Radiation oncology occupies a very important place in cancer therapy as an essential member of the multidisciplinary approach to cancer treatment . Of the near 146 000 Australians diagnosed with cancer each year is estimated that about half would benefit from radiation therapy as part of their overall cancer treatment.

Radiation therapy is a highly cost-effective cancer therapy contributing only about 10% of each healthcare dollar spent on treating cancer overall yet vital in about 40% or cancers that are cured. The technology employs ionising radiation that causes the ejection of an orbital electron which is the molecular event leading to damage and eventually cell death. The radiation used may be either electromagnetic in nature using photons or gamma rays or particulate- directing a stream of electrons, protons or other atomic particles to the target and causing DNA damage to both normal tissue and tumour cells. Cells are most susceptible in the G1 and G2 phases which represent growth and preparation for mitosis as well as the mitosis phase referred to as the M phase. Additionally, hypoxic cells are thought to be less susceptible to radiation than well-oxygenated cells as free radicals formed by ionising radiation are more easily repaired in the absence of oxygen.

Photon therapy is interesting in allowing delivery of energy to internal malignancies with relative tolerance at the level of the skin.

Radiation dose is measured as energy per unit mass -where 1 J/kg is 1 Gray.

In this podcast I was joined by Dr Marcus Foo who is a radiation oncologist with Genesis Care. Marcus graduated from the University of Melbourne in 2000 and trained in radiation oncology at the Peter MacCallum Cancer Centre before undertaking a clinical and research fellowship at the BC Cancer Agency in Vancouver, Canada focusing on gastrointestinal, breast and genitourinary oncology. He has strong interest in stereotactic radiation therapy and image-guided radiation therapy. I was keen to discuss with Marcus the principles of radiation oncology in more depth and understand much of the terminology used such as ‘fractionated radiotherapy’, ‘external beam’, ‘brachytherapy’, ‘stereotactic’ and ‘palliative therapy'. This conversation is covered across two very interesting episodes. I hope you enjoy the interview and I am pleased you have joined us.

References:

Dr Marcus Foo: www.genesiscare.com

Introduction to Radiation Oncology: www.astro.org

Introduction to Radiation Oncology : Apicelli, Parikh and Zoberi, Haematology and Oncology Subspecialty Consult, 4th Ed,Wolters Kluwer

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

Radiation oncology occupies a very important place in cancer therapy as an essential member of the multidisciplinary approach to cancer treatment . Of the near 146 000 Australians diagnosed with cancer each year is estimated that about half would benefit from radiation therapy as part of their overall cancer treatment.

Radiation therapy is a highly cost-effective cancer therapy contributing only about 10% of each healthcare dollar spent on treating cancer overall yet vital in about 40% or cancers that are cured. The technology employs ionising radiation that causes the ejection of an orbital electron which is the molecular event leading to damage and eventually cell death. The radiation used may be either electromagnetic in nature using photons or gamma rays or particulate- directing a stream of electrons, protons or other atomic particles to the target and causing DNA damage to both normal tissue and tumour cells. Cells are most susceptible in the G1 and G2 phases which represent growth and preparation for mitosis as well as the mitosis phase referred to as the M phase. Additionally, hypoxic cells are thought to be less susceptible to radiation than well-oxygenated cells as free radicals formed by ionising radiation are more easily repaired in the absence of oxygen.

Photon therapy is interesting in allowing delivery of energy to internal malignancies with relative tolerance at the level of the skin.

Radiation dose is measured as energy per unit mass -where 1 J/kg is 1 Gray.

In this podcast I was joined by Dr Marcus Foo who is a radiation oncologist with Genesis Care. Marcus graduated from the University of Melbourne in 2000 and trained in radiation oncology at the Peter MacCallum Cancer Centre before undertaking a clinical and research fellowship at the BC Cancer Agency in Vancouver, Canada focusing on gastrointestinal, breast and genitourinary oncology. He has strong interest in stereotactic radiation therapy and image-guided radiation therapy. I was keen to discuss with Marcus the principles of radiation oncology in more depth and understand much of the terminology used such as ‘fractionated radiotherapy’, ‘external beam’, ‘brachytherapy’, ‘stereotactic’ and ‘palliative therapy'. This conversation is covered across two very interesting episodes. I hope you enjoy the interview and I am pleased you have joined us.

