estimated the Flinders Medical School managed supporting Australia in and through
$1-1.5 billion of funding support to to stage its commemorative event, and this critical period.
medicSA | 5
EDITORIAL
last month: Dr Roy Scragg AM OBE, Dr John Crompton AM,
Dr John Willoughby OAM and Dr David Hamilton OAM. We
hope this additional exposure in some way reinforces the
appreciation we feel for all they have done.
But health care is not and has never been just about
doctors. Our patients wouldn’t achieve the levels of health
Editor’s we want them to without the thousands of nurses, allied
letter health professionals and other health care workers who
work alongside us to improve patients’ health and lives.
COVID-19 has provided daily reminders of that, too. Last
Dr Philip Harding month, my wife Margie and I attended the funeral of former
Royal Adelaide Hospital Director of Nursing Pam Spry AM.
I
Pam held many positions in nursing and health in this
t is a wonderful thing, to be a doctor. We have so many state, Sydney and Melbourne, including as one of the first
opportunities to perform important work that helps the staff members at the Queen Elizabeth Hospital in 1959,
lives of our patients, their carers and loved ones, and and also worked overseas. She was a Commissioner at the
the communities in which we live. If there was a chance South Australian Health Commission, and a member of
that we forgot the value of our profession, the pandemic has the planning team for the first college-based nurse training
provided constant reminders of it. course at the then-Sturt College of Advanced Education. She
But there are those of us who do go above and beyond in advocated for fairer conditions and promotion opportunities
serving our patients and communities – who do more at for her fellow nurses and for diversifying the range of nurses,
home or venture overseas to care for and protect the health including more males.
of people in need. Sometimes, the work and its importance At her funeral, I recalled Pam’s dedication, her curiosity,
are never known or sufficiently recognised, even among her close working relationships with senior medical
the medical fraternity. At other times, acknowledgement colleagues such as now-Professor Brendon Kearney and
comes later. In this issue, we recognise four South me, and her sense of humour. I remembered that during
Australian medicos who received Australia Day Honours the building program at the old RAH in the 1990s, when the
link on the upper level between Teaching and Services and
the Eleanor Harrald Building was to be named ‘Spry Way’,
much merriment ensued when CEO Nobby Elvin dubbed it
‘Pam’s Passage’.
‘Matron Spry’ was 96 when she died. I like to think she was
happy with her ‘innings’, despite not quite reaching the ton,
and that she was aware that her contribution was, and will
continue to be, remembered and appreciated.
Pam Spry AM, and nursing in 1948
New access to mortgage advice
W
ith hundreds of loans to the competitive and ever-changing AMA members avoid taking out loans
choose from and multiple mortgage landscape to help find the they later regret.’
banks and institutions to right loan for each individual. A new cashback offer available to
deal with, busy doctors may not have Ms Warne said some loans may not AMA South Australia members allows
time to identify which loan best suits offer the flexibility doctors need for eligible people to receive up to $2,000
their needs. the future. cashback on any loans successfully
AMA(SA) CEO Dr Samantha Mead ‘Mortgage brokers have a legal duty
settled between 4 November 2020
said she welcomed the opportunity to to make credit recommendations that
and 31 December 2021. The cashback
work with WA-based AMA Mortgage are in the best interests of the client.
offer is in addition to any bank or
Brokers to offer local AMA members Brokers also have the experience to help
targeted mortgage broking services. choose the right loan for each person,’ lender cashback offers (if eligible),
AMA Mortgage Brokers is a service she said. leaving customers with more cash in
now available to AMA members ‘Some products seem to offer a great their pockets.
and non-members across Australia. deal but may have penalties, fees and For more information see
Mortgage broker Racheal Warne charges that others may not be aware https://www.amafinance.com.au/
said the company can help navigate of. We will be across this and will help home-loans/cashback-offer/
6 | medicSA
NEW SERVICE UPGRADED MAGNET COMING MID-MARCH
Bone Density Port MRI at our MRI at our
Augusta & Gawler Modbury Clinic Gawler Clinic
We have recently installed Bone We are now offering additional We are installing MRI at our
Density scanners at our Port rebated and non-rebated MRI Gawler clinic, located within
Augusta and Gawler Heath Service services at our Modbury clinic, with the Gawler Health Service.
clinics. the installation of our new licenced
Siemens Aera 1.5T scanner. This represents a further
Patients and referrers from the substantial investment
Spencer Gulf region, Northern We are committed to delivering in our range of services
Adelaide region and Barossa region the highest quality imaging to your offered in Gawler.
can access our new Bone Density patients with the inclusion of the
service. following services for specialists The service will be of significant
now offered at our Modbury clinic: benefit to local patients and
This investment builds on our referrers, and will service both
commitment to deliver high- MRCP | Rectal staging inpatients and outpatients
quality, accessible medical imaging Prostate | MRI Enterography throughout the Gawler and
services to regional communities. Barossa regions, and other areas
This is a partial rebate licence,
in regional South Australia.
