Spring 2013 • Issue 12
Exercise for Life
GP NEWS
The latest digital ideas
A new remit for the practitioner
THE INCONVENIENCE OF GLASSES Improving vision in the modern age
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
Welcome Spring has come late this year but that only helps us to celebrate the second anniversary of our Platinum Medical Centre which is coming up mid May. The first two years of service have flown by with the centre growing in capacity and helping to support the local community. I am pleased to announce that Dr Romeo Vecht has returned from Israel where he worked as Senior Consultant Cardiologist of the Lady Davis Cardiovascular Department at the Carmel Medical Center in Haifa. He will be commencing consulting sessions in the Platinum Medical Centre from June onwards and will provide us with a full update in the next edition. In the last issue we introduced our new Inpatient Oncology Unit which is providing a much needed service for patients. This complements our daycase chemotherapy unit located at the Platinum Medical Centre. Also in this issue: Barbara Jemec takes a look at a common hand injury that can present in patients after spending a holiday on the slopes. We take a look at how bariatric surgery treatments have evolved over the last ten years, and on page 10 & 11 two consultant specialists look at conditions that can be detected due to recent advances in scanning technologies. We also talk to Practice Manager, Virginia Wood, who offers a valuable insight into CPR training for GP Practices. Finally, I’m pleased to be able to tell you that after two years our Practice Matters magazine is receiving some fantastic feedback from our readers. Taking these comments into account, we are launching Practice Matters online with this latest issue. www.practicemattersmag.co.uk will give you access to our entire back catalogue of articles from the past publications, where you can find out more about the contributing consultants and search for information on treatments and services available for your patients. Best Wishes for a warm and happy summer.
Keith D Hague CEO
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Editor: Jaclyn Lott Production & Distribution: Runwild Media Group
PRACTIcE MATTERS
13
Contents 04 | After effects of the Ski Season
Identifying and treating Skier’s Thumb with Barbara Jemec
05 | The Biological Solution to Knee Injuries Fares Haddad explores knee preservation
06 | The Evolution of Bariatric Surgery
Majid Hashemi talks about current treatments
08 | Improving Vision with Surgery
Allon Barsam discusses the options for vision correction
09 | The Role of the Rehabilitation Advisor
An insight into the Acute Neuro Rehabilitation team
10 | Pancreatic Cysts – not so innocent
Bobby Prasad discusses cysts found during GI investigations
05
11 | Advances in Detection and Treatment of Renal Masses
Guy Webster identifies the options available
08
12 | The Modern Management of Colorectal Cancer
Daren Francis summarises the pathway for colorectal cancer patients
13 | Exercise for Life
A programme for a healthier lifestyle is outlined by Cathy Speed
14 | A Different Kind of Bunion
Mark Herron talks about big toe arthritis
16 | GP News
Updates from the primary care sector
18 | Latest News and New Consultants
11 www.practicemattersmag.co.uk 3
HAND UNIT
After effects of the
ski season Barbara Jemec from The London Hand and Wrist Unit talks about ‘skier’s thumb’, one of the most common skiing injuries, that often goes undetected Skier’s thumb describes an injury to the ulnar collateral ligament (UCL) of the thumb, whereby a large force to the thumb web space (such as the force of the ski poles in a fall) can rupture the ligament or cause a bony avulsion fracture. Often missed and left untreated, it can be simply addressed with appropriate assessment.
If the tear requires surgery, what is involved?
The person will feel immediate pain and experience swelling and bruising. However, sometimes it is difficult to diagnose the injury at the acute phase and the person often presents to the doctor later with pain and instability of the thumb. An injury is indicated if there is pain, limited movement and swelling over the base of the thumb. An X-ray will confirm this injury, along with specialist ligament stability testing.
What treatment is required? The extent and type of the tear will determine the course of treatment, which initially will often be rest, ice and immobilisation in a protective splint that positions the UCL to rest. • The tear can be partial or complete, with complete tears sometimes including a small fragment of bone, which has been avulsed with the ligament, and is visible on an X-ray. • If the tear is incomplete or if there is only tenderness, and no instability of the joint, the injury can be treated by splinting for 6–8 weeks. The splints are usually custom made by a trained hand therapist, though some off-theshelf models are acceptable. • If the tear is complete, the joint is unstable or there is a small fragment visible on the X-ray, then the ligament must be repaired surgically.
What will happen if treatment is not undertaken? The long-term effect of a torn UCL is pain and an unstable thumb, which leads to secondary deformities of the other joints of the thumb.
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Complete tears and unstable joints require surgical intervention. The surgery involves a repair of the ligament under local or general anaesthetic. Sometimes it is not possible to repair the ligament as it is, and an accessory wrist tendon is needed to strengthen the repair. If a small bony piece is attached to the ligament, then this is replaced in its original position and secured. Even after an operation, the thumb is held in a splint for 4–6 weeks and regular review by a hand therapist is undertaken. Normal light daily activities can be resumed after 6–8 weeks without a splint, but a return to sport is only advised after three months. Once out of the splint, hand therapy will be required to strengthen the thumb and regain movement.
Assessment advice Should you suspect a UCL injury, refer these promptly to a hand specialist for assessment. This is to rule out the potential of a Stener lesion where the ruptured UCL becomes obstructed by the adductor aponeurosis, which prevents the ligament from healing through intention. This will prevent a simple injury becoming chronic.
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An injury is indicated if there is pain, limited movement and swelling over the base of the thumb. An X-ray will confirm this injury.