References:

Dr Marcus Foo :www.genesiscare.com

Introduction to Radiation Oncology: www.astro.org

Introduction to Radiation Oncology : Apicelli, Parikh and Zoberi, Haematology and Oncology Subspecialty Consult, 4th Ed,Wolters Kluwer

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

In the September 25-26 edition of the weekend Australian magazine, I was drawn to a very interesting feature article reviewing the book Hippocrasy co-written by Professor Rachelle Buchbinder who is a rheumatologist as well as director of the Monash Cabrini Department of musculoskeletal health and clinical epidemiology at Cabrini Hospital and Professor of clinical epidemiology at Monash University with Ian Harris who is an orthopaedic surgeon at Liverpool St George and Sutherland hospitals and Professor of Orthopaedic surgery at the University of New South Wales Sydney and Honorary Professor at University of Sydney. The article was confronting in that it raised concerns that many of the medical procedures and treatments we are engaged with as clinicians may not help patients and that over diagnosis and the “medicalisation of normal” may be leading to a medical system failure.

The question the authors ask us to consider is whether doing a specific medical procedure or intervention is better for the patient than not doing it and they set the context of this question by drawing from a wide review of studies within the framework and reflecting of the Hippocratic oath. I subsequently purchased and read Hippocrasy which was as illuminating as it was confronting and would strongly recommend this book as essential reading for all doctors both graduated and training and hope it becomes a staple for medical students everywhere. Hippocrasy asks us to question the true value of specific medical practice, to choose wisely and to recognise cognitive dissonance and confirmation bias noting that up to a third of medical care may be of no value and that up to 10% of treatments and interventions may be harmful with medical error the third leading cause of death in the United States. We should all strive to practice evidence-based medicine when possible and there are many organisations such as the United Kingdom National Institute for Health and Care Excellence, Cochrane Collaboration and the United States Preventative Services Task force to guide us.

In this podcast with Rachelle Buchbinder, we discuss Hippocrasy in more detail including how the problem of the medicalisation of normal has arisen and what needs to change. Please join me on this interesting conversation.

References :

Prof Rachelle Buchbinder:www.malvernrheumatology.com

Hippocrasy: Buchbinder and Harris, NewSouth Publishing, 2021

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

The field of regenerative medicine is likely to significantly change how we practice medicine in the future with some amazing capabilities -harnessing the power of stem cells to restore form and function of damaged tissue. The potential of regenerative medicine has already being recognised in the areas of immunotherapy and bone marrow transplantation however the future is likely to see many further shining examples of its promise ,application and capability. Consider the possibility of injecting cardiac stem cells into the surrounding viable ventricular myocardium adjacent to an acute myocardial infarction providing functioning myocardial cells to restore cardiac output or indeed replacing a damaged organ such as a cirrhotic liver allowing restored hepatic synthetic function.

A group of scientists at St Vincent's Institute of Medical Research in Melbourne with co lead researcher Kiryu Yap are attempting to do just that. Following a breakthrough over 4 years ago their team has the aim of growing entire lobes of the liver by taking patients’ blood and carefully reprogramming cells to become stem cells .This technology became available after the amazing techniques described by Sir John Gurdon and Shinya Yamanaka who discovered that mature cells can be reprogrammed to become pluripotent leading to their 2012 Nobel Prize in Physiology and Medicine.

It is known that about 7000 Australians die each year from chronic liver disease and that 260 livers are transplanted each year between Australia and New Zealand so if this bold project is successful, it will provide significant value to patients suffering with advanced and deteriorating liver disease. After genetically reprogramming cells to become pluripotent stem cells the application of very specific nutrients exerts the appropriate epigenetic effect to induce tiny liver cells. The plan is to implant these into the groin of patients where the small liver buds will be supported by the patient's blood vessels before the liver lobe is eventually harvested and transplanted to replace the diseased organ. Please join this fascinating discussion with Kiryu.

References:

Dr Kiryu Yap-School of Biomedical Sciences-University of Melbourne

www.svi.edu.au- Vacular biology-St Vincents Institiue of Medical Research-Dr Kiryu Yap

www.nobelprize.org- The 2012 Nobel Prize in Physiology or Medicine

www.anzdata.org.au

https:/transplant.org.au

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

About 7 million Australians, around 28% of our population, live in rural and remote areas encompassing many diverse locations and communities that in some instances have poor access to the medical services we may take for granted in metropolitan centres. Higher rates of hospitalisations, deaths and injury are reported from remote and rural areas and statistics show that remote and very remote areas experience a greater burden of disease and injury compared to major city populations (about 1.4 times). The practice of medicine in such communities requires a higher level of medical literacy.

On average, people living in remote and very remote areas are younger than those in major cities and 18% of people living in remote and 47% in very remote areas are indigenous (aboriginal or Torres Strait Islander people) compared to 1.7% in major cities. Health risk factors such as smoking overweight and obesity, diet, high blood pressure, alcohol consumption and physical activity are just some of the factors influencing health outcomes.