GPs can refer for Medicare indicated
Our Southern Specialist Centre imaging:
and Burnside clinics upgraded We anticipate services
their already existing Bone Density Head | Cervical spine | Knee* commencing mid-March.
services, completing the Bone All other imaging not Medicare indicated *Where clinically indicated
Density fleet upgrade for 2020. can still be performed on this scanner.
drjones.com.au/online-referring
medicSA | 7
Doctor Led • Patient Focused • Quality Driven drjones.com.au
AGED CARE
The rights approach
Human rights academic Professor Wendy Lacey and
aged care activist Daniella Greenwood write that a
human rights approach to caring for older Australians will
transform conditions that have led to a Royal Commission
and been in the spotlight again during the pandemic.
H
uman rights do not change abuse, and these statistics are no
simply because we age. No doubt conservative and do not include
human right disappears instances of financial or sexual abuse.
when we reach 65 years of As the Royal Commission into Aged
age or when we start receiving aged care Care Quality and Safety has already
services. As professionals in the sector, disclosed, additional investment has
we must ensure that we preserve the not resulted in better outcomes for Human rights academic
human rights of older Australians, at older people. Professor Wendy Lacey
every turn. The failure to do so means None of this is news to those who have
we will be letting down our most been following the Royal Commission, PATERNALISM AND
vulnerable patients, neighbours, family least of all members of the medical DECISION‑MAKING
members and friends. profession who have long been calling A commitment to human rights law
Around $27 billion a year goes into for a complete overhaul of the aged and norms moves aged care beyond
the provision of aged care in Australia care system. A key outcome of the Royal patient-centred approaches that have
– 76 per cent of this is covered by Commission is very likely to be the failed to protect the rights of the most
government subsidies and 21 per cent creation of a new Aged Care Act based vulnerable – particularly the right to
by individual private contributions. on human rights principles. This shift self-determination. Based on the closing
Residential aged care providers constitutes more than an overhaul – it submissions of Senior Counsel assisting
receive around 18 billion of the total requires a complete re-engineering of the Commission, a rights-based
annual aged care spend -$13 billion in aged care services in Australia. It will approach will be embedded in new law
government subsidies and a further also require a paradigm shift among and policy. However, we do not yet know
$4.8 billion from resident contributions. medical professionals. what that will look like in terms of the
None of these figures include the
A HUMAN RIGHTS detail for health professionals.
estimated $41.7 billion that is spent on
the health care needs of Australians APPROACH TO AGED CARE What we do know is that it will
aged 65 years or over. It is important to stipulate that require considerable effort in calling
These are the types of figures that excellent medical care where needed out paternalistic practices that
take centre stage in articles and is fundamental to a human rights have been codified and normalised
conversations about the state of aged approach. This includes ensuring GPs across aged care. The normalisation
care in Australia. The figures provide are at the centre of medical planning of these practices has occurred
answers to important questions and that there are enough aged care staff because paternalistic attitudes and
such as how much? Who gets it? and registered nurses to provide skilled assumptions in relation to vulnerable
What is it achieving? Can it be done and humane care and support. older people are largely invisible and
more efficiently in light of an ageing A system underpinned by human accepted. Paternalism is the anthesis of
population? But the figures do not rights demands clarity around what human rights.
provide an answer to the most pressing does and does not come under There is considerable overlap with
question we are called upon to ask the umbrella of medicine. This is discussion of the rights of persons
ourselves as a community – how do we particularly vital in residential aged care with disabilities –particularly in the
want to grow old together in Australia? where everyday decisions, tasks, desires, area of decision-making. Article 12
When it comes to residential expressions and functions – all central of the Convention on the Rights of
aged care, it seems we are spending to human rights and citizenship – are Persons with Disabilities (CRPD) seeks
$18 billion annually on something frequently subject to medical sanction, to address the legacy of paternalism
that no older person wants – at least the opinions of family and aged care and the stripping away of human and
no one wants what it currently does, staff, or to the strict routines in care citizenship rights associated with
with some saying they would rather homes designed to optimise financial substitute decision-making. It outlines
die than move into a residential aged efficiencies. Currently, all aspects of an the rights of persons with disabilities
care facility. It is estimated that 39 per older person’s life are on the table for to enjoy ‘legal capacity on an equal
cent of residents living in residential others to approve of, make decisions basis with others in all aspects of life’,
aged care have experienced some form about or override – frequently for the highlighting that people have a right
of emotional abuse, neglect or physical older person’s ‘own good’. to make their own decisions and to be
8 | medicSA
AGED CARE
This will involve re-engineering - Ensure that legal powers are used
an aged care system founded on only for the explicit purposes they are
consumerist and market-based meant to under law, as required, and
principles and ideology. Human rights always giving effect to the current will
cannot be left in the hands of market- and preferences of the individual.
forces, because vulnerable people are - In situations where the capacity to
not consumers with the capacity to express decisions and preferences is
engage in complaint mechanisms or most compromised, the current will
abandon services that are below par. and preferences of an older person is
A human rights approach recognises a measure of their self-determination
that vulnerability is part of the and it is a matter of human rights that
human condition and, thus, it is the this be upheld (not someone’s opinion
responsibility of society to include and of what is ‘best for them’ or based
support vulnerable citizens – that this on a memory of the way someone
is a moral responsibility that cannot be ‘used to be’).
