Summer / Autumn 2015 • Issue 21
INFLAMMATORY BOWEL DISEASE New therapies for 2015
STEM CELL TECHNOLOGY
Improving long term outcomes
VARICOSE VEINS
The revolution in vein management
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
WELCOME Despite the school holidays and summer weather, since the last issue we have been working hard on plans to expand our highly sought-after services – enabling us to provide care to more people. These plans include extending our current facilities in our central London and Golders Green locations, in addition to ongoing refurbishments already taking place across our North and South Buildings. This expansion will allow us to reconfigure and increase our award-winning intensive care facilities to provide 36 beds, while also expanding our theatre capacity too. In the long term, we aim to create a brand new outpatient centre and develop the current Platinum Medical Centre into a complete inpatient facility, which would see our overall capacity rise to over 300 beds. Our GP Liaison team will be updating you as these changes happen and there will be regular news bites to read here in Practice Matters, or online at: practicemattersmag.co.uk In this issue: On the theme of developments, we hear from Mr Simon Moyes about the rapid progress of stem cell technology and what the near future holds for this evolving treatment option; likewise Professor Ellis Downes has news of three pioneering advances happening now in the gynaecology and obstetrics field. Our Breast Care Unit reflects on the services available here at The Wellington, in the lead up to the Breast Cancer Awareness Campaign taking place next month; while Dr Charles Murray reports on the developments which have opened up the possibility for better management of patients with inflammatory bowel disease. I hope you enjoy this latest issue and remember our GP Liaison team are always ready to listen to any feedback you may have about the hospital, and even which topics you would like to see featured in future issues of Practice Matters. Best Wishes,
Neil Buckley CEO
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Editor: Claire McKinson Production & Distribution: Runwild Media Group
PRACTICE MATTERS
CONTENTS 04 | Expert care, rapid diagnosis: The Breast Care Unit Mr Muhamed Al-Dubaisi and Mr David Floyd
04
06 | Inflammatory bowel disease therapy in 2015
07
Dr Charles Murray
07 | Obesity, genetics, physiology and bariatric surgery Mr Andrew Jenkinson
08 | The revolution of stem cell technology
08
11
Mr Simon T. Moyes
10 | The revolution in varicose vein management Professor Nick Cheshire and Mr Maz Mireskandari
11 | Obstetrics and gynaecology: A trio of new developments Professor Ellis Downes
12 | Diet and supplements and their role in cancer prevention Tara Whyand and Professor Martyn Caplin
14 | The invasion of minimally invasive surgery: Laparoscopic hernia repairs Mr Steve Warren
15 | The management of stroke/ brain injury and cerebral palsy in the hands and wrists Mr Maxim Horwitz
12
16 | GP news 18 | News from The Wellington 19 | 60 Seconds with...
www.practicemattersmag.co.uk PRACTICE MATTERS SUMMER / AUTUMN 2015 • 3
BREAST CANCER
EXPERT CARE, RAPID DIAGNOSIS: THE BREAST CARE UNIT
By Mr Muhamed Al-Dubaisi and Mr David Floyd
The incidence of breast cancer continues to increase in the UK with the lifetime risk of a woman developing breast cancer now at 12% (1:8), with 50,000 new diagnoses per year. In the presence of BRCA1 and 2 gene mutations, the lifetime risk rises to 35-85%. Since Angelina Jolie (a gene carrier) had bilateral prophylactic mastectomy, there has been a surge in patients requesting gene testing and appropriate treatment. Despite the increasing incidence of breast cancer, mortality rates have decreased yearon-year and this has been attributed to a combination of factors, including:
With 80 - 90% of worried patients presenting with benign disease, instant reporting of radiology investigations allows us to provide swift and comprehensive reassurance in one visit. one of our breast surgeons and on-site imaging, including: state-of-the-art digital mammography, ultrasound, CT and MRI; in addition to a diagnostic biopsy. With 80 - 90% of worried patients presenting with benign disease, instant reporting of radiology investigations allows us to provide swift and comprehensive reassurance in one visit.
A Multidisciplinary Approach • Earlier detection • Screening programmes • Advances in imaging technology • Improved surgical and oncological treatments
In order to meet the growing demand for diagnosis and treatment, we have worked hard to create a truly comprehensive one-stop diagnostic Breast Care Unit at The Wellington Hospital’s Platinum Medical Centre (PMC).
The service is managed within a multidisciplinary team environment, which meets regularly to discuss all new diagnoses. We are fortunate to be able to work with a regular team of clinicians, each of whom is an expert in breast cancer treatment. The team includes: breast surgeons, radiologists, pathologists, clinical and medical oncologists and plastic surgeons who review all case notes and results before preparing a comprehensive treatment plan for the patient. For further information on the members of the team, please visit: www.thewellingtonbreastcareunit.co.uk
Within the same building and during the same visit, patients can have an initial consultation with
The National Institute for Health and Care Excellence (NICE) has made very clear
A Truly One-Stop Clinic
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recommendations on the patient pathway for breast cancer, and we are very proud that our service at The Wellington Hospital meets all proposed criteria.
Breast Reconstruction A third of patients with a diagnosis of breast cancer will require mastectomy. For these patients, we offer a comprehensive reconstructive service and offer every patient the
My role as clinical nurse specialist is to provide a patient-focused service, always acting in the patient’s best interests by providing advocacy, emotional and psychological support, information and practical advice. Every patient is treated as an individual and with complete dignity and respect. Bernie Phelan, Clinical Nurse Specialist
CONSULTANT
FOCUS
Mr Muhamed Al-Dubaisi
MBCHB, FRCS, DGS
Consultant Breast Surgeon
Mr Al-Dubaisi is a Consultant Breast Surgeon at Barnet and Chase Farm NHS Trust and The Wellington Hospital. His special interests are the management of benign and malignant breast diseases, as well as management of high risk patients, and selecting patients for immediate breast reconstruction when indicated.