The Doctors, nurses, paramedics and hospital staff working at remote locations must be capable of dealing with a wide range of medical, surgical, obstetric, paediatric and psychiatric conditions that may present as emergencies. Where support help such as tertiary transfer may be hours or days away it takes a special team to come together to manage such difficulties. It was a great pleasure to interview Etienne Cawood who has spent the majority of his medical career working in rural and remote locations throughout the length and breadth of Australia and we him great debt gratitude for his services.

Etienne Cawood :[email protected]

Rural and remote health. aihw.gov.au

Australian College of rural and remote medicine. mycollege.acrrm.org.au

www.jcu.edu.au

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

The journey from the VCE student to University and medical studies is highly competitive and never easy and for those undertaking a postgraduate degree in medicine, the graduate medical school admissions test-GAMSAT-designed to assess the capacity to undertake high-level intellectual studies in the medical and health professional programmes provides yet a further hurdle. Dr Nick Shearer completed his postgraduate medical studies at Deakin University before choosing and being accepted as an intern at the Northern Hospital Epping. In his dream of becoming a doctor he was immediately thrust into the incredible difficulty of not only managing the brutal responsibilities of internship but even more the harsh reality of coping with the COVID-19 pandemic at the very interface between disease and treatment in a hospital tasked with frontline COVID-19 responsibilities. Donning personal protective equipment for the entire year and honing his communication skills with often frustrated and frightened patients and their relatives Nick has become a shining example of how good our medical personnel and profession can function and be in a time of deep crisis.

References :

gamsat.acer.org

www.nh.org.au

www.deakin.edu.au

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

Observed abnormalities in the full blood count are not uncommon, they may be transient and mild, often involving one cell lineage and most likely benign, or progressive involving more than one cell lineage and pointing us toward a condition requiring further investigation, possible referral and treatment.

In foetal life, haemopoiesis occurs in the yolk sac and later in the liver and spleen. After birth normal haemopoiesis is restricted to the bone marrow. Infants have haemopoietic marrow in all bones but in adults, haemopoietic marrow is found in the central skeleton and proximal ends of long bones. Expansion of haemopoiesis down the long bones may occur in bone marrow malignancy such as with leukaemia or when there is increased demand such as with chronic haemolytic anaemias. Both the liver and spleen can resume extra medullary haematopoiesis when there is marrow replacement such as in myelofibrosis or when there is excessive demand for example in severe haemolytic anaemia such as thalassaemia major. Incredibly the bone marrow produces more than 1 million red cells per second in addition to similar numbers of white cells and platelets .Common primitive stem cells in the marrow have the capacity to self replicate and give rise to increasingly specialised and committed progenitor cells. Myeloid progenitors differentiate into platelets, red blood cells, eosinophils neutrophils, basophils, macrophages, mast cells and dendritic cells. Lymphoid precursors differentiate into T cells (CD4 helper and CD8 suppressor) B cells (plasma cells and memory cells) and natural killer cells.

In conditions of disease or physiologic stress, there may be a reduced number of cells in the full blood count assessment suggesting decreased production or loss (e.g. bleeding), sequestration (spleen, lymph nodes), or peripheral destruction. Elevated counts suggest an excess production which may be reactive (physiologic stress) or reflective of a primary abnormality of the bone marrow or other haemopoietic organs.

Please join these interesting conversations with Dr Thomas Lew - haematology advanced trainee at the Peter MacCallum Cancer Centre with special interest in novel therapies for haematological disorders.

References:

Dr Thomas Lew: petermac.org

www.wileymedicaleducation.com

www.sciencedirect.com

www.uptodate.com

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

Observed abnormalities in the full blood count are not uncommon, they may be transient and mild, often involving one cell lineage and most likely benign, or progressive involving more than one cell lineage and pointing us toward a condition requiring further investigation, possible referral and treatment.

In foetal life, haemopoiesis occurs in the yolk sac and later in the liver and spleen. After birth normal haemopoiesis is restricted to the bone marrow. Infants have haemopoietic marrow in all bones but in adults, haemopoietic marrow is found in the central skeleton and proximal ends of long bones. Expansion of haemopoiesis down the long bones may occur in bone marrow malignancy such as with leukaemia or when there is increased demand such as with chronic haemolytic anaemias . Both the liver and spleen can resume extra medullary haematopoiesis when there is marrow replacement such as in myelofibrosis or when there is excessive demand for example in severe haemolytic anaemia such as thalassaemia major. Incredibly the bone marrow produces more than 1 million red cells per second in addition to similar numbers of white cells and platelets .Common primitive stem cells in the marrow have the capacity to self replicate and give rise to increasingly specialised and committed progenitor cells. Myeloid progenitors differentiate into platelets, red blood cells, eosinophils neutrophils, basophils, macrophages, mast cells and dendritic cells. Lymphoid precursors differentiate into T cells (CD4 helper and CD8 suppressor) B cells (plasma cells and memory cells) and natural killer cells.