KNEE INJURIES
The Biological Solution to
Knee Injuries Professor Fares Haddad is a Hip and Knee Reconstructive Orthopaedic and Sports Surgeon at University College Hospitals and The Wellington Knee Unit and discusses the importance of not treating a knee injury in isolation
We all know someone who has suffered a knee injury and not recovered fully. It is a familiar theme both in elite sport and amongst our family and friends. Our goal is to minimise the risk of that occurring. Injury prevention is the ideal, and should be part of everyone’s exercise regime, but not all injuries can be avoided. The Holy Grail after knee joint injury is the restoration of normal pain-free function without any structural or functional deficits, and without the risk of later deterioration. Modern clinical assessment, improved diagnostics, improved early intervention and rehabilitation have made that a reality for many, but we also recognise that there are many injuries where the ultimate outcome does not meet the patient’s expectations, particularly in relation to return to sport or in terms of their risk of later problems such as osteoarthritis. The ease of information transfer has sometimes complicated this arena, as talk of stem cells, genetic manipulation and other novel interventions often either leads patients and practitioners astray or increases expectations inappropriately. Our armamentarium is now impressive: • Imaging allows an evaluation of both structure and function so that treatment can be appropriately planned. The misconception that MRI scans provide all the required information is still commonplace. MRI is useful but not all MRI scanners, protocols and radiologists are equal! Moreover, there are sequences – for example, for articular cartilage imaging – that are very useful but not routinely applied. Weight-bearing radiographs are very helpful in many circumstances, CT scans give great clarity in relation to the bony anatomy and for surgical planning, and nuclear imaging allows us to assess physiology and function.
• Meniscal tears can be sutured in a variety of ways, and if that is not feasible, the meniscus can be augmented with scaffolds. • Articular cartilage can be restored through microfracture, through membrane application and with the use of implanted scaffolds or through autologous implantation of the patient’s own cultured chondrocytes and matrices. • Ligaments can now be reconstructed with autograft, allograft or synthetics with increased accuracy and much improved kinematics. • Alignment can be easily managed using modern osteotomy techniques with computerised planning, navigation and bone grafting such that early weight-bearing is possible. In skilled hands, these techniques can be combined so that multiple interventions are avoided. We have also made dramatic progress in terms of accelerated rehabilitation and the ways in which it can be applied. Knee joint preservation is certainly more realistic than it was 20 years ago, but each injury must be considered in a systematic and very structured way. For example, a meniscal tear or cartilage defect in the knee must never be considered in isolation. The management of a knee injury should involve an evaluation of the individual and of their function, their gait, their alignment, their hip and ankle function, and their ability to comply with rehabilitation. It is only by understanding how their knee fits into their normal gait cycle, their normal sports patterns and what they hope to achieve in future, that the best treatment modality can be determined.
Many patients who present with cartilage problems will have had previous ligamentous or meniscal injuries or surgery, and it is only by addressing those issues at the same time that we can have any hope of successfully using the available modern technology to deal with cartilage defects. The flip side of this argument is that many patients who present with meniscal tears also require careful assessment of their alignment, of the integrity of their ligaments and their chondral surfaces, because treatment of the meniscus alone is unlikely to lead to resolution of symptoms or a good long-term recovery unless the other issues are addressed. We have in particular moved forward radically from routine meniscal resection towards meniscal preservation and repair that allows preservation of meniscal function and protection of the all-important articular cartilage. Neither meniscal, chondral or ligamentous surgery will succeed in a mal-aligned knee; that too would need to be addressed either surgically or through realignment with orthotics and physiotherapy for the patient to make a good recovery. In the modern world, we have access to refined diagnostics and exciting treatments but the skill still lies in the evaluation of the patient as a whole, in a critical clinical analysis of the problem and data available, and in understanding the expectations and implications of any treatment offered. Biological knee preservation/restoration is realistic but must be offered in the right setting. To find out more information about Professor Fares Haddad, please visit www.practicemattersmag.co.uk/website/ contributors.php or www.fareshaddad.co.uk/
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‘
BARIATRICS
The Evolution of
Bariatric Surgery
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A lot has changed in bariatric surgery since 2001 when many still regarded bariatrics as cosmetic. Now it is accepted that sustained weight loss that follows successful bariatric surgery leads to vast improvements in quality of life and the reversal or improvement in co-morbidities.
In December 2001 as a newly appointed consultant with the encouragement of my then-colleague, Mr John Cochrane, I performed my first gastric band. The laparoscopic approach and the ease of application of the gastric band found a ready and eager reception amongst the patient population and referrers alike. By 2005 I was receiving more than 200 new referrals a year, and performed six or more laparoscopic bands in a day. The procedure proved to be quick, safe and even suitable for day surgery. Sarah, that first patient, still has her gastric band 11 years on and has become a good friend, but of the nearly 500 bands that I have placed since then, more than 30 have been taken out. Until 2005, the gastric band made up the vast majority of obesity procedures I did. However, by 2012 only 10 per cent of my cases were gastric banding. In 2004 I started performing the gastric bypass as a more durable and effective alternative. This was a more complex procedure and in order to minimise the risk on the heavier or sicker patients, a two-stage solution was formulated. I used the sleeve gastrectomy (where about 70 per cent of the stomach is removed) as a first step; patients Enquiry Helpline: 020
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Mr Majid Hashemi discusses the advances in weight loss surgery and improving quality of life for obese patients
Bariatric surgery is very safe when properly performed by experienced and trained teams, and the benefits far outweigh the risks of surgery.
would then lose some weight and a year or so later would be at lower risk for a longer anaesthetic that was required for the full bypass. After a while, I found that the majority of patients who had had a sleeve gastrectomy no longer needed any form of bariatric surgery. They were achieving weight loss of about 60 per cent of their excess weight and their co-morbidities improved significantly. The sleeve gastrectomy therefore became the third bariatric option.
Gastric Banding The ideal patient for the band is a non-diabetic volume eater with a BMI greater than 40, who is likely to comply and adopt a sensible balanced diet in the longer term. Previous, initially successful, attempts at weight loss (even if the weight is all subsequently regained) is a good prognostic indicator. Success requires a determined effort by the patient and binge eating and a high intake of sweets and ‘meltable’ calories will defeat the objective. The band is a purely restrictive procedure.