Mr David Floyd
MSc, FRCS, FRCS (Plast) chance to discuss reconstructive options with our plastic surgeon, prior to mastectomy. Using either autologous tissue from the abdomen or back, or implant based surgery, all reconstructive procedures are performed at the PMC, either with a combined procedure at the time of mastectomy or after completion of treatment.
Genetic Screening In the last few years, BRCA genetic screening has become an integral part of patient care in high-risk groups. In order to support this group of patients we have a specialist psychologist
and a genetic councillor who see all patients undergoing genetic testing, as recommended by NICE guidelines. All patients are accompanied throughout their treatment pathway by Bernie Phelan, our experienced breast care nurse. She can be contacted for further information at: Bernadette.Phelan@HCAHealthcare.co.uk For further information on all the breast care options available please visit: www.thewellingtonbreastcareunit.co.uk
Consultant Plastic Surgeon
Mr David Floyd is a Consultant Plastic Surgeon and Honorary Senior Lecturer at The Royal Free, University College London Hospitals and The Wellington Hospital. He specialises in cosmetic and reconstructive surgery of the breast and abdomen. He has a specialist interest in cosmetic and reconstructive surgery of the breast and abdomen. For more information about Mr David Floyd please visit: www. mrdavidfloyd.co.uk
www.practicemattersmag.co.uk PRACTICE MATTERS SUMMER / AUTUMN 2015 • 5
GASTROENTEROLOGY
INFLAMMATORY BOWEL DISEASE THERAPY IN 2015
By Dr Charles Murray
Over the last few years we have seen real changes in the understanding and treatment of inflammatory bowel diseases (IBD). As the incidence of both Crohn’s disease and Ulcerative Colitis (UC) continue to rise, so too has our understanding of some of the pathophysiological mechanisms that underlie them and, through this, the development of more targeted therapies. As important as the advancements in new therapies has been the development of more structured management, a national IBD audit, the creation of a national IBD registry and the publication of national IBD standards. All of these developments promote a multidisciplinary approach to management and encourage standardisation of excellent care in all hospital settings. In order to really excel in IBD care, the patient needs to be central to all treatment decisions. Information is key, and fortunately, in addition to discussing with their doctor or specialist nurse, there are excellent organisations such as Crohn’s and Colitis UK which can provide accurate and up-to-date information, while offering networking and support. Clinically, patients with IBD will need the input of multiple specialists, including: dieticians, gastroenterologists, surgeons, radiologists, IBD specialist nurses and psychological input, where needed. We have moved from a clearly symptom based approach to demonstrating that there is
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often a clear mismatch between symptom burden and extent of disease (particularly in Crohn’s disease). This is important because we now know that early intervention and aiming for mucosal healing is an effective strategy to preventing complications in the long term.
In order to really excel in IBD care, the patient needs to be central to all treatment decisions Fortunately, at the GI Unit at The Wellington Hospital, we are perfectly placed to provide the type of personalised care that is associated with the best outcomes. Our JAG accredited Endoscopy Centre provides stateof-the-art endoscopic imaging and therapy. This includes a large and active video capsule endoscopy unit, which can now provide video capsule colonoscopy. The radiology department provides high quality imaging, including advances in MRI small bowel imaging and small bowel ultrasound. We work closely with our excellent colorectal surgeons who are experts in advanced laparoscopic surgery, and importantly are experienced in the management of IBD patients and bowel sparing surgery.
Last, but of course, not least, are our gastroenterologists, who are experts in the management of these complex conditions and are at the cutting-edge of new therapies. Greater knowledge of the genetics and immunology of IBD, the microbiome and the multiple points in the inflammatory process at which we can intervene has not as yet led to a cure, but the treatments are increasingly effective. Anti-tumour Necrosis Factor biologics, such as inflximab and adalimumab, are now used frequently by physicians with a vast experience of them. More recently, the integrin monoclonal antibodies, such as vedolizumab, have come into clinic practice and offer alternative and effective interventions in conditions in which surgery was previously the only other option. Multiple other targets are in the pipeline and there are multiple new therapies are on the horizon. In summary, therefore, the treatment of IBD in 2015 is evolving all the time, with new treatments in development, more understanding of the pathophysiology of these complex diseases, and by working in a multidisciplinary way we can move towards truly personalised care in the future. To find out more about Dr Charles Murray, please visit: www.thewellingtongiunit.com
BARIATRICS
OBESITY, GENETICS, PHYSIOLOGY
AND BARIATRIC SURGERY By Mr Andrew Jenkinson
Genetic studies have suggested that some people are sensitive to an obesogenic environment and some people seem resistant to it. In fact, genetic factors contribute to approximately 85% of a person’s body mass index (BMI). In an obese person, the normal homeostatic factors that should maintain energy balance break down. The development of leptin resistance results in a failure of the hypothalamus to respond appropriately to the signal that energy stores, in the form of adipose tissue, have exceeded requirements.