outsourced or left to the whims of the - Model threshold thinking in
profit motive. situations where the currently
expressed will and preferences of
CONTINUITY an older person is at risk of being
Understanding the currently
overridden - demanding that the
expressed will and preferences of threat of serious and imminent risk
Aged care consultant Daniella Greenwood vulnerable people and those living with to the person or others be established
cognitive changes such as dementia before paternalism is considered.
provided with decision-making support requires time and patience in the - Clearly articulate the areas that come
that gives effect to their current will context of long-term relationships. under the umbrella of medicine
and preferences. The CRPD and Article Adhering to Article 12 of the CRPD and those that do not. Medical
12 cover a broad range of disabilities means a commitment to continuity professionals – particularly GPs
including the physical and sensory of care and consistency in care – can assist the aged care workforce
disabilities experienced by older people and therapeutic relationships as a in understanding the importance of
and the cognitive changes experienced by reasonable accommodation to support teasing apart the medical from all
people living with dementia. human rights. In this respect, changes to other aspects of people’s lives.
We argue that in situations where the the aged care system must prioritise the - Acknowledge that in supporting
currently expressed will and preferences maintenance of long-term therapeutic the most vulnerable citizens in the
of an older person are contested, a relationships between older citizens community there is a risk of creating
threshold in relation to the severity and their GPs, and consistency in ‘perfect and compliant’ patients –
and likelihood of the proposed harm the staff providing day-to-day care often because their expressions of
to the individual or others must be in a community or residential aged preference take time and patience
established. This is vital in ensuring care context. to understand, and/or because these
that the approach adopted in cases of MOVING BEYOND HIGH-LEVEL expressions are simply overruled,
serious and imminent risk is not applied ABSTRACT PRINCIPLES. ignored or pathologised by aged
to everyday decisions that others in the In their submission to the Royal care professionals.
community would expect to be permitted Commission, the AMA pointed out - Ask different questions when
to make for themselves, without medical the danger in relying on high level and presented with the possibility of
or family sanction. ‘potentially vague’ principles such as prescribing psychotropic medication
HUMAN RIGHTS FOR THE those underpinning the new Aged Care in a residential aged care context.
MOST VULNERABLE Quality Standards, including the risk A human rights approach calls for a
that these will translate to little more range of practice and operational non-
It is estimated that 70 per cent of
than a ‘tick box’ administrative exercise negotiables such as relaxed schedules,
residents living in aged care institutions
on behalf of aged care providers. The consistent staffing, and affording
are experiencing some form of cognitive
same danger exists with the shift to adult-status in communications
decline, yet the system still persists
a human rights approach, which is and interactions. These shifts can
with survey, assessment and evaluation
why there must be clarity in a range influence the behaviour, moods,
methods that do not accommodate
of observable and measurable human protests and responses of people
people experiencing a range of cognitive
rights expectations and non-negotiables living with dementia and so it is vital
changes. It is the equivalent of not they are in place before medication
providing wheelchair ramps, Braille relating to the practice and operations of
aged care services. is considered.
resources or sign language interpreters
to support the inclusion of all abilities. HOW CAN MEDICAL Daniella Greenwood is an international
Under a human rights approach, efforts PROFESSIONALS consultant in human rights policy and
to promote decision-making, choice, SUPPORT HUMAN RIGHTS practice in residential aged care. Professor
and engagement with care planning and IN AGED CARE? Wendy Lacey is Executive Dean of the
quality assurance processes will have to - Model behaviours and practices Faculty of Business, Government & Law at
be re-designed to accommodate these that reflect respect for human the University of Canberra. Her research
people so that their voices can be heard rights – the right to health is not has centred on the rights of older persons
beyond proxy accounts and inputs. the only human right. and the prevention of elder abuse.
medicSA | 9
Bulk Billing
most Medicare
eligible
indications
OPENING FEBRUARY 2021
Qscan Windsor Gardens
Qscan is pleased to announce the opening of our latest radiology clinic in Windsor Gardens.
Our state of the art facility will provide a comprehensive array of specialist medical imaging services that include:
Digital x-ray • Ultrasound • CT • Interventional procedures • PET-CT.
Most Medicare eligible examinations will be Bulk Billed, with x-rays and scans interpreted by Qscan’s
focussed team of highly trained subspecialty Radiologists.
Bulk Billing most Digital x-ray, ultrasound, CT, Supported by local
Medicare eligible interventional procedures and on-site and national
examinations PET-CT team of subspecialty
Radiologists
Qscan Windsor Gardens
Level 1, 480 Specialist Centre
480 North East Road (access via North East Road) WE ACCEPT ALL REFERRALS
Windsor Gardens SA 5087
p: (08) 8164 5600 f: (08) 8164 5045
e: windsorgardens@qscan.com.au From diagnosis to cure, Qscan will partner with you
and your patients by providing unparalleled service,
Monday - Friday: 9:00am - 5:00pm utilising exceptional technology and the most trusted
Ample free on-site parking for patient convenience. interpretation of disease process.
Trusted Analysis | Excellence | Compassionate Care qscan.com.au
10 | medicSALocal prescribers
embrace e-scripts
The ease of use and benefits to doctors and patients
are prompting the rapid adoption of ‘ePrescriptions’
Andrew Matthews Sarah Wiles
in South Australia.