Laparoscopic Roux-en-Y Gastric Bypass (RYGBP) The bypass superseded the band and since 2006 I have been offering this as the default procedure for all – although always guided by the patient’s own choice. The ideal candidate is a patient with a BMI of 40, but those with a BMI of 35 or above with a comorbidity would also benefit. The effect on diabetics is dramatic and all experience improvement with more than 50 per cent able to come off all their diabetic medication within the first three months after surgery. Patients who are enrolled in fertility programmes often opt for bariatric surgery to increase their chances of conception and to reduce the risks of complications during pregnancy and labour. As well as this mal-absorptive effect, the RYGBP is effective in leading to weight loss due to restrictive and anorectic mechanisms. The small pouch and the narrow outlet from the pouch provide a restrictive component and patients modify their eating pattern as a result. Post operatively, supplementation with Vitamin B12 and vitamin D and over-the-counter combined mineral and multivitamins such as forceval or sanotogen gold are routinely recommended.Other micronutrient deficiencies that can rarely develop include those of thiamine, folate, and the fat-soluble vitamins and I recommend blood tests for all these at six monthly and then annual intervals.
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We have come a long way since 2001. The range of procedures available allows a tailored approach to each patient. There is general acceptance of the benefits of sustained weight loss.
Laparoscopic sleeve gastrectomy Although less technically demanding than a gastric bypass, this is still a very major procedure and the key is in careful patient selection and counselling. However, it has advantages in that it can be completed in an hour and requires a one- or two-day stay in hospital. The sleeve gastrectomy is extremely effective provided it is properly performed and properly calibrated. There is no need for band adjustment, no risk of emergency re-intervention being required for band slippage or erosion as there is with the gastric band, and no added risk of small bowel obstruction with an internal hernia as there is in a bypass. I also warn all sleeve patients of the risk of weight regain and the risk of exacerbation of reflux. In such an event a laparoscopic conversion to a gastric bypass is possible.
Endobarrier The gastric bypass in particular seems to cure diabetes in many patients, and allows patients to come off their medication. The most amazing thing about this observation was that the diabetes goes away or improves even before any weight
BARIATRICS
loss has been achieved, sometimes within days of the surgery. This observation suggested there is something about the prevention of contact between the food and the upper gut that leads to this phenomenon. The Endobarrier is a new device that seeks to exploit this observation. It is a 60cm sleeve made of special plastics that is placed by means of an endoscope. There is no cutting or abdominal surgery involved. There is a good response with weight loss and diabetes and this occurs soon after device insertion. The Endobarrier is then endoscopically removed after one year.
Safety and training
Selection Criteria For Bariatric Surgery • Age 18–55 • BMI 35 with a co-morbidity or >40 or over • No alcohol or drug dependence • No delusional or psychotic illness
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Bariatric surgery can be complex and obese patients tend to have pre-existing co-morbidities that increase their risks in general and reduce their ability to withstand complications. I have preformed nearly 900 cases with no mortality.
It is universally accepted that technical competence is essential to the objectives of safe bariatric surgery. Sometimes less emphasis is placed on the technique being performed within the context of a properly configured service. Patient selection, procedure allocation and aftercare are, by necessity, multidisciplinary processes. The peri-operative environment involves input from professionals from the wider organisation and outside the influence of the immediate bariatric team itself and so a large number of variables are introduced that can impact the outcome of surgery, and so clear and reliable care pathways, together with excellent communication ensures excellent outcomes.
• Agreement to follow up
Now it is accepted that sustained weight loss that follows successful bariatric surgery leads to vast improvements in quality of life
In Summary The bypass is the most complex of the procedures. It gives the best weight loss and is the surgery of choice in diabetic patients because of the striking results – cure or remission of diabetes in over 80 per cent of patients. It is also the default procedure for the obese patient with reflux or a hiatus hernia because it provides a diversion of the gastric and biliary juices. The sleeve gastrectomy is extremely effective provided it is properly performed and properly calibrated. The gastric band is simple and quick to place and also effective but needs a lot more work on the part of the patient and requires adjustments over time. A proportion of these bands need to be removed over time. The Endobarrier is an exciting new development; simple to put in, requiring a quick general anaesthetic and an endoscopy. Initial results suggest it is a very effective alternative for patients with diabetes. It is removed after one year so there is a risk of weight regain. The appeal is that it is reversible and removable with no lasting scarring. We have come a long way since 2001. The range of procedures available allows a tailored approach to each patient. There is general acceptance of the benefits of sustained weight loss. Bariatric surgery is very safe when properly performed by experienced and trained teams and the benefits far outweigh the risks of surgery. Mr Majid Hashemi is a Senior Consultant for Upper Gastric and Bariatric Surgery at UCLH.
Sleeve gastrectomy The new stomach tube – what is left behind
The 70 per cent of stomach that is removed – greater curve from above the pre-pylorus to near the gastro-oesophageal junction
To find out more information about Mr Majid Hashemi, please visit www.practicemattersmag. co.uk/website/contributors.php
www.practicemattersmag.co.uk 7
Ophthalmology
Consultant
FOCUS
Improving
vision with surgery
Mr Allon Barsam discusses the inconvenience of glasses in the modern age and suggests different options to increase your vision We live in a world that is increasingly visually orientated, with much of our communication occurring through visual media such as websites and smartphones. Alongside this is a demographic of patients, the baby boomers and their children (Generation X), with the motivation and the means to be independent of glasses and contact lenses. Glasses are more than just an inconvenience because for many patients the distortion associated with glasses for various prescriptions affects their quality of vision all of the time. Patients with cataracts often already know that the surgery on offer today gives them the options of a standard monofocal lens that corrects most of their distance vision, and a toric intraocular lenses to correct any remaining astigmatism and/or multifocal intraocular lenses to correct presbyopia (reading vision). After cataract surgery there will be no further need for glasses at all. As a surgeon who routinely combines cataract surgery and refractive (vision correction) surgery,
I would like to highlight the variety of options now available to some patients with an interesting case study. This demonstrates how different considerations apply to different patients, and how important it is to be able to tailor treatment options to the individual needs of the patient.
CASE STUDY Mrs KJ is a 68-year-old lady who had previously undergone routine left cataract surgery. She complained of worsening right vision and glare when driving in sunny conditions. She wore bifocal glasses and she also enquired about becoming glasses free. On examination her vision with glasses was 6/6 on the left and 6/9 on the right. A refraction (which tests the need for glasses) showed that her left eye had been left with 2 Diopters (unit of power for a refractive lens) of astigmatism and the right eye was hypermetropic (far sighted) also with 2 Diopters of astigmatism. She had a cataract in her right eye and her left eye had a nicely centred intraocular lens.