The physiological changes that occur when a person diets are also misunderstood. The longer the period of calorific restriction, the more pronounced the rise in ghrelin (a hormone secreted by the stomach driving appetite), and the lower the level of peptide YY (the satiety hormone) secreted by the small bowel. Increasing evidence suggests that in individuals who have tried low calorie dieting in order to lose weight, the appetite and satiety changes that are experienced during
Genetic factors contribute to 85% of a person’s body mass index a diet are, in fact, still present a year after dieting has ceased. This explains the common description of yo-yo weight fluctuation in response to dieting, with a slow and inexorable long-term weight gain. In 2014, the cumulative evidence that ultra-low calorie dieting is, in fact, counter productive in weight regulation, led NICE to warn against this form of intervention for obese people. In the face of the development of our obesogenic environment and the subsequent obesity pandemic, coupled with the failure of conservative forms of treatment for obesity, it is not surprising that bariatric surgery has risen in popularity. In the US, the number of bariatric procedures now exceeds the number of gallbladder operations, with over 200,000 procedures performed annually.
Benefits of Bariatric Surgery Following gastric bypass or sleeve gastrectomy surgery, patients routinely report that their lives have been transformed. After decades of struggles with dieting and yo-yo weight fluctuation, their weight loss is maintained. A good estimate of weight loss, following either of these procedures, is
at least 70% excess weight lost. For example, a man of average height (1.75m, 5 foot 9 inches), weighing 120kgs (18 stone 12lbs) would expect to reset his weight to 89kgs (14 stone 1lb), or lower, within a year of surgery. This level of weight loss is generally maintained long term if patients are given appropriate lifestyle and dietetic education. As well as good weight loss, the sleeve and bypass procedures have an excellent effect on metabolic syndrome. Over 60% of diabetic patients will be off medication following surgery and the remainder will have better glycaemic control. The majority of patients with hypertension, dyslipidaemia and sleep apnoea will have resolution or significant improvement in their symptoms. For women of reproductive age, fertility will improve following weight loss through bariatric surgery, pregnancy will be safer and there will be less chance of emergency caesarean section. In addition to weight loss and better health, quality of life scores improve dramatically following gastric bypass and sleeve gastrectomy. To find out more about Mr Andrew Jenkinson, please visit: www.andrewjenkinson.com
www.practicemattersmag.co.uk PRACTICE MATTERS SUMMER / AUTUMN 2015 • 7
ORTHOPAEDICS
THE REVOLUTION OF STEM
CELL TECHNOLOGY By Mr Simon T. Moyes
There has been a surge in interest and research into options available for restorative orthopaedic treatment in recent years. Previously, there were only limited options available for patients who were suffering from meniscal and articular cartilage lesions and defects. However, new techniques for cartilage regeneration and repair, including stem cell technology, are now revolutionising this sector and the way that these injuries are treated. The issue is that previously, most meniscal tear surgery and articular cartilage surgery involved simply removing the damaged cartilage rather than repairing it, and we should be doing far more in the way of restorative surgery. Data from the US shows that less than 5% of meniscal surgery, for example, involves meniscal repair with all the rest of the meniscal surgery being resection. Far more menisci are repairable than most people think. In regards to articular cartilage repair, firstly, stem cell technology is moving at a fast and exciting pace. There is already, as an example, a system from Regeneus, in Sydney, where adipose derived stem cells can be injected into the knee for osteoarthrosis, with 80% of patients responding to this treatment and patients seeing an 80% reduction in their symptoms. Regarding currently available techniques, in addition to standard current cartilage repair techniques such as micro fracture, there are new
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augmentation procedures becoming available, including CarGel from Primal Life Sciences. This produces a scaffold for the micro fractured stem cells to build around and this electro statically binds to the defect, encouraging healing and improving results. There is also shortly to arrive, a product called Bio Gel from a company called Arthrex, which enhances cartilage repair. This is currently licensed in the US but not yet in the EU; this should hopefully change this year. A host of other stem
Stem cell technology is moving at a fast and exciting pace cell technologies are available outside the EU at the moment, with a number of these companies and clinics being based in Zurich. For larger or more resistant cartilage defects, cartilage transfer procedures are available: either autograft, i.e. from your own spare cartilage, or allograft from a cadaveric donor. While these restorative techniques are more involved than routine keyhole surgery, and patients may be out of action for longer, ultimately, I believe that they will prove more beneficial to the sufferer in the long term;
as damaged joint surfaces are restored and reconstructed rather than the damaged tissue being removed. To improve patient care long term outcomes therefore, it is important that more is done in this way of restorative orthopaedics. To find out more about Mr Simon T. Moyes, please visit: www.simonmoyes.com
HEAD AND NECK
A MULTIDISCIPLINARY APPROACH TO TRACHEOSTOMY MANAGEMENT By Freyja Bell, Lead Speech and Language Therapist in rehabilitation
The Wellington Hospital recently opened the Prolonged Disorders of Consciousness Unit (PDoC), consisting of 10 beds which are part of the rehabilitation wards. A high proportion of these patients are tracheostomised, as a result of the severity of their medical status. This population will have their own tracheostomy ward round and outcomes will be monitored separately to rehabilitation and acute wards. A current review of literature surrounding tracheostomy care strongly supports the institution of a multidisciplinary approach to management, provided by a dedicated and experienced team guiding the weaning process. Evidence has shown shorter time to decannulation, with greater success, fewer tracheostomy related complications, and improvement in patient comfort, safety and satisfaction with the use of tracheostomy teams. The Wellington’s tracheostomy team is the first of its kind in UK private healthcare. In our experience, developing a dedicated, expert team has resulted in streamlining tracheostomy management in a highly complex patient population. This approach has also enabled a standard of excellence in patient management, including: successful tracheostomy decannulation and the return home of patients who would otherwise require long term hospitalisation. This novel approach in private patient care exceeds leading national health guidelines, and allows us to lead the way
in future development and research for tracheostomy management and care.