T
he number of electronic over a paper prescription, they will be a patient’s active prescriptions and
prescriptions in South Australia able to get this dispensed at their local repeats that may be dispensed. Patients
increased dramatically as community pharmacy.’ who choose to use an ASL will not need
electronic prescribing formally General practices and community to keep their prescription tokens. ASL
expanded in December 2020. More than pharmacies should communicate to will be increasingly available from April,
500 prescribers are now using them ensure they are ready to write and and functionality is expected to improve
across the state. dispense electronic prescriptions, during 2021.
Adelaide’s COVID cluster in November he says. Ms Wiles says ASLs will be especially
provided a catalyst, enabling general Mr Matthews says medicine safety, useful for doctors caring for patients in
practice management software and including errors in transcribing residential aged care facilities. ‘Access to
pharmacy dispensing software to medication into drug charts, was a and use of the ASL will provide another
be upgraded with a new electronic focus of the Royal Commission into option for patients to track and manage
prescription functionality that boosted Aged Care Quality and Safety. Electronic their prescriptions with no more repeat
the number of general practices using prescriptions will support GPs in requests due to lost scripts,’ she says.
the technology. managing medicines safely, including in She predicts that ASLs will become
Australia’s COVID-19 National Health residential aged care facilities, he says. more useful in aged care facilities
Plan and the fast-track implementation Adelaide GP and AMA(SA) Councillor as online medication charts are
of electronic prescribing to support Dr Danny Byrne is an early adopter of integrated with software systems.
telehealth measures were announced ePrescribing. ‘Electronic prescriptions ‘It will enable a prescriber to send the
in March last year. Country SA PHN’s have proven their worth for simple, one- prescription directly into the medication
Manager of Digital Health and Systems off scripts in conjunction with telehealth, chart and notify the pharmacist for
Integration, Sarah Wiles, says electronic dispensing, with alerts on the chart for
and dramatically simplified my workload
prescribing provides advantages beyond
for bulk repeat scripts for aged care home administration in the facility,’ Ms Wiles
the immediate benefit of a single
residents,’ he says. says. ‘That is a single entry - no more
electronic script, especially as telehealth
‘With a telehealth consult, a patient transcribing of medications.
has been announced as a permanent
doesn’t have to come to the surgery to ‘Being ready for ePrescribing will
Medicare subsidised fixture in Australia’s
pick up the script and we don’t have to also set GPs up to participate in South
health system.
fax it to the chemist. It’s now a three- Australia’s Real Time Prescription
‘The viability of telehealth consulting
second process.’ Monitoring (RTPM) Script Check, which
has always been constrained by the
With patients receiving their is due to start roll-out in March.’
limitations of a paper prescription as
ePrescription ‘tokens’ by mobile phone For more information about electronic
the only legal form to supply medicines,’
or email, Dr Byrne says it is critical prescribing and electronic prescriptions:
Ms Miles says. ‘Even beyond COVID-19,
it will be a great advantage for a rural patients’ contact details are accurate, to • Department of Health: www.health.
patient to have a telehealth consult with avoid a potential breach of privacy. ‘The gov.au/initiatives-and-programs/
a doctor in Adelaide and receive their important thing is to think before you electronic-prescribing
prescription electronically.’ click to issue an ePrescription, to ensure • Australian Digital Health Agency:
The Australian Digital Health the mobile number is the correct one,’ www.digitalhealth.gov.au/
Agency (ADHA) has been responsible he says. get-started-with-digital-health/
for the technical framework for Pharmacists are also beginning to electronic-prescriptions
electronic prescribing and the national use the Active Script List (ASL), another • Country SA PHN: www.countrysaphn.
implementation, with the Department ePrescription option. The ASL includes com.au/support/digital-health/
of Health. ADHA’s Director of Medicines
Safety, Andrew Matthews, says more GROWTH IN ELECTRONIC PRESCRIPTIONS IN SOUTH AUSTRALIA
than 98 per cent of South Australian
community pharmacies are now Number of
Number of Number of
dispensing electronic prescriptions. community
ePrescriptions prescribers who
‘Since the first ePrescription was DATE pharmacies
issued by have issued
generated in May 2020, more than three dispensing
prescribers ePrescriptions
million have been issued nationally,’ ePrescriptions
Mr Matthews says. ‘Prescribers can be 18 November 2020 7,684 114 246
confident that if a patient prefers an
electronic prescription from their doctor 12 January 2021 42,366 555 500
medicSA | 11COMBATTING CORONA
No one left behind
The AMA’s advice, advocacy and intervention are instrumental the continuation of current COVID-19
in planning and managing Australia’s delivery of COVID-19 precautions, and that being vaccinated
vaccines, writes AMA Vice-President and AMA(SA) President will not mean that international
Dr Chris Moy. travellers will not need to quarantine.