How surgery for Cataracts and Intraocular Lens Implants looks in 2013 Cataract surgery today is a world away from its most recent predecessor 20 years ago. Nowadays highly accurate imaging technology allows for detailed and individual mapping of a person’s eye. Based on this precise map a high definition, intraocular lens is selected to maximise a patient’s independence from glasses and contact lenses. The ability to accurately predict the outcome of surgery, as well as safely complete it, is like never before. This means that refractive lens exchange surgery, where a patient undergoes the same procedure as a cataract operation in the absence of actually having a cataract, has become an
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acceptably safe surgical option for patients who want to be free of glasses or lenses, but are unsuitable for other correction procedures. Many consultants routinely practice injection-free small incision surgery, where visual rehabilitation is so fast that patients can often leave the operating theatre being able to see better than before. Furthermore, after two or three days the vision often improves to a level whereby patients have the best vision that they have ever had. The most common complaint that my patients offer is that they can now see all of the dust in their house and every wrinkle on their face!
Mr Allon Barsam MA MB BS FRCOphth Consultant Ophthalmic Surgeon Allon is a Consultant Ophthalmic Surgeon at Luton & Dunstable Hospital, UCL and Honorary Consultant at the Western Eye Hospital, where he specialises in Cornea, Cataract & Refractive Surgery. He is one of only a handful of Consultant surgeons in the UK who is fellowship trained in Cornea, Cataract and Laser Vision Correction. Allon has undergone extensive training in the world’s most prestigious institutions. He graduated from Cambridge University and UCL Medical Schools with Honours and a Distinction in Surgery. After completing his training at Moorfields Eye Hospital, Allon went on to complete a fellowship in New York with Drs Donnenfeld and Perry, two of the US founding fathers of modern Cornea and Refractive Surgery. He is actively involved in teaching and has been a clinical examiner and lecturer for City University, School of Optometry. He is on the Executive Board of the London Deanery. He is regularly invited to speak, chair and moderate research sessions nationally and internationally. After an examination to accurately predict what kind of vision she would be most happy with postoperatively, a management plan was formulated whereby right cataract surgery was carried out with an astigmatism correcting toric intraocular lens and to overcorrect this eye to leave her with -0.75 Diopters of near sightedness; to allow her to read large print such as menus in a restaurant and the dashboard of her car, as well as to apply make-up without glasses. At the one month post operative visit she was able to see 6/5 for distance and N7 for reading unaided, and only required reading glasses for reading small print in a book. Needless to say, she was delighted with the outcome of surgery.
Acute Neurological Rehabilitation
The role of the
Rehabilitation Advisor The Acute Neurological Rehabilitation Unit is a 46-bedded unit providing inpatient care for patients recovering from acute brain injury The Rehabilitation Advisor role is diverse and holds responsibilities for different areas of the provision of care for our patients.
follow up telephone calls to UK patients after discharge, to ensure they are safe and progressing well at home.
Firstly, it holds the responsibility of assessing patients to be admitted for neurological rehabilitation, liaising with family members, therapy and medical teams, insurance companies, embassies, solicitors and case managers advocating on behalf of patients that are assessed as being appropriate for admission. It also involves signposting and advice provision for patients, families and medical teams of patients who are deemed inappropriate for admission to the unit.
The advisors also assist with the ongoing application for CARF accreditation for the rehabilitation unit. These standards are a benchmark of quality and evidenced-based care and further underline the high standard of neurological rehabilitation care that is provided by The Wellington Hospital. Many of these standards are in line with the National Stroke Strategy guidelines and the Department of Health best practice guidelines. Maintaining these high standards of care and ensuring patient involvement at all levels is vital to ensuring the image and reputation of The Wellington Hospital is second to none within the UK healthcare market.
Service development is at the heart of improving seamless and patient-centred care. The role of a Rehabilitation Advisor focuses on education about services and improving relations within the UK market. This side of the role incorporates attending and presenting at events aimed at UK healthcare market providers and service users, building links with third sector organisations that may open up new markets for the organisation, e.g. the Stroke Association, and helps to improve the whole patient experience during their stay. This includes assisting clinical staff to coordinate complex UK-based discharges and setting up a new service that will
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Evidence-based care is at the heart of the therapy provided by the Acute Neuro Rehab team. The Rehabilitation Advisor role identifies current local, national and international training, CPD and medico-legal events and will exhibit at these or organise for appropriate staff to attend and exhibit at these, further raising the profile of the unit and its services at The Wellington Hospital.
Service development is at the heart of improving seamless and patient-centred care. The role of a Rehabilitation Advisor focuses on education about services and improving relations within the UK market. www.practicemattersmag.co.uk 9
Gastroenterology
Pancreatic cysts
- not so innocent!
Consultant
FOCUS
Dr Priyajit Bobby Prasad, Consultant Physician and Gastroenterologist MBBS, FRCP, FACP, FRCPI, FASGE
Dr Bobby Prasad talks about the different types of Pancreatic Cysts that can be picked up during a scan of the GI tract Recent advances in cross-sectional imaging have led to the identification of a number of coincidental abnormalities in the gastrointestinal tract, which in the past we would have ignored as not being significant. Among these abnormalities are pancreatic cysts, which are often asymptomatic. These cysts are important because some cysts have premalignant potential and can become cancerous over time, leading to the diagnosis of pancreatic adenocarcinoma. Removing a cyst with worrying features before it becomes malignant may prevent a pancreatic cancer from developing.
What kinds of pancreatic cysts exist? Although many cysts will subsequently be seen on CT or MRI scans, a number of them may well have already been noted on abdominal ultrasound scans. What seems to be particularly important here is whether these cysts are mucinous or not. Mucinous cysts can be pre-malignant.
Pancreatic cysts can be split into two types: Non-Mucinous Cysts These do not have malignant potential, such as pancreatic pseudocysts, which are often related to alcoholic, gallstone or post-traumatic pancreatitis. Simple pancreatic cysts and serous cystadenomas are not usually considered pre-malignant. Mucinous cysts These cysts, such as mucinous cystadenomas and IPMN’s (intraductal papillary mucinous neoplasms) can both lead to pancreatic adenocarcinoma over time, and therefore need careful monitoring before they start to progress.