Role of the Tracheostomy Team:
33 patients treated in the unit with a tracheostomy in situ. Of them, 88% were successfully decannulated. The other 12% were discharged with a further weaning plan in place. On average, the weaning process took 67 days from the time of initial cuff deflation trials to tube removal. Fig.1 outlines the reasons for hospital admission of these 33 rehabilitation patients with tracheostomies.
Fig 1 • To monitor tracheostomy care to ensure evidence-based, best practice and excellence in healthcare provision • I dentify patients who require tracheostomy changes • Joint sessions with treating therapists and ENT consultants In response to published evidence and guidance • Set, review and monitor a weaning regime in relating to the prevention of ventilator/hospital collaboration with consultant and primary therapists acquired pneumonia (VAP/HAP), in February • Set protocols for emergency tracheostomy 2013, all standard cuffed tracheostomy equipment procedures tubes throughout The Wellington Hospital • Provide education for the multidisciplinary team were removed from stock and replaced with • Keep up-to-date knowledge of research tracheostomy tubes with a subglottic suction port and guidelines in the area of tracheostomy feature. This enables the secretions and mucous management and disseminate to teams, that has been aspirated into the trachea to be as appropriate removed manually from above the cuff of the • Streamline documentation tracheostomy tube, hence preventing migration • Educate all staff, with formalised training for of the secretions into the pulmonary tree. The The Wellington's staff and monthly HCA-wide tracheostomy and infection control team are tracheostomy courses for relevant clinical currently working closely to analyse data relating team members to pulmonary infection rates in the presence of a tracheostomy tube.
Recent Outcomes:
An audit of our tracheostomy practices on the acute neurological rehabilitation wards in 2013 revealed that there were:
To find out more about our PDoC Unit please contact our Unit on 0207 483 5591
www.practicemattersmag.co.uk PRACTICE MATTERS SUMMER / AUTUMN 2015 • 9
VASCULAR
THE REVOLUTION IN VARICOSE VEIN MANAGEMENT
By Professor Nick Cheshire and Mr Maz Mireskandari
Abnormal leg veins have been recognised since ancient times, and so surgical treatment has similarly been around for a long time, too. Saphenofemoral ligation and stripping, popularised in Europe and the USA in the 1960s, was the mainstay of treatment until very recently. Over the last decade, technological developments have revolutionised the way in which we now treat varicosities. Combined with modern microsclerotherapy for small veins, these techniques provide successful, affordable, walk-in/walk-out treatment. Here we will describe some of the techniques.
Endovenous Closure of the Long and Short Saphenous Trunks For patients with true varicosities (fig. 1), around 80% will have reflux in the groin, filling the long saphenous vein in the thigh. Of the remainder, over half will have reflux at the sapheno-popliteal junction. The excess pressure exerted causes side branches to dilate. A central tenet of treatment of varicose veins, therefore, involves identification of the site of valve failure and saphenous extirpation to prevent pressure transmission. Fig 1
Fig 3
Fig 2
The endovenous closure procedures (there are variations) use a fine bore energy source delivered to the inside of the vein, to cause thrombosis and ultimately scar formation (fig 2). Energy sources include laser, radio frequency (diathermy) and mechanical plus sclerotherapy, with the former requiring local anaesthetic. The newer mechanical / sclerotherapy procedures, however, are acceptable to most patients without anaesthetic. Randomised trial data is difficult to interpret, as recurrence occurs following all treatments. Available data shows that endo-closure is comparable to traditional operations, results in high vein occlusion rates and is more acceptable to patients. It is our practice to tell patients that vein treatment – whichever method – is associated with recurrence, and that most patients who have vein treatment will require follow up and may need further intervention, even many years in the future. Endovenous techniques combined with hook avulsion of local varicosities, provide a one-stop
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service for true varicosities. Early post-operative follow-up is required by a GP or surgeon after endovenous intervention. Treatment may be required to treat uncomfortable phlebitis; although oral or topical NSAID antiinflammatory agents are usually sufficient. However, increasing ankle swelling or pain should prompt a duplex scan.
Endovenous Therapy and Micro-sclerotherapy Microsclerotherapy (using fine bore needles to inject an irritant agent and induce scarring) is the accepted therapy for small calibre thread veins, spider veins and reticular veins under 2mm diameter (figure 3). In skilled hands, a ‘20 minute’ session can result in significant improvement in appearance. Many patients today present with both varicose veins and thread/spider veins. We believe that a combination of the endo-venous closure and microsclerotherapy, delivered over 2-4 weeks as planned elective procedures, offered around the patients’ schedule, offers what most 21st century patients are looking for. Here, we offer same day duplex scan, a truncal closure procedure (if indicated), avulsion and microsclerotherapy. For further information on Professor Nick Cheshire and Mr Maz Mireskandari please visit: www.practicemattersmag.co.uk/contributors
GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY: A TRIO OF NEW DEVELOPMENTS
By Professor Ellis Downes
In the last few months, a number of developments in our speciality are becoming more established in routine clinical practice. Rather than focusing on one topic, I thought it would be more interesting to discuss a few exciting advances.
The Wellington Hospital has now established a pelvic floor MDT group.
Drug Treatment for Fibroids Up to 20% of women have fibroids which can cause menorrhagia, pressure symptoms and infertility. Traditionally, fibroids have been treated by surgery (myomectomy or hysterectomy) or LHRH agonists (Prostap or Zoladex). These agonists can cause menopausal side-effects and require monthly injections. Now, there is a new daily oral treatment, ulipristal acetate (Esmya). I’ve been using it for around two years and in my experience (about 50 women), it is well tolerated and gives a good reduction in fibroid size. It can be used to shrink fibroids before surgery (its initial licence) or can be prescribed in three-month cycles with a three month break. In a major randomised trial against Zoladex, both drugs demonstrated a 50% reduction in fibroid size after 12 weeks of treatment, with fewer side-effects in the Esmya group. I think Esmya is an important new addition in our treatment options for uterine fibroids.
