Dr Peter Brukner OAM is Professor of Sports Medicine at the Latrobe Sport and Exercise Medicine Research Centre and is one of Australia’s most respected and best-known specialist sports physicians with a wide breadth of knowledge of the subject. He has extensive experience, having enjoyed a stellar career with elite sports teams and Olympians over multiple decades in his professional capacity.

Dr Peter Brukner OAM is Professor of Sports Medicine at the Latrobe Sport and Exercise Medicine Research Centre at Latrobe University and is one of Australia’s most respected and best known specialist sports physicians. He has a deep breadth of knowledge and experience and was a founding partner at the Olympic Sports Medicine Centre in Melbourne as well as a sports physician to the Collingwood and Melbourne AFL clubs, Liverpool Football Club and has served as team doctor to the Australian cricket team, Socceroos and several Olympic teams. He has authored multiple best-selling books on sports medicine and more recently has become interested in the important relationship between lifestyle and health and after determining that he was pre-diabetic he embarked on a low carbohydrate ketogenic style diet. He has subsequently become a strong advocate of the low carbohydrate diet both in managing a healthy BMI and avoiding development of the metabolic syndrome and all its consequent health effects and authored the very popular and best-selling book A Fat Lot of Good. He energetically has also established the not for profit campaign Sugar By Half. He joins us today to discuss his experience and journey to a low carbohydrate diet and how such an approach may be highly beneficial to athletes of both amateur and elite persuasions. Please enjoy this podcast.

The Peter Doherty Institute was the first Australian laboratory to establish a Covid 19 PCR test and diagnose the first SARS- Cov 2 infection on Australian shores, its research scientist is heavily involved in developing novel diagnostic tools applied across many areas of medical science and the institute plays a key leadership role in advising state and federal government on best medical practice. It’s no great surprise therefore that we have learned of their ground-breaking development of a new subunit Covid 19 vaccine utilising the receptor binding domain at the tip of the virus’s spike proteins. This is the region responsible for virus attachment and infection and for eliciting over 90% of neutralising antibodies following SARS Cov-2 infection. Parallel with the subunit vaccine development, another Melbourne group – the Monash Institute of Pharmaceutical Sciences has developed a similar vaccine but using mRNA technology copying the virus’s genetic sequence that codes for the receptor binding domain.

Delivering hard news to a patient or their relatives and admitting error can be one of the most difficult duties encountered by a doctor. Significant effort is now spent in teaching young training doctors techniques and strategies to avoid miscommunication and uncertainty in undertaking this complicated task whilst also remaining emotionally engaged and empathetic to their situation.

Chronic pain affects about 1 in 5 people in Australia and is a common reason for patients to see their doctor and to seek treatment. As patients seek ever increasingly strong pharmacological therapies they may become increasingly depressed, fatigued and dislocated from society.

Genetic testing for cancer is important for a small number of families at increased risk due to the inheritance of genetic mutations. Most commonly this involves the inheritance of breast cancer genes such as the BRCA 1 and 2 or colorectal cancer genes such as the Lynch syndrome genes. Although these only represent a small percentage of total cancers reported there is significant public interest in these syndromes.

In the context of family cancer screening, genetic testing looks for specific inherited changes or variants in a person’s genes which may predispose them to an increased risk of developing a neoplasm. Harmful variants in some genes are known to be associated with an increased risk of developing specific cancers such as mutations to the BRCA 1 and 2 genes associated with breast and ovarian cancer and the Lynch genes associated with colorectal and endometrial cancer.

The ketogenic diet has recently become popular as an effective dietary approach to weight loss. The diet restricts carbohydrates to just 5-10% of total calories and relies on caloric intake from fats (55-60%) and proteins (30-35%) forcing metabolism to shift from gluconeogenesis to ketogenesis with the production of acetoacetate, beta-hydroxybutyrate and acetone – ketone bodies – as the usable energy source. People adopting this diet report a significant reduction in hunger, increase in energy, clarity of thought and reduction in chronic inflammatory conditions. Some are concerned the diet is difficult to maintain long term and may be risky in patients that are diabetic and in those with chronic kidney disease.

Before proceeding, we apologise for the audio quality in this week's episode. Unfortunately, we experienced some technical difficulties and we will endeavour to resolve these problems in future episodes of Everyday Medicine.