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Both types of category of cysts may be comprised of a number of smaller cysts.
Are there any features that would be more worrying? Yes. As a rule, larger cysts (more than 3cm), those connecting or associated with a large main pancreatic duct, abnormal eccentric wall thickening or calcification of the cyst walls tends to be of more concern.
How are cysts assessed? If a cyst were picked up on ultrasound, then the next imaging modality of choice would be a CT scan with a pancreatic protocol. MRI scanning with an MRCP also helps to delineate the pancreatic cyst and its relationship with the main pancreatic duct. Both can be expertly done by our GI radiologists at the Platinum Centre. Assessing the cyst fluid can sometimes be very helpful in determining whether it is mucinous or not. This is achieved by performing endoscopic ultrasound (EUS) in our brand new state-of-the-art Endoscopy Centre. Here, a thin gauge needle can be safely placed under endoscopic guidance, usually across the wall of the stomach, directly into the pancreatic cyst and then the cyst fluid is aspirated. Fluid samples are then sent for carcino embryonic antigen (to see if it is high and therefore likely mucinous), amylase (to see if it is high and so likely to be directly communicating with the pancreatic duct) and also for cytology to assess malignancy. We tend to reserve EUS for the cysts that are more likely to be mucinous or have worrying features.
Dr Prasad is a Founding Partner of London Gastrointestinal Associates and was a Consultant Physician and Gastroenterologist at Chelsea & Westminster Hospital, where he was the Clinical Lead Physician for Gastroenterology and Hepatology. He has also consulted at the Royal Marsden and Royal Brompton Hospitals in London. Strongly believing in adopting a kind, friendly and holistic approach to patient care, Bobby sees patients from all walks of life, with a national and international referral practice. He trained at Guy’s and St Thomas’ Hospital, London, and in Boston, USA, completing prestigious Advanced Endoscopy Fellowships in Endoscopic Ultrasound at Yale University, and Therapeutic Endoscopy and ERCP in Charleston, under Professors Peter Cotton and Robert Hawes. On Yale’s Faculty as an Attending Physician, Bobby was the recipient of a Yale New Haven Hospital All Star Award and the prestigious Imperial College Faculty of Medicine Teaching Excellence Award.
What happens next? Due to the nature of pancreatic cysts, close collaboration by a multidisciplinary team is required. The team would include gastroenterologists, radiologists and pancreaticobiliary surgeons with patient support throughout the whole process. • Asymptomatic pancreatic pseudocysts often spontaneously resolve over time. Simple cysts and serous cystadenomas do not require surveillance. • Low-risk mucinous lesions should be monitored at regular intervals for surveillance, often with MRI. • Patients with high-risk mucinous lesions who are surgical candidates may then be referred to a pancreatic surgeon for resection.
RENAL CANCER
Advances in detection and treatment of
Renal Masses Mr Guy Webster, Consultant Urologist, discusses the different types of Renal Masses and the treatments you can undertake depending on the size, staging and age The management of renal masses has seen significant advances over the past five years. The increase in availability of Multi-detector CT (MDCT) and MRI mean that most renal masses can be diagnosed with imaging alone; therefore biopsy for histology is rarely required. Historically, renal cancer would present with the classic triad of loin pain, mass and haematuria. Now they mostly present incidentally as a result of a scan being performed for another reason, e.g. biliary colic. As a result of this earlier detection, the size of renal masses are smaller and the treatment is different with an improved prognosis. The most common form of renal mass is a cyst, which occurs more frequently after 40 years of age and is rarely symptomatic, sinister or associated with renal impairment other than in polycystic renal disease. An increase in complexity of the mass is associated with increased malignant risk. Renal masses are classified according to the Bosniak Classification on CT criteria, though most are simple and accurately diagnosed with Ultrasound alone (as type 1) and can be confidently discharged.
Types of Renal Mass About 15 per cent of small solid renal masses are benign and angiomyolipomas (AML) and oncocytomas make up the vast majority. AML have specific criteria on CT imaging due to the fat component. They have a risk of spontaneous bleeding when more than 4cm in size and can be embolised by radiological means if necessary. Although they do occur as part of tuberous sclerosis (mental retardation and epilepsy) they are far more commonly sporadic in nature.
Renal cancer is most commonly a renal cell carcinoma (RCC). The incidence is increasing due to early diagnosis and obesity. The diagnosis can be made fairly confidently by contrast CT to include the thorax for staging to exclude lung metastases.
Treating a Renal Mass The treatment depends on the size of the mass, the staging and the age and co-morbidities of the patient.
• A large localised polar mass of 6cm or more is best removed along with the kidney as a total nephrectomy. This can be done laparoscopically either through a single port or more commonly through three or four ports. The kidney is retrieved in a sealed bag, via an extended port incision of 5–10cm in a complete state, in order to avoid tumour seeding and allows for historical staging. The patient can often be discharged within 48 hours.
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• A small renal mass (SRM), of less than 3cm, in a patient who is more than 75 years old, may be best treated by surveillance as the natural history of RCC in the elderly can be of slow growth (approx. 0.3cm/year). However, in general, surgical excision is the favoured option as metastases can occur in this size, albeit rarely. For those patients with a SRM fit enough to have a GA but not major surgery, there are methods of using energy to ablate by freezing (cryo) or heating (radiofrequency) by minimally invasive techniques. • For patients with a small exophytic mass even with normal renal function, a partial nephrectomy is indicated. Significant advances in technology, such as the da Vinci surgical robot, provide the surgeon with an improved laparoscopic view and manoeuvrability and greater dexterity for suturing, resulting in a more focused excision of the mass and subsequent suture repair of the kidney defect. Outcomes have resulted in lower risks of an incompletely resected mass, blood loss and urine leaks. Despite the blood supply being temporarily clamped (warm ischaemia), there is minimal loss of renal function.
The most common form of renal mass is a cyst.