Pelvic Floor With an increasingly aging population, and an understandable and growing desire not to ‘put up’ with symptoms, more women are presenting
with utero-vaginal prolapse. They may have a combination of urinary incontinence, bowel symptoms, dyspareunia and an uncomfortable vaginal lump. Many patients with mild prolapse will respond to physiotherapy (from a good women’s health physiotherapist), but ultimately many will need surgical repair. While most repairs will be straightforward – an anterior, posterior repair or vaginal hysterectomy, or a combination thereof, sometimes an abdominal (laparoscopic) approach will be needed. Sometimes, especially with rectocoeles and enterocoeles in patients with bowel symptoms, a rectal approach may be better. The Wellington Hospital has now established a pelvic floor MDT group, where a group of clinicians – gynaecologists, colorectal surgeons – nurse specialists, radiologists and physiotherapists, all interested in complex pelvic floor conditions, meet to review complex cases and plan the best course of care for patients. We hope this approach will lead to the best level of care for these complex patients.
Progesterone and Pregnancy Hot off the press. Recent trials, giving women with poor pregnancy outcomes
(miscarriage and pre-term labour) progesterone supplementation, have demonstrated that it may have a beneficial effect. For years, many gynaecologists have been giving women with a history of miscarriage progesterone pessaries, the evidence base for this was questionable. However, it now looks as though this is a beneficial intervention, probably due to the effect of progesterone on smooth muscle relaxation. It is expected that NICE will issue updated guidance soon. To find out more about Professor Ellis Downes, please visit: www.ellisdownes.com
www.practicemattersmag.co.uk PRACTICE MATTERS SUMMER / AUTUMN 2015 • 11
ONCOLOGY
DIET AND SUPPLEMENTS AND
THEIR ROLE IN CANCER PREVENTION
By Tara Whyand and Professor Martyn Caplin
The prevention of cancer is one of the most important achievable global public health challenges. The financial costs of treating cancer place a significant burden on health services and other resources in the UK. The World Cancer Research Fund and the American Institute for Cancer Research have gone as far as to suggest that two thirds of cancer cases are preventable, through a combination of smoking/tobacco avoidance, appropriate diet, regular physical activity and maintaining a healthy body weight. The same report estimated an astonishing amount of cancer cases could be prevented through appropriate weight control, food, nutrition and physical activity. See Table 1: Cancer Research UK supports the belief that 9% of cancer cases in the UK are linked to a less healthy diet.
What Diet Helps Prevent Cancer? The European Prospective Investigation to Cancer and Nutrition (EPIC) study is the largest study into diet and cancer to date, involving over 500,000 people from 10 European countries. Results from EPIC and other large studies are already providing us with firmer answers. For example, several significant associations were found in 2010: • High intake of dietary fibre, fish, calcium, and
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Cancer Site
Percentage of Cancer Cases
Colorectum
43
Breast
42
Prostate
20
Pancreas
41
Liver
17
Table 1. Percentage of cancers which may be potentially preventable from appropriate nutrition, food, body fatness and physical activity. Table adapted from the 2007 WCRF/AICR Diet and Cancer Report
plasma vitamin D were associated with a decreased risk of colorectal cancer. • High red and processed meat intake, alcohol intake, high body mass index (BMI) and abdominal obesity were associated with an increased colorectal cancer risk. • A high saturated fat intake and alcohol intake was associated with an increased risk of breast cancer. In postmenopausal women, BMI was positively and physical activity negatively associated with breast cancer risk. • High intake of dairy protein and calcium from dairy products was associated with an increased risk of prostate cancer. Since 2010, many other EPIC analyses have been released concluding: • More than 569 g/day of fruits and vegetables
had lower risks of death from diseases of the digestive system when compared with participants consuming less than 249 g/day. • High adherence to the Mediterranean style diet reduces risk of hepatocellular carcinoma, even in patients with hepatitis B and C, and moderately reduces the risk of colorectal cancer. Adherence (excluding alcohol) is related to a modest reduced risk of breast cancer in postmenopausal women, and this association was stronger in receptornegative tumors. • High intake of tea and coffee reduce incidence of hepatocellular carcinoma, even in patients with hepatitis B and C. • High intake of dietary flavanols may reduce oesophageal cancer in smokers.
There is no one combination of supplements for general health and prevention of pre- and cancerous conditions. Different organs are more at risk from the effects of inflammation, oxidation and certain vitamin and mineral deficiencies.
CONSULTANT
FOCUS
Tara Whyand M.Sc, B,Sc
Should People Supplement Their Diet to Reduce Cancer Risk?
Oncology Dietitian
Individually, the following nutrient and botanical extract supplements have shown favourable effects against certain cancers by preventing vitamin deficiencies, treating cancer risk factors or by interrupting tumour pathways directly.
Tara Whyand is the ProfBiotics nutrition advisor and an oncology dietitian, specialising in neuroendocrine tumours. She has recently co-authored a number of papers on diet, supplements and different cancers, as well as for probiotics in gastrointestinal disorders. Tara is currently undertaking research using the Low FODMAP diet.