This is a project of unforeseen scale
A
in this country. In some forums, I’ve
ustralia’s COVID-19 strategy At the time of writing, the Pfizer likened it to Dunkirk – both in terms of
is rapidly evolving as details vaccine had been provisionally approved size and in how many critical elements
firm – about developing for use in patients over 16 years, with must be considered and addressed for us
scientific evidence the first round of vaccinations about to to be successful.
and the practicalities of what is a begin. The AstraZeneca vaccine had also
just been approved by the independent INFECTION VS DISEASE
massive undertaking to protect the
regulator and it will be largely PREVENTION
Australian community.
manufactured at the Commonwealth Given early fears that a vaccine
The AMA has been a key player against COVID-19 might never be
in advocating and intervening to Serum Laboratories in Melbourne –
hopefully bypassing emerging problems developed, we should be relieved and
ensure the strategy provides the best thankful that a slew of safe and effective
with global supply chains. A consulting
possible outcomes for public health vaccines has already appeared, and
firm was commissioned to analyse the
and for doctors who must deal with others are being developed.
potential for Australia to manufacture
the consequences. Beyond some debates about the
mRNA vaccines, and while there is some
As shown on p13, the Australian expertise in this space, it is not yet at a relative ‘efficacies’ of the first two
Government has entered four commercial level. vaccines off the rank – the Pfizer/
contracts for the supply of COVID-19 While attention has understandably BioNTech and AstraZeneca (AZ)
vaccines, should they be approved by been on vaccines – particularly as new vaccines – the only clear evidence is
the regulator. Some of the vaccines variants emerge – the Prime Minister that both are safe and are very good
will be used to supply Australia’s has reminded us all that the vaccination at stopping severe disease and death.
Pacific neighbours. program will not be a substitute for ...Continued on page 13
New rooms now open
North Eastern Community Hospital
580 LOWER NORTH EAST ROAD, CAMPBELLTOWN
• Convenient parking
• Expert care
• Priority appointments available
The most comprehensive range of expert care in SA, consulting from over 20 locations.
Dr Philip Brook Dr Saleem Hussenbocus Dr Daniel Mandziak Dr Anthony Samson Dr Darren Waters
Dr Jonathan Cabot Dr David Hermann Dr James McLean Dr Aman Sood Dr Justin Webb
A/Prof Peter Cundy Dr Mark Inglis Dr Yu Chao Lee Dr Aaron Stevenson A/Prof Nicole Williams
Dr George Dracopoulos Dr Meng Ling Dr Andrew Mintz Dr Brian Wallace Dr Peter Viiret
Prof Brian Freeman Dr Matthew Liptak Dr Mario Penta Dr Jason Ward
P 08 8267 8267 orthosa.com.au
12 | medicSACOMBATTING CORONA
Continued from page 12 ...
COVID-19 vaccine national
roll-out strategy
Phase 1a – up to 1.4m doses Ongoing
Phase 1a – up to 1.4m doses
Quarantine and border
70,000
workers
Phase 1b – up to 14.8m doses
Frontline health care
worker sub-groups for 100,000 Elderly adults aged 80
1,045,000
prioritisation years and over Phase 2a – up to 15.8m doses
Elderly adults aged 70-
1,858,000
Aged care and disability 79 years Adults aged
318,000 2,650,000
care staff Other health care 60-69 years
953,000
workers Phase 2b – up to 16m doses
Adults aged
Aged care and disability Aboriginal and Torres 3,080,000
190,000 50-59 years
care residents Strait Islander people > 87,000
Balance of adult
55 6,643,000
Aboriginal and Torres population Phase 3 – up to 13.6m doses
Total 678,000 Strait Islander people 387,000
Younger adults with an 18- 54
underlying medical Catch up any
2,000,000 unvaccinated < 18 if recommended* 5,670,000
condition, including
those with a disability Other critical and high Australians from
453,000 previous phases
risk workers
Critical and high risk
workers including Total 6,570,000
defence, police, fire, 196,000
emergency services
and meat processing
Total 6,139,000 Population numbers are current estimates for each category.
* 16 and 17 year olds will be able to access the Pfizer vaccine in line with the relevant cohort.
Australia Government, February 2021
As such, the current primary goal of the The Pfizer vaccine will be rolled out evidence yet of any significant safety
COVID-19 vaccination program is the to the first group of about 600,000 issues, even those that were thought
protection of individuals from having to Australians at high risk of being infected possible in the current vaccines.
go to hospital and perhaps dying from or serious disease. Given its storage For example, there have been
the virus. requirements, it’s primarily being rolled concerns about mRNA vaccines and
What is unclear is whether these out through hospitals. whether their genetic material could be
vaccines can prevent asymptomatic The AZ vaccine, a viral vector vaccine incorporated into our genome. But we
infection or transmission. As a result, that can be stored in a standard freezer have two decades of experience with
the goal of the current program is not and comes in more manageable DNA vaccines and there has been no
attaining ‘herd immunity’, although batch sizes, will be easier to deliver in evidence of this so far.
this is a secondary aim and our capacity the community and to more people. In addition, concerns about the
to achieve it will emerge with further A vaccine developed by Novavax – a vaccines causing Guillain-Barre
scientific evidence. protein-based vaccine that will be syndrome or antibody-dependent
Further unknowns are for how long manufactured in Australia – may be enhancement of disease have not
these vaccines will be effective, and more widely used later as its transport
been borne out, despite significant
how emerging variants of COVID-19 and storage requirements are
international experience.
will impact on their effectiveness. So, less onerous.
until we know more it is likely that the With changes to scientific evidence, COMMUNITY ACCEPTANCE
vaccine program may have to adjust and we may end up with mixed regimes – The AMA will have an important
incorporate new vaccines, or booster say, with AZ first and then an mRNA or role in encouraging community
shots of updated versions of the current protein vaccine as a second dose or a acceptance and overcoming lingering
ones, as we work towards maximal booster later. vaccine hesitancy. We’ve continually
protection against an evolving virus. SAFETY emphasised that we are an independent
LOGISTICS So, the $1 million question – especially voice, focused on achieving the best
It’s not the vaccine that will save us, considering all the anti-vax sentiment, possible outcomes for the health of
our patients.