• Large masses of more than 15cm are still often best dealt with by traditional open surgery due to the size of the incision required to retrieve the kidney and mass. Lympadenectomy of lymph node masses does not add a survival benefit, but can aid in staging and therefore prognosis. It is now recommended that the adrenal gland is not removed with the kidney as previously performed routinely in a radical nephrectomy. If the adrenal gland is involved through the disease, the prognosis is very poor with a high risk of the contralateral gland also being involved resulting in adrenal failure. The risk versus benefit is in favour of palliation. Further advances are also taking place in immunotherapy of renal cancer utilising the tyrosine kinase pathway to block renal angiogenesis. This is the domain of oncologists who are treating high-risk localised disease before and after surgery and metastatic disease in strict protocols. To find out more information about Mr Guy Webster, please visit www.practicemattersmag. co.uk/website/contributors.php
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Colorectal Cancer
The modern management of
colorectal cancer
Mr Daren Francis, Consultant Colorectal & General Surgeon, talks about what happens after colorectal cancer is diagnosed and how radiotherapy before surgery can shrink the tumour Once a patient has been diagnosed with colorectal cancer, their specialist will proceed to put a treatment plan in place. QOF requires that all patients diagnosed with cancer are to receive a Cancer Care Review (CCR) by their GP within six months of the GP receiving confirmation of their diagnosis. To support GPs to conduct their CCRs regarding colorectal cancer, this is an explanation of the pathway that patients with colonic and rectal cancers are likely to undertake.
What happens after the diagnosis is made? Once confirmed, the decision making process regarding further care is conducted by a team of specialists known as a multidisciplinary team (MDT). The team consists of surgeons, oncologists, radiologists and clinical nurse specialists (CNS). The team will normally meet on a weekly basis to discuss the care of the patient. At this time further tests are organised, including blood tests and specialist scans such as a CT for colonic and rectal cancer and an additional MRI scan for rectal cancers. These tests enable a full assessment of the primary bowel cancer and the extent to which it has spread, allowing for the most appropriate treatment to be planned. It is important to be aware that there is a difference between the planning of treatment for colonic cancers and treatment for rectal cancers.
Colonic cancers After the tumour has been assessed, most colonic cancers are treated by surgery in the first instance. The surgery allows removal of the tumour and the lymph glands surrounding it. The specimen that has been removed is then looked at by the histopathologist and the level of invasion through the bowel wall is assessed, along with the number of lymph glands that are affected. This allows the planning of any post-operative chemotherapy. With early cancers, sometimes surgical removal alone is all that is necessary. Radiotherapy is not usually employed for the treatment of colonic cancer.
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Rectal cancers
What are the current hot topics?
The planning of the treatment of rectal cancer is very different from colonic cancer, as radiotherapy aimed at the cancer can shrink the tumour before surgery and improve cure rates. Thus an MRI for local staging is mandatory. Following radiotherapy, surgery can remove all of the tissue surrounding the cancer. This is known as a Total Mesorectal Excision (TME). After the tumour is removed, a sample is looked at by the histopathologist to decide if any further treatment such as chemotherapy is needed. Treatment is dependent on how far into the bowel wall the tumour has invaded and if it has affected any of the lymph glands which have been removed at operation. It is much more likely for the patient to require either a temporary or permanent stoma if they present with a rectal cancer.
• The treatment for colon and rectal cancer is continuously improving and advancing on a regular basis. The introduction of screening has meant earlier detection and endoscopic removal.
Have there been any changes in the postoperative recovery of patients following colorectal resections? Most hospitals now employ an enhanced recovery programme (ERP). This can help reduce complications following surgery and speed up recovery. The programme involves careful planning before surgery. This ensures that the patient is properly prepared and any arrangements that are needed for them to go home are already in place. They are encouraged to take high-protein and high-calorie supplements before and after surgery and to start moving around as soon as possible, sometimes immediately after the operation. The surgeon will try to use minimally invasive surgery (laparoscopic) and avoid the use of nasogastric tubes and drains. Any catheters and fluids through a vein will be removed soon after surgery and patients can commence eating and drinking immediately following surgery. It is important to note that not all patients are suitable for this type of postoperative management.
• Laparoscopic or keyhole surgery allows much smaller incisions which, coupled with ERP, allows for quicker recovery following surgery. Surgery remains the mainstay of treatment for colonic cancer. • Robotically assisted surgery, such as a rectopexy performed with the da Vinci Si robot, is now being employed for rectal tumours and I am currently involved in a trial comparing laparoscopic and robotic resection of operable rectal cancer. • Larger tumours, which on initial staging do not appear to be operable, are being shrunk with specific chemo and radiotherapy to allow surgical removal. In some cases, the response to radiotherapy and chemotherapy is such that the tumour disappears. This is known as a “complete response”. • There is currently a trial which adopts deferral to surgery and in some trial cases surgery has been avoided. Liver and lung surgery is now possible for selected patients who have developed metastases from both colon and rectal cancer with a view to cure. Here at the The Wellington Hospital we are able to carry out laparoscopic resection of colonic tumours and synchronous liver metastases. Further information on colorectal cancer, treatments and surgery is available on the consultant’s website: www.darenfrancis.co.uk For further guidance on CCR and the National Cancer Survivorship Initiative (NCSI) please visit: http://www.ncsi.org.uk/what-we-are-doing/ assessment-care-planning/cancer-care-review/ To find out more information about Mr Daren Francis, please visit www.practicemattersmag. co.uk/website/contributors.php
SPORTS MEDICINE
Exercise for
Life
through education and helped by prompt diagnosis and management. Acute cardiac ischaemia and sudden cardiac death occur rarely and typically with unaccustomed vigorous exertion on a background of known or subclinical disease. Screening of individuals for signs and symptoms, past history and risk factors for cardiovascular events is recommended. Educating adults on the relevance of the onset of cardiac symptoms and signs and the appropriate steps may reduce the risk. Importantly, the risk in those with coronary artery disease will be expected to decline with increasing physical fitness.
Who should be screened before exercise? Only the minority and young high-performing athletes are screened routinely now for congenital disorders.