Colorectal - Curcumin, Green Tea, Vitamin D Breast - Vitamin D, Curcumin, Lycopene, Zinc Prostate - Lycopene, Green Tea, Pomegranate Pancreatic - Selenium, Green Tea, Curcumin Liver - Vitamin E, Curcumin, Lycopene and Thiamine In addition, there are ongoing clinical trials, for example, of curcumin being added to chemotherapy in the treatment of bowel cancer, as previous experimental studies had shown benefit of the combination over chemotherapy alone. There is no one combination of supplements for general health and prevention of pre- and cancerous conditions. Different organs are more at risk from the effects of inflammation, oxidation and certain vitamin and mineral deficiencies. People who understand the importance of good health often seek to improve their diet by seeking advice, eating specific foods or taking supplements as part of complementary therapy. It is important, however,
that those patients choose safe supplements based on evidence rather than marketing.
Cautions • High doses of selenium and vitamin E should not be taken by people with prostate cancer. • Green tea may interact with some medications. Most cancers are preventable – we just need to understand the right way to go about preventing it and better inform the medical and general populations. For further information on diet and supplements please visit: www.ProfBiotics.com and www.dietandcancer.co.uk
Professor Martyn Caplin BSc (HONS), DM, FRCP Consultant Gastroenterologist
Professor Martyn Caplin is Professor of Gastroenterology and Tumour Neuroendocrinology at the Royal Free Hospital, University College London and The Wellington Hospital. He leads the Royal Free Hospital European Neuroendocrine Tumor Society Centre of Excellence and the affiliated London WELLNET Unit. He is also is chairman of the European Neuroendocrine Tumour Society.
www.practicemattersmag.co.uk PRACTICE MATTERS SUMMER / AUTUMN 2015 • 13
GENERAL SURGERY
THE INVASION OF MINIMALLY INVASIVE SURGERY: LAPAROSCOPIC HERNIA REPAIRS By Mr Steve Warren
Increasingly, patients with a hernia might ask about laparoscopic surgery versus open repair. So which is the best advice?
such as diabetics, immunosuppressed, and a small proportion will develop catastrophic mesh infections, – unheard of laparoscopically.
Inguinal Hernias
With recurrent and bilateral hernias, there is no question that a laparoscopic repair is best and accepted by NICE guidelines. Laparoscopic repairs of bilateral hernias require no new incisions or ‘additional’ discomfort; our publication showed 34% of clinically unilateral hernias are actually bilateral.
Can asymptomatic groin hernias be ignored? Usually, inguinal hernias will continue to enlarge and become symptomatic; larger defects associated with increased recurrence rates and small risks of bowel incarceration. Obviously, advice is tailored to individual patients, eg. a 23 year old builder versus an 85 year old co-morbid patient. Both open or laparoscopic techniques use a polypropylene mesh and recurrence rates for experienced surgeons should be equal at less than 1%. Open groin dissection causes postoperative pain for up to four weeks, limiting normal activity. Nerves injured during this dissection can lead to chronic unremitting groin pain, which is rare with the laparoscopic technique. Our published data shows an average postoperative analgesic requirement of only 24 hours of simple paracetamol and return to completely normal lifestyle by 11 days; many returning to work within a few days. Larger open groin incisions, where we all have more skin bacteria, can result in haematoma and wound infection, particularly in high risk groups
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With a recurrence of an open repair, the resultant scar tissue makes an open recurrent operation difficult, with greater likelihood of injury to testicular vessels and nerves with chronic groin pain, haematoma and infection. However, the intra-abdominal tissues are completely unscarred favouring laparoscopy.
So when are open hernia repairs advocated? Laparoscopic repairs must be performed under general anaesthetic and some patient’s co-morbidities preclude this, requiring open surgery under sedation and local anaesthetic. Worries about laparoscopic major intraabdominal injury, e.g. bowel and vascular injuries, have not been realised, but do increase with previous intra-abdominal surgery and should only be performed by experienced laparoscopic surgeons.
What about challenging groin hernias? Extremely large inguinoscrotal hernias can be very difficult to repair laparoscopically, particularly if the bowel is incarcerated within the scrotal hernial sac. I commence laparoscopically with a small scrotal incision to free adhesions, and patients benefit from the less painful laparoscopic repair, less risk of wound infection and huge scrotal haematomas.
Incisional Hernias Incisional hernias are more challenging laparoscopically, especially following a previous operation which has caused varying degrees of adhesions, particularly in overweight patients. Laparoscopic post-operative pain and recovery benefits are more marginal since the mesh is stapled to the abdominal wall, which is just as painful. I am currently trialling glue mesh fixation with encouraging results. The greatest benefits relate to recurrence rates and mesh infection, with open mesh repairs having a 12-15% recurrence and an increased potential in obese patients for haematomas and disastrous mesh infections. Our laparoscopic results show a 2.7% recurrence rate and no mesh infection. To find out more about Mr Steve Warren, please visit: www.stephenwarren.com
HAND AND WRIST
THE MANAGEMENT OF STROKE/BRAIN INJURY AND CEREBRAL PALSY IN THE HANDS AND WRISTS By Mr Maxim Horwitz
The effects of neurological injury, such as stroke, traumatic brain injuries (TBI) and cerebral palsy (CP), can be debilitating and life changing. Stroke tends to affect older patients, whilst TBI typically occur in younger patients following an accident. Cerebral palsy is generally present from birth and the effects can vary widely.
and other specialised surgeons. Careful assessment, often on more than one occasion, must take place before considering any form of treatment. Individual goals and needs are evaluated and a patient’s specific treatment plan must be developed. Children and adults can be treated in a similar manner, but it must be remembered that children grow and further treatment may be needed as they age.