© Australia Government, February 2021
but the vaccination of the majority of confusion and crack-pot science in
the community. the community: are the vaccinations It is important that the AMA walks
However, logistics associated with really safe? a careful line between asking the
the vaccines, such as having to store Australia has had the benefit of being hard questions about issues such as
the Pfizer vaccine at minus 70 degrees able to watch and learn from overseas which vaccine should be adopted or
Celsius and large batch numbers, are experiences, as first the clinical trials, the practicalities of the roll-out and
playing a major part in the roll-out and then large-scale deployments of the reassuring the public about the overall
strategy. But because it was the first vaccines under emergency provisions, sense of the strategy and purpose in this
approved, the Pfizer vaccine will be the has occurred. The information from effort to protect them.
first one we see. overseas has been positive, with no ...Continued on page 14
medicSA | 13COMBATTING CORONA
Continued from page 13 ... Phase 2b AMA advocacy, the funding secured for
We need strong, clear, consistent • Remaining adults distribution via Australia’s GP practices
messaging. Just as the Prime Minister • Any missed from earlier phases is many times that being directed
has been pressured to keep Craig Kelly to pharmacies.
SIDE EFFECTS
in line because of the divisive nature The AMA advocacy has also secured
Reports from international
of his false and inflammatory claims for GPs more after-hours and rural
jurisdictions, including the UK,
and statements, so must doctors stick funding support, allowing appropriate
suggest side effects are likely to be few.
together. It is important to build and co-claiming with other MBS items,
People may experience chills, fatigue
maintain trust in the vaccine program and the provision of consumables and
and headaches. In clinical trials of
in public, rather than reinforce required PPE. The increased loading to
both vaccines, mild to moderate side
inaccuracies or create distractions. support vaccination after hours was key
effects were common within a week of
to helping practices provide the vaccine
PRIORITY GROUPS vaccination. Most side effects, however,
while not upsetting the care of their
The vaccine will be rolled out to usually occur within a day or two and go patients in-hours.
priority groups first – those at greater away in a few days.
An NHS study in the UK found few RECORDING, INDEMNITY
risk of exposure or likely to have a more
side effects in a study of about 40,000 AND SYSTEMS
serious disease – and then sequentially
people, most of whom were healthcare The recording of vaccinations is
in groups, with the overall aim to
workers. The study found: critical to the roll-out strategy. The type
reduce risk.
• 37 per cent of participants and sequence of vaccinations must be
Trials will have to be conducted on
experienced some local ‘after-effects’, recorded in the Australian Immunisation
children and younger people before
such as pain or swelling near the site Register, and this requirement has now
a vaccine is approved for paediatric been enshrined in legislation. This will
use, as is the case with other vaccines of the injection, after their first dose,
rising to about 45 per cent of the be crucial, particularly for individuals
developed for adults. who will need proof of vaccination in
Children under five years who are 10,000 who had received two doses
the future.
more at risk of complications such • 14 per cent had at least one whole-
The AMA has advocated for
as febrile convulsions are unlikely to body (systemic) after-effect – such as
doctors to have the informed consent
receive a vaccine in the near future and fever, aches or chills – within seven
process reviewed by medical defence
are more likely to receive a protein- days of the first dose, rising to about
organisations (MDOs) and the Australian
based vaccination (such as the Novavax), 22 per cent after the second dose.
Health Practitioner Regulation Authority,
which is less reactogenic. Young people People with a history of significant
and to fully address indemnity issues –
won’t be negatively affected by the delay allergic reactions, rather than general
although all major MDOs have confirmed
in vaccinating them because they tend allergies, have been advised not to have
they will cover doctors administering
not to be symptomatic or to have mild the mNRA Pfizer-BioNTech vaccine or
COVID-19 vaccines to their patients.
symptoms. However, this strategy will the similar Moderna vaccine because
There are also questions about how
reduce the potential for herd immunity, of a small number of anaphylactoid
to ensure the National Booking System
as young people under 20 account for reactions. Because the vaccine is not will operate – for example, for less IT-
25 per cent of the Australian population. ‘live’, theoretically it can be given to literate patients and for those for whom
At the time of writing, the roll-out in immune-compromised people and English is not the primary language.
Australia will look like this: pregnant women, and it will be, offered At this stage, the proposal is that the
Phase 1a on a case-by-case basis. National Booking System will comprise
• Quarantine and border workers ADMINISTERING THE VACCINE a one-stop shop website where a patient
• Frontline health care workers While pharmacists have campaigned can obtain information about COVID-19
• Aged care and disability staff to deliver the vaccine, the AMA has vaccination, determine their eligibility,
• Aged care and disability residents argued that the credibility of the and find a practice for service with which
Phase 1b program is boosted when the program they will be able to book an appointment.