Diabetic foot is the name given to the condition commonly experienced by people with diabetic peripheral neuropathy and results in an insensitive and often deformed foot. Found in both type I and type II diabetic patients (of which there are 1.8 million living in Australia-one new diagnosis is made every 5 minutes), even minor trauma in the diabetic foot may lead to the development of an ulcer. The combination of impaired vascular supply from micro and macro vascular disease and neuropathy presents real challenges for healing. Consequently, diabetic foot ulcer is a major event in 85% of subsequent amputations and is the cause of 20% of hospital admissions related to diabetes. Ten to 15% of diabetic foot ulcers fail to heal and of these, 25% lead to an amputation. In one study up to 50% of diabetic patients undergoing amputation were dead within 2 years. Failure to be seen and managed by medical attendants more than 6 weeks after developing an ulcer in a diabetic foot vastly increases the amputation risk however just one year after appropriate vascular surgical management, between 70 and 90% of limbs will be saved from amputation. Furthermore, one year after vascular intervention up to 60% of diabetic foot ulcers are healed, highlighting the importance of vascular surgical expertise early in the management of the diabetic foot.

It is common in clinical practice to identify patients with impaired renal function as determined by diminished glomerular filtration rate and elevated creatinine. The decision to undertake thorough work-up and investigation of such patients or to observe and monitor, removing any potential offending nephrotoxic agent, is a clinical problem we address in this podcast with expert nephrologist Dr Tony Amin, who considers:

Sodium is a major extracellular cation. Normal sodium concentrations range between 135 and 145 mmol/L. Alterations in sodium concentration, particularly hyponatraemia is the most common electrolyte disorder doctor’s encounter in clinical practice. Up to 20% of people admitted to hospital have hyponatraemia and it is estimated that 1.7% of population also have hyponatraemia.

The consequences of dementia with short term memory loss, visuospatial dysfunction, executive dysfunction, apathy, word-finding difficulty and apraxia is devastating both to the patient and family. It is estimated that 1% of Australians aged 65 years have dementia and that almost half of our population over 85 years have dementia to varying degrees. Alzheimer’s (60% of cases), vascular dementia (15% of cases), Lewy body and frontotemporal (each 5% of cases) and other forms of dementia secondary to alcohol, trauma and neurodegenerative disorders reflect the main forms of dementia seen in our society

Each year in Australia, over 125,000 of our more elderly population are admitted to hospital consequent to a fall. About a third of people over the age of 65 years fall each year and this figure rises exponentially with age. In up to 10% of falls, serious injuries such as fractures (a third of which are hip), soft tissue injuries and direct brain injuries arise. Falls and injuries from falls have serious implications and consequences.

Couples are said to be infertile if pregnancy does not result after a year of carefully timed sexual activity without the use of contraceptives and is estimated to affect up to one in six Australian couples. It is also estimated that male partners contribute approximately 40% to cases of infertility, the same percentage as women. In a third of couples, a combination of male and female factors both need consideration. Today, women in Australia are 31 years of age before their first child is born compared to a generation ago where women on average were 24 years of age, this change in timing of first pregnancy and lifestyle may also be contributing to the difficulty some couples have starting their families.

Altered uterine bleeding is estimated to affect 10-30% of women in midlife and constitutes about a third of outpatient gynaecological reviews. There are many aetiologies to consider including leiomyomas (fibroids), endometrial pathologies, polyps, malignancy, platelet dysfunction and coagulopathies.

The detection of colorectal polyps is of critical importance in the prevention of colorectal cancer. Studies have demonstrated that colorectal cancer arises from colorectal polyps in more than 95% of cases. Fortunately most polyps do not become malignant (less than 1%) and it is known that less than 5% of all colonic adenomas harbour malignancy. The National Bowel Cancer Screening Program has been a government initiative to assist in the detection of early cancers and malignant polyps through the detection of occult haemoglobin in stool and some larger clinical trials have demonstrated the benefits of screening population this way. Once a malignant polyp is determined colonoscopically a fresh set of questions arises in regards to best management practice.

Rectal bleeding is a very important clue to the possibility of serious internal colonic pathology. Whilst our approach to work up of patients with rectal bleeding is determined by the description of blood, the age of the patient and background history, it is extremely important not to overlook rectal bleeding as a possible early sign of a malignant polyp, premalignant polyp, colorectal malignancy or inflammatory bowel disease.

Metabolic bone disease is common, it is estimated that about 4.75 million Australians have either osteopenia or osteoporosis. Osteoporosis affects up to 23% of women and 6% of men over the age of 50 with a markedly increased risk of minimal trauma fractures including hip fracture with increased morbidity and mortality. Osteoporosis is characterised by microscopic architectural deterioration of bone structure, loss of bone mass and a change in bone metabolism and can be confirmed by dual-energy x-ray absorptiometry (DEXA scan). Until recently 70-85% of patients presenting with a minimal trauma fracture have tended to be both under investigated for osteopenia and osteoporosis, nor appropriately managed to prevent a further fracture. Metabolic bone disease is a silent epidemic.

Centrally mediated abdominal pain syndrome is a chronic recurrent condition that is not related to bowel function, diet or definite organic pathology such as inflammatory bowel disease, diverticulosis, vascular syndromes nor neoplasia.