The hands and wrists are affected in varying degrees and, as a result, patients will have difficulty with activities of daily living. These include eating, the use of mobility aids (from walking sticks to electric wheelchairs), personal hygiene and dressing. In the general population, the shoulder and elbow position the hand in a gross non-specific manner and provide power, while the hand and wrist provide fine movement and dexterity. As a result of the above mentioned brain-related conditions, there is a tendency for the elbow to be in a flexed position, the forearm is more often than not in a pronated position and the fingers and wrist flex downwards. The thumb turns into the palm. The resulting position is both uncomfortable and functionally limiting. Furthermore, cutting nails and washing hands is difficult with curled fingers; negatively impacting hand hygiene. Thus, treatment becomes essential in many cases.
Treatment Options These patients are treated in a multi-disciplinary team which may include hand therapy, neurology
Initial management includes optimisation of function by stretching and the provision of splintage. This may involve botulinum toxin to decrease spasticity in muscles that are overactive, so that inactive or minimally active muscles can come to the fore. The hand therapy colleague will usually provide splints for various activities, such as eating or mobilisation using wheelchairs or crutches, to optimise function. Rehabilitation may take months rather than weeks and frequent re-assessment and flexibility is the key to progress.
Careful assessment, often on more than one occasion, must take place before considering any form of treatment Surgical Options Surgery can involve the soft tissues in the form of muscle and tendon releases or transfers to change the role of the muscles, thus improving the function of the hand and wrist. Should there be severe deformity in the hand and wrist, then a fusion is a very good option to facilitate improved positioning. All surgical planning is undertaken with an anaesthetic doctor, who appreciates a previous brain injury, and a thorough rehabilitation plan is created to ensure that a slow and steady improvement of function is achieved after surgery. Rehabilitation after such a procedure can take up to six months. Treatment of these conditions is very much individual to each patient and realistic goals must be created from the outset. Dramatic improvements in function can occur after reasonably simple operations and this treatment can be very rewarding. To find out more about Mr Maxim Horwitz, please visit: www.thehanddoctor.co.uk
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GP NEWS
GP NEWS Round-up HOW ARE DOCTORS APPROVED TO PRACTISE? With over 400 consultants regularly practising at The Wellington Hospital, it is imperative we ensure that doctors who treat patients are competent and experts in their field. All our consultants meet the recognised medical professional standards set by the General Medical Council, the medical regulator for the UK, and alongside this, The Wellington has an established Medical Advisory Committee (MAC) chaired by Dr Mark Hamilton. Within the committee each area of specialty has a lead consultant representative who has been nominated by their consultant counterparts. The MAC meet every two months to discuss ongoing considerations for the specialties and the hospital, this includes, regulations, new business ventures and feedback to the hospital. They also review all new consultant applications to practise at the hospital. Consultants approved at the last meeting include: Mr Zameer Shah (Orthopaedics), Dr Michael Koa-Wing (Cardiology), Mr Michael Perry (Oral & Maxillofacial), Dr Shahir Hamdulay (Rheumatology), Ms Sadaf GhaemMaghami (Gynaecology) and Dr’s Olaga Kirmi, Katie Planche, Andrew Plumb and Robert Thomas (Radiology) Throughout the year in a similar vein to the NHS, consultants are independently appraised and need to undertake continuous training and educational activities (CPD). This area of work is overseen by The Wellington’s Medical Director, Mr Geoffrey Glazer COMMENT AND DEBATE IBM’s Watson supercomputer is working with healthcare companies in the US and Canada to support decisions made about cancer care. Would you like to see this supercomputer working to support GPs?
EXPANDING HORIZONS OF CARE - ANNUAL PRIMARY CARE CONFERENCE 2015 This year’s conference from the Royal College of General Practitioners will take place 1st - 3rd October in Glasgow. The three-day conference covers a variety of topics directly affecting GP and their practice including:
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16 • PRACTICE MATTERS SUMMER / AUTUMN 2015
• Cultural sensitivities in GP Education • Hidden Complexity: Pain, function and other symptoms • Public and third sector engagement in general practice The full programme and list of speakers is available by visiting www.rcgp.org.uk/annualconference
GET READY FOR REVALIDATION 2016
DO YOU NEED TO ‘TOP-UP’
YOUR EDUCATION FOR REVALIDATION?
Or would you like to set up a programme of educational talks for 2016? Whether it’s an individual talk you’d like to organise, or a whole series of talks to take place across 2016, we understand that as busy practitioners, it’s not always possible to attend our educational events at the hospital. So we are now bringing the education to you.
HOW CAN I ARRANGE A CONSULTANT TALK? Simply send an email to wellington.gpl@hcahealthcare.co.uk and we’ll call you back. We’ll need to know: • Which topic/s you would be interested in learning more about (you can even request for us to bring a particular consultant) • How many people will be attending the talk • Which dates and times are best for you Your GP Liaison Officer – Ricky, Veronica, Supriya or Ricardo – will then arrange everything for you – from booking the consultant to bringing the equipment for the presentation. They’ll even provide refreshments, too. Suggested talk topics for 2015/2016 • Hand and Wrist • Breast • Colorectal • Gynaecology • Knee • Hip
• Foot and Ankle • Cardiology • Oncology • Ophthalmology • Haematology • Paediatrics
TO CONTACT THE GP LIAISON TEAM… How do individually tailored consultant talks, brought to you at your practice, sound?