• Adults over 80 years is led by doctors. We have argued that However, there are complex issues
• Adults 70-79 it would be difficult for pharmacists to finalise, such as how patients can
• Other health care workers to provide the vaccination in privacy determine and confirm their eligibility
• Aboriginal and Torres Strait Islander and in a COVID-safe way; that it is based on medical conditions. And to
people over 55 important that the vaccine is delivered prevent wastage, there must be accurate
• Younger adults with an underlying by people trained to manage potential matching of the number of patients
medical condition, including those risks associated with allergic reactions. booked to the number of doses contained
with a disability How could pharmacists know a patient’s in each multi-dose vial.
• Critical and high-risk workers. history to assess whether and when they MY ELEVATOR PITCH
including defence, police, should get the vaccine? The COVID-19 vaccine roll-out is
fire, emergency services and In addition, there seem to be major a hugely important undertaking for
meat processing barriers to pharmacy provision of the our patients and our communities.
Phase 2a vaccine, including lack of privacy for Australians are crying out for this
• Adults aged 60-69 years discussions, difficulties in providing protection and for their lives to get
• Adults aged 50-59 years the vaccine in a COVID-safe manner closer to normality. As doctors, it is a
• Aboriginal and Torres Strait Islander in a busy pharmacy, and the ability to time to stand up, remember why we
people 18-54 observe and properly respond post- joined the profession, and get the job
• Other critical and high-risk workers vaccination. As I write this, largely due to done for them.
14 | medicSA?????
AMA highlights
vaping harm
The AMA is encouraging limitations to Australians’
access to vaping products.
R
egulatory changes to close a is evidence to suggest vaping causes in quit rates, compared to other forms of
loophole that allows people harm in brain development and can smoking cessation assistance.
to access imported nicotine increase the risk of respiratory and It also noted that people using
products for vaping without cardiovascular disease.’ nicotine vaping products to stop
a prescription will come into effect ‘At the moment, public discourse smoking were significantly more
from October 2021, amid evidence that is focused on vaping as a smoking likely than people using other forms
young people are increasingly taking up cessation tool but there is little of nicotine-replacement therapies
e-cigarettes. discussion about the rising social to continue using the products after
The Therapeutic Goods uptake.’ one year.
Administration (TGA) announced In a media statement, Federal Health ‘On the basis of the eight or so RCTs
in December that imports of Minister Greg Hunt said there had been the review looked at, vaping was not
nicotine e-cigarettes and liquid rapid growth in vaping uptake by young found to be a more effective aid in
nicotine for vaping will require a people around the world. smoking cessation than counselling and
doctor’s prescription, aligning with • Between 2016 and 2019, the number other forms of nicotine replacements
domestic laws. of current e-cigarette users in such as patches, gums and nasal sprays,’
It rectifies a regulatory twist through Australia aged 15-24 increased by Dr Khorshid said.
which consumers could import nicotine 72,000, or 95.7 per cent, to reach Under the new regulations, medical
products, even though possession or 147,000. practitioners who consider nicotine
use without a prescription is illegal in • Recent Australian National University e-cigarettes an appropriate treatment
all states except South Australia and (ANU) research indicates e-cigarette for a patient trying to quit smoking can
domestic sales are illegal. users are three times more likely to prescribe them if they have approval
The TGA scheduling delegate said, take up traditional cigarette products through the TGA Access Pathways. This
‘restrictions on the availability of as non-users. is because there are no TGA-approved
e-cigarettes are necessary to mitigate • Between 2015 and 2019, e-cigarette nicotine vaping products. The medical
the potential uptake of smoking in usage by US youth increased by practitioner does not have to apply if
young adults who would otherwise be at about 1.13 million young people aged the patient is importing less than a
low risk of initiating nicotine addiction’. 14-19 years (a 71.9 per cent increase). three-month supply through the TGA
This responds to evidence that Around 4 million US high-school Personal Importation Scheme. Nicotine
nicotine e-cigarettes act as a ‘gateway’ students use e-cigarettes. e-cigarettes will also be dispensed
to smoking in youth, and that Even vaping products without from pharmacies.
exposure to nicotine in adolescents nicotine are considered potentially Yet most medical practitioners are
may have long-term consequences for harmful. Flavoured vaping products likely to support vaping as a quit-
brain development. are not illegal but contain harmful smoking tool only as a last resort.