In conditions of disease or physiologic stress there may be a reduced number of cells in the full blood count assessment suggesting decreased production or loss (e.g. bleeding), sequestration (spleen, lymph nodes), or peripheral destruction. Elevated counts suggest an excess production which may be reactive (physiologic stress) or reflective of a primary abnormality of the bone marrow or other haemopoietic organs.

Please join these interesting conversations with Dr Thomas Lew -haematology advanced trainee at the Peter MacCallum Cancer Centre with special interests in novel therapies for haematological disorders.

References:

Dr Thomas Lew: petermac.org

www.wileymedicaleducation.com

www.sciencedirect.com

www.uptodate.com

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

Observed abnormalities in the full blood count are not uncommon, they may be transient and mild, often involving one cell lineage and most likely benign, or progressive involving more than one cell lineage and pointing us toward a condition requiring further investigation, possible referral and treatment.

In foetal life, haemopoiesis occurs in the yolk sac and later in the liver and spleen. After birth normal haemopoiesis is restricted to the bone marrow. Infants have haemopoietic marrow in all bones but in adults, haemopoietic marrow is found in the central skeleton and proximal ends of long bones. Expansion of haemopoiesis down the long bones may occur in bone marrow malignancy such as with leukaemia or when there is increased demand such as with chronic haemolytic anaemias . Both the liver and spleen can resume extra medullary haematopoiesis when there is marrow replacement such as in myelofibrosis or when there is excessive demand for example in severe haemolytic anaemia such as thalassaemia major. Incredibly the bone marrow produces more than 1 million red cells per second in addition to similar numbers of white cells and platelets .Common primitive stem cells in the marrow have the capacity to self replicate and give rise to increasingly specialised and committed progenitor cells. Myeloid progenitors differentiate into platelets, red blood cells, eosinophils neutrophils, basophils, macrophages, mast cells and dendritic cells. Lymphoid precursors differentiate into T cells (CD4 helper and CD8 suppressor) B cells (plasma cells and memory cells) and natural killer cells.

In conditions of disease or physiologic stress there may be a reduced number of cells in the full blood count assessment suggesting decreased production or loss (e.g. bleeding), sequestration (spleen, lymph nodes), or peripheral destruction. Elevated counts suggest an excess production which may be reactive (physiologic stress) or reflective of a primary abnormality of the bone marrow or other haemopoietic organs.

Please join these interesting conversations with Dr Thomas Lew - haematology advanced trainee at the Peter MacCallum Cancer Centre with special interests in novel therapies for haematological disorders.

References:

Dr Thomas Lew: petermac.org

www.wileymedicaleducation.com

www.sciencedirect.com

www.uptodate.com

To be a guest on the show or provide some feedback, I’d love to hear from you: [email protected]

Venous thrombosis affects more than 30,000 Australians each year and is responsible for over 5000 deaths per annum, this is more than the number of Australians who die from motor vehicle accidents annually. VTE is the third leading cause of death amongst hospitalised patients and patients admitted to hospital are at least 100 times more likely of developing a clot compared to being active in the community-a risk that may be assessed by the modified Wells criteria.

Tellingly 60% of all venous thromboembolisms occur within 90 days of hospitalisation and importantly it is predicted that up to 70% are preventable.

Whilst 10% of clots form either in the upper limbs or mesenteric system, the vast majority of clots-90%- occur in the lower limbs. Although pulmonary emboli may include fat, amniotic fluid, may be septic or be formed from contaminants such as talc we will restrict discussions in this podcast to blood clots and focus on lower limb clots.

This is potentially a huge subject with multiple factors leading to abnormal clotting, excessive clotting, and subsequent potentially fatal thromboembolism. The more one considers coagulation in both the normal and pathophysiologic states the more fascinating the subject becomes. No wonder then that Associate Professor Sanjeev Chunilal from Monash Health has developed a deep interest and expertise in this subject. Sanjeev completed a clinical and research fellowship in venous thromboembolism at McMaster University Ontario Canada, has published widely and is a member of the International Society of Thrombosis and Haemostasis as well as the Australasian Society of Thrombosis and Haemostasis, please welcome Sanjeev to the podcast.

References:

Associate professor Sanjeev Chunilal: jessiemcpherson.org, monashpathology.org

www.ncbi.nlm.nih.gov: Deep venous Thrombosis: pathogenesis, diagnosis, and medical management,2017

Khan Academy-khanacademy.org

Australian Family Physician VOL 39, No 7 July 2010

Dr Luke Crantock MBBS, FRACP, is a gastroenterologist in practice for over 25 years. He is the founder of The Centre for GI Health, based in Melbourne Australia and is passionate about educating General Practitioners and patients on disease prevention and how to manage and improve their digestive health.