You can find the dedicated GP Liaison Officer for your area listed on the back page of this issue, along with their contact details. Please note: Although we cannot provide CPD points, we do provide certificates of attendance which can be counted towards CPD points
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NEWS FROM THE WELLINGTON HOSPITAL
NEWS FROM DEVELOPING OUR PAEDIATRIC SERVICES IN NORTH WEST AND CENTRAL LONDON
services, such as: phlebotomy, allergy testing and immunisations. For any children who need further ongoing treatment or intervention, we can organise swift referrals to our sister hospital – The Portland Hospital for Women and Children, based at nearby Nottingham Place. Paediatric patients may be seen in our Radiology Department, Knee Unit, Hand and Wrist Unit, Ophthalmology and Neurophysiology Departments, but patients are mostly seen at our outpatient centre in Golders Green: The Wellington Diagnostics and Outpatient Centre (WDOC), where there is a weekly paediatric rota in place to ensure the very best service is offered to our younger patients. This rota includes the following consultants:
CONSULTANTS Allergy Lee Noimark Dermatology Anjali Mahto* Malcolm Rustin
In the last month, between our two outpatient departments: The Wellington Diagnostics and Outpatients Centre (WDOC) at Golders Green and the Platinum Medical Centre (PMC) in St John’s Wood, we have seen approximately 500 paediatric patients. It is a service that some didn’t know existed at The Wellington’s outpatient centres, but it is now a growing one… The biggest change to the service over the past six months is the appointment of three full-time paediatric nursing posts. We now have a staff nurse at WDOC, another at the PMC, in addition to a clinical nurse specialist who oversees all our hospital sites. This is a huge step forward in terms of expanding this crucial service and looking at how we can continue to provide the best possible care for these patients now, and in the future. Providing Care for All of the Family There a number of consultants available, across a large range of specialties, to see paediatric patients for consultations and to provide minor intervention
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General Mike Greenberg Nathan Hasson Benjamin Jacobs Austin Isaacs Lee Noimark Stan Rom Gastroenterology Mark Furman ENT Helen Caulfield Martin Bailey Elliot Benjamin
Orthopaedics Benjamin Jacobs (Musculoskeletal) Derek Park (Foot & Ankle) Plastics Abhilash Jain (Hand)* Rheumatology Nathan Hasson Vascular George Hamilton* Allied Health Professionals Jane Schlezinger – Dietician Dalia Nessim – Physiotherapist* *Consultants who see both adults and children
Tell Me More... In our 60 Seconds with... section we speak to Gemma Frankham, Paediatric CNS, about the developing paediatric services at available at The Wellington Diagnostics Centre in Golders Green and The Platinum Medical Centre in St John’s Wood, her new role here and what we can expect from the service in the future…
60 SECONDS WITH...
60
In the near future we can expect to see paediatrics becoming a more recognised and established outpatient service throughout all The Wellington Hospital’s sites
SECONDS WITH...
Gemma Frankham, Clinical Nurse Specialist for Paediatrics
PM: How long have you worked at The Wellington now? GF: I have been at the hospital for three months now. I started here in May, as clinical nurse specialist for paediatrics.
PM: What keeps you going on a difficult day and what do you do to relax? GF: If I have a difficult day all I need to do is look on my phone at a picture of my three year old daughter, who is very cheeky and always happy; her smile gets me through. I try and remind myself that the patients are the ones that are suffering and I am there to help them and improve things for them.
PM: What made you choose a career in healthcare? And what other hospital roles did you do before coming to The Wellington? GF: Ever since I can remember, I wanted to be a children’s nurse, there was no other career alternative that I was interested in. I have been a qualified children’s nurse for 10 years now, seven of which have been within the HCA Hospitals Group.
Being a female, I am totally addicted to chocolate, so eating chocolate on the sofa and watching something silly on TV or wildlife documentaries with my husband really relaxes me. I am a very creative person, and sometimes drawing or creating something is very therapeutic for me. I have just finished making a patchwork quilt out of my daughter’s baby clothes. And I have a small cake business outside of nursing, I make celebration cakes and again it is something that I enjoy and find relaxing (except when it goes wrong).
Prior to working at The Wellington, I worked at The Harley Street Clinic. I started there as a senior staff nurse, progressing to sister and then clinical practice facilitator for paediatric oncology and bone marrow transplant. I worked as a clinical practice facilitator for five years and enjoyed being involved in staff education and the development of a service.
PM: What is the one motto you live by? GF: ‘It could be worse’. Be grateful for the things you have, because elsewhere in the world people are suffering. I am very grateful for my family and close friends. I also believe that if you’re not happy, you are the only person that can change it - you go for what you want in life.
My big passion throughout my career has been paediatric oncology, it is, and always will be, an area of interest. However, there are new things I want to learn, and areas I want to develop. Service development and standard of care are two of those areas. PM: Talk us through an ‘average’ day as a paediatric clinical nurse specialist? GF: I’m not sure that an ‘average’ day exists in healthcare; however, my days at the moment are focused on establishing the current service, whether that is writing policies and guidelines, assessing staffing requirements, the safety of our paediatrics, development of processes within the hospital, etc. My first few weeks were mostly spent finding out about the current service and facilities that are provided for little people, what processes are in place and where the gaps are which need focusing on. I have also been busy meeting lots of new faces. The Wellington is far bigger than Harley Street Clinic, so there a lot more people and many more sites to get to know. I am still meeting new people three months in. PM: What can we expect from our paediatric services in the future? GF: The biggest change over the past six months is that the hospital has taken on three full-time paediatric nursing posts: one staff nurse at the PMC, one staff nurse at WDOC and myself; so expect to see this service become much more established and recognised.
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www.practicemattersmag.co.uk For more information about the GP Liaison service, or to make a referral, please contact the GP Liaison Officer for your area: Supriya Taggar Central London 07826 551 318
Ricky McKinson North & East London 07889 317 769
Ricardo Pereira North West London 07889 318 336
Veronica Brown Beds, Herts, Bucks & Middx 07889 317 774
supriya.taggar@hcahealthcare.co.uk
ricky.mckinson@hcahealthcare.co.uk
ricardo.pereira@hcahealthcare.co.uk
veronica.brown@hcahealthcare.co.uk