The amendment to limit access chemicals such as formaldehyde and ‘The amendment will mean that
to imported nicotine products by other carcinogens and, disturbingly, rather than having ready access to
rescheduling it on the Poisons Standard despite the ban on nicotine in imported vaping products, patients will
aims to eliminate an ‘ON RAMP’ to e-cigarettes, random sweep-studies of be required to discuss the whole range
nicotine addiction for non-smokers, vaping products found nicotine in many. of treatments with their GP if they are
while enabling smokers to legally access ‘In the past, people did not realise the seeking a vaping prescription. Some
nicotine e-cigarettes to help them quit dangers of smoking. Everyone smoked will not be willing to prescribe it at all,’
smoking – to provide the ‘OFF RAMP’ in the car, they smoked inside,’ Dr Dr Khorshid said.
for smokers. Khorshid said. ‘There are some alarming He said the TGA should consider
AMA President Dr Omar Khorshid similarities in the present day in terms additional regulations on the vaping
said the AMA supported the of lack of public awareness. There’s not a products – as well as their use – to limit
amendment as an additional barrier lot of understanding among people who potential harms.
to people taking up vaping. However, don’t vape about what is occurring and ‘It’s important that people continue to
he said, concerns remain around why it is appealing or how people access be made aware of the potential harms of
characterising vaping as an effective e-cigarettes.’ vaping,’ he said. ‘The new amendment
© istock - ljubaphoto
smoking cessation tool. In its submission to the TGA review, means that rather than relying on
‘We do not have credible evidence the AMA noted that a recent ANU anecdotal evidence or Dr Google,
to show that e-cigarettes and vaping review of randomised controlled trials patients who are trying to quit smoking
are safe, or that they are effective as a (RCTs) found e-cigarette use was not will have access to evidence-based
cessation aid,’ Dr Khorshid said. ‘There associated with a significant difference advice about the most effective tools.’
medicSA | 15RESEARCH
New research
a watershed
South Australian research into breast cancer
treatments may transform outcomes for
women around the world.
A
fter more than 30 years of Marshall swallowed
research, an international the H. pylori bacteria to
team led by researchers at the prove it caused stomach
University of Adelaide has ulcers, debunking the
published paradigm-shifting evidence prevailing wisdom that
that will offer hope to metastatic they were caused by
breast cancer patients where standard acid build up.
treatment has failed. ‘We could have Professor Wayne Tilley, Associate Professor Theresa Hickey
It will also potentially improve their published this research and Dr Stephen Birrell
quality of life during treatment. three to five years ago,’
The paper in the prestigious journal Professor Tilley says, ‘but we wanted to The DRMCRL research has provided new
Nature Medicine provides definitive publish in a high-impact journal such insight into the way androgen receptors
preclinical evidence that stimulating as Nature Medicine, which required work in the breast.
androgen receptor activity is a better generating compelling evidence that Professor Tilley says it’s well
way of treating estrogen-receptor driven this strategy would work across the understood that abnormal estrogen
breast cancer (in 75 to 80 per cent of all spectrum of ER-positive breast cancers. receptor activity can lead to cancer cells
cases) than the standard approach of ‘This required us to develop a range proliferating and surviving in the breast,
inhibiting estrogen receptors. It also of contemporary preclinical breast just as abnormal androgen receptors
shows the treatment has positive rather cancer models using human tissues and do in the prostate. However, he says,
than negative side effects. interrogating these models with new confusion reigned about whether
The Dame Roma Mitchell Cancer genomic technologies.’ androgen receptors were a help or a
Research Laboratories (DRMCRL) at ‘By holding our nerve and producing hindrance in breast cancer treatment.
the University of Adelaide collaborated definitive data in the Nature Medicine Androgens were historically
with researchers the Garvan Institute publication, including preclinical data used in treating breast cancers,
of Medical Research in Sydney and in independent laboratories around the but the mechanism was poorly
overseas institutions to develop the world using multiple models, we can understood and the treatment, based
compelling evidence required by Nature now put to rest a lot of the arguments on naturally occurring androgens
Medicine to end a long-standing debate against using androgens in the in men, was discontinued because
about the role of the androgen receptor treatment of breast cancer,’ he says. it had masculinising side-effects.
in breast cancer. ‘We believe these findings will result New estrogen receptor targeting
The team was led by DRMCRL director in a seismic shift in how to exploit the drugs (that is, endocrine therapies)
Professor Wayne Tilley, who cloned androgen receptor in breast cancer replaced androgens as the standard of
the human androgen receptor in the using selective androgen receptor care treatment.
late 1980s at the University of Texas modulators that lack the virilising side The prevailing thinking around breast
Southwestern Medical Center in Dallas; effects of “male” hormones and are not cancer treatment focused on inhibiting
the head of the DRMCRL Breast Cancer metabolised to estrogen. estrogen biosynthesis or blocking
Group, Associate Professor Theresa ‘It’s uncommon to have this estrogen receptors. But, says Professor
Hickey; and DRMCRL affiliate Dr much reproducibility … that’s pretty Tilley, although endocrine therapies
Stephen Birrell, former director of the extraordinary and I think that’s why the have very good initial treatment
Breast Cancer Unit at Flinders Medical scientific and medical community has responses, endocrine therapies are
Centre and now chair of Adelaide- embraced this as being an important not curative. Not only do they fail to
based HAVAH Therapeutics and step forward in developing a potential prevent breast cancer recurring in some
Wellend Health. new hormone therapy to treat women, but they can also have terrible
The DRMCRL team says the finding breast cancer.’ side effects.
is the type of light-bulb moment that Researchers have long known that Most people do not appreciate that
occurred when Australian researcher estrogen receptor-positive breast while the five-year survival rate for
and Nobel Laureate, Professor Barry cancers also have androgen receptors. breast cancer has risen impressively
16 | medicSAYou can also read