Professor Cathy Speed, Sports Medicine Physician, discusses the recommendations of a healthy lifestyle and talks about the benefits of undertaking exercise on top of our daily routines “All parts of the body if used in moderation and exercised in labors to which each is accustomed, become thereby healthy and well developed, and age slowly; but if unused and left idle, they become liable to disease, defective in growth, and age quickly.” [Hippocrates] Being physically active is a natural state of human existence. Modern lifestyles – technology, transport and food – promote unnatural sedentary behaviour and numerous disease states including obesity. The continued encouragement of physical activity for health-related benefits and exercise promotion have now become a remit of the practitioner and also the physician. Regular exercise delays all-cause mortality, lowers blood pressure and CHD biomarkers such as CRP and lipid profile. It decreases the risk of developing CHD, stroke, type 2 diabetes and some forms of cancer such as colon and breast cancers. Additionally, exercise helps to preserve bone mass, control and reduce weight, reduce falls, and improve anxiety/depression, well-being and enhance cognitive function. There is a no more cost-effective or efficient form of intervention for the maintenance and enhancement of health across all ages, all abilities and all diseases than regular exercise.
Exercise Recommendations In addition to activities of daily life, a strong programme of regular exercise should include: • Cardiorespiratory – the circulatory and respiratory systems’ ability to supply oxygen to skeletal muscles during sustained physical activity. • Resistance – the use of resistance to induce muscular contraction, which builds the strength, anaerobic endurance and size of skeletal muscles. • Flexibility – the development of a wide range of movement in a joint or series of joints that is attainable in a momentary effort.
• Neuromotor – exercises that focus on improving and maintaining motor skills such as balance, coordination, gait, and agility.
Current recommendations Most adults should engage in moderate to intense cardiorespiratory exercise training for at least 30 mins per day, five days a week and vigorous to intense cardiorespiratory exercise training for 20 minutes per day, three days per week. OR
Adults who should be screened by a sport and exercise medicine consultant or cardiologist before starting moderate to vigorous exercise include: asymptomatic people with diabetes mellitus, or other metabolic disease; those with known cardiac disease; or asymptomatic men over 45 years old and women over 55 years old; or those who meet the threshold for more than two risk factors. Any patient with an uncontrolled cardiovascular condition should defer from exercising until stable and should have medical clearance before beginning a programme.
An Exercise Prescription Service Where there are concerns about the safety or efficacy of an exercise programme, its design for an individual patient, or if injuries/illnesses occur, a sport and exercise medicine consultant can help.
A combination of moderate, vigorous and intense exercise to achieve a total energy expenditure of 500–1000 MET/min/week.
At the time of initial assessment, clinical risks, barriers to exercise and adherence are identified and goals are set, after which some undergo further investigation.
For two to three days a week, adults should perform resistance exercises for each of the major muscle groups and neuromotor exercises involving balance, agility and coordination.
When fully assessed, an exercise programme is written, which provides direction and enhances motivation. The patient is offered a variety of settings in which they can pursue their programme, and a choice of follow-up and support through an exercise supervisor. As a result, compliance is maintained through continued contact with the team as appropriate during the prescribed exercise programme.
Flexibility exercises for each of the major muscle/ tendon groups (a total of 60 sets per exercise) on two days a week are also recommended. The exercise programme should be modified according to the patient. Those who cannot reach these targets should still be encouraged to engage in smaller amounts, progressively building as they adapt [American College is Sports Medicine, 2011]. All should be encouraged to increase non-specific activity, i.e. move more.
What about the risks? The benefits of exercise far outweigh the risks. The most common complication is musculoskeletal injury and many of these incidences can be prevented
Summary Simple as it may seem, exercise prescription can have its challenges. Nevertheless, it is a highly effective intervention in the promotion of health for our patients, so should never be neglected. After all, “The wise, for cure, on exercise depend”. To find out more information about Professor Cathy Speed, please visit www.practicemattersmag.co.uk/website/ contributors.php
www.practicemattersmag.co.uk 13
‘
FOOT AND ANKLE
A different kind of
bunion
‘‘
Big Toe Arthritis
Arthritis of the big toe is frequently confused with a bunion, but is a very different condition requiring different considerations. With a bunion the issue is the forefoot being too wide, the prominence being to the inner aspect of the big toe. With big toe arthritis (Hallux Rigidus) the lump is on the top of the toe. During early stages there may be little to see externally other than intermittent swelling, but sometimes there may be nothing at all.
A Bunion
Mr Mark Herron talks about the symptoms of arthritis in the big toe and how best to manage the condition
During walking the foot acts like three separate rockers.
The symptoms of Hallux Rigidus are often a deepseated ache within the joint, not simply pain in narrower shoes. In fact, shoes can make the toe feel more comfortable (which tends not to happen with bunions). In general, the joint is uncomfortable when going through its range of movement, which is also different from a bunion where movement is expected to be pain free. The joint will also progressively stiffen and a more noticeable restriction in the upward direction of movement occurs, producing pain when wearing heels, as the position of the big toe is relatively upward pointing. Additionally, it may produce pain simply when barefoot, or wearing shoes with thin soles, as more force is placed through the front part of the foot.
It is this final part of the gait cycle which is most painful in Hallux Rigidus and knowing this, the pain can be eased by wearing shoes that might minimise the symptoms. The key features in choosing supportive footwear are that it provides a curvature (rocker) to the front part of the sole, which should be relatively stiff and unyielding, thus reducing the forces through the big toe. Ideally, the sole should also be shock absorbing and have a good insole to allow weight to transfer equally through most of the sole of the foot. A fit-flop shoe has all these characteristics and is certainly worth trying; the effect of wearing it should be immediate if it is going to assist. (www.fitflop.co.uk)
Managing the condition During walking the foot acts like three separate rockers. At the start of each gait cycle the heel strikes the ground and as the body weight progresses through the foot there is a “rocker-action” through the heel, followed by a rocker action through the middle part of the foot. Finally a “rocker-action” takes place through the forefoot, after which the foot leaves the ground momentarily.
Hallux Rigidus
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For ladies, a wedge type shoe will have some of these features and training shoes might also be helpful. In more advanced cases, footwear modifications are unlikely to make enough difference and this is where medical intervention is of use.
‘‘
FOOT AND ANKLE
Ideally, the sole should also be shock absorbing and have a good insole to allow weight to transfer equally through most of the sole of the foot.
Big Toe Replacement
Types of treatment available When determining which treatments are going to be the most appropriate it is important to consider a combination of factors: The level of symptoms that a person is experiencing is the most important. If severe and continual pain is present, including at rest or at night, it is likely that a “definitive” procedure to the joint is required, either a replacement or fusion. Where the degrees of symptoms are more minor, lesser procedures such as an injection to the joint, can be used. It is also important to consider the amount of discomfort that is produced when the toe is moved and the extent of the arthritic X-ray changes. Injection: Injection of steroid and local anaesthetic into the joint has the advantage of being easily done with a quick recovery. The injection can be done in an outpatient setting and usually requires no time off work. At best it will provide six or twelve months of symptomatic relief. This treatment is generally only used in early arthritis. Minimally invasive (keyhole) surgery: This is a treatment which is appropriate for people with intermittent symptoms of pain from the joint and where a reasonable degree of movement from the joint exists. It is a minor operation performed under anaesthetic which would require a day case stay. In principal, the inside of the joint is ‘tidied up’. The bony growth on the top of the joints can also be removed, with a minimally invasive technique, which flattens the prominence down and increases the upward movement of the joint. There will be small scars, each just a few millimetres, to the top part of the joint and patients are able to weight bear immediately after the operation. Driving is normally allowed by five days post-operatively and is followed a week later by physiotherapy to help maintain the improved range of movement post-operatively.
Big Toe Replacement: This procedure is used for a severely painful and arthritic joint. It has the advantage of maintaining some movement through the joint, though the advantages of this are not as great as one might imagine, compared to a fusion of the big toe. The operation has a particular advantage in that it offers somewhat more variability in achievable heel heights in certain patients post-operatively. The disadvantage of the procedure is, as with all joint replacements, that they ultimately wear out and the length of time it lasts varies, depending on the usage and type of replacement. Big Toe Fusion: A fusion of the big toe joint is the mainstay of treating severe arthritis of the big toe. Although it sounds dramatic as a procedure, the outcome is highly effective. In the majority of patients all pain is lost and it allows normal walking, most sports, including returning to running and a degree of heel wearing. The operation involves encouraging bone to form across the joint, which results in a stable and pain-free joint (though one that doesn’t move). The key to understanding this procedure is to appreciate that the big toe acts like a lever to push forwards during the final phase of gait. To do this effectively, it needs to point in the right direction and be comfortable during weight bearing. The loss of movement is not a particular disadvantage as movement through this one joint is not required for most activities.
Consultant
FOCUS
Mr Mark Herron, FRCS (Tr & ORTH) Mark has a decade of experience at Consultant level in managing all adult and adolescent foot and ankle disorders. He qualified from Birmingham University Medical school in 1991 and trained in Orthopaedic surgery between Birmingham and Bristol. He was later awarded fellowships in Foot and Ankle surgery in Oxford and Dublin and Bristol. His appointment to a Consultant post was at The Royal Orthopaedic Hospital in 2003 and he spent the next five years developing the Foot and Ankle Unit into a nationally recognised tertiary referral service. Following this work, he set up in private practice in Birmingham and London where he continues to see patients from around the world. Mark has worked widely in elite sport, including dance, and has been the foot and ankle specialist for the British gymnastics team and currently he is the foot and ankle surgeon for Warwickshire County Cricket Club. Within the field of sports injuries he has developed particular expertise in Achilles tendon disorders and all aspects of ankle instability and impingement syndromes. He has a specific interest in minimally invasive surgical techniques around the foot and ankle, especially for the ankle and great toe. In general these significantly limit post-operative discomfort, allowing rapid weight bearing, minimise recovery times and accelerate return to function. They are often of great use in arthritic and post-traumatic problems.
Heel rise after big toe fusion. Heel rise after big toe fusion The Wellington Foot & Ankle Unit are Nick Cullen, Andy Goldberg, Mark Herron and Simon Moyes. www.thewellingtonfootandankleunit.com
For Bunion correction he uses a wide variety of techniques with the emphasis being on minimising pain and allowing early return to work. He regularly undertakes all other deformity correction (such as flat feet and high-arched feet) as well as revision cases.
www.practicemattersmag.co.uk 15
GP news Round-up
In the busy world of General Practice, we look at trending stories and interesting updates from the primary care sector
The Digital Dilemma More and more people are using the internet to try and diagnose their health problems before seeing a GP. ‘Dr Google’ as it has been dubbed in the media, is used by millions of people throughout the world, whereby the person adds their symptoms to a search engine and uses the results to predict what health problem their symptoms might indicate. The dangers of this are that a person does not then seek a diagnosis by a health professional or that they begin to believe they are suffering from a lifethreatening illness. On the flipside, the internet is not necessarily a ‘demon’; using it for information can help a patient to make an informed decision about the type of treatment available or can prompt someone to visit their GP when they wouldn’t usually.
Let’s get Social You hold in your hands your neat new smart phone…now what do you do with it? Social media is a little daunting for many and if you’re in the healthcare profession it can be even more so. To provide a helping hand, The Royal College of General Practitioners (RCGP) has published a practical guide to help UK doctors navigate social media systems. The Social Media Highway Code was produced in collaboration with Doctors.net.uk and LimeGreen Media taking into account advice provided by a range of people with an interest in social media. The code helps to address ethical and confidential dilemmas that doctors may experience whilst using social networks. A draft of the guide was launched at the RCGP annual conference last October prompting exciting online debate by doctors across the UK, Europe and Australia and it was even the top trending subject in the UK on Twitter. Since then, healthcare professionals from all over the world have been providing feedback on the Code through Twitter, Facebook and the online forums on Doctors.net.uk. Social media is a great tool for debate and can be fun. To ensure you get the most out of it, while ensuring you meet professional obligations and protect patients, download a copy of the Social Media Highway Code from the RCGP website, www.rcgp.org.uk/social-media.
Comment and Debate IBM is developing a system called Watson to help health professionals make informed decisions about medical conditions. According to IBM, it can digest information and make recommendations much more quickly and intelligently. Watson even has the ability to convey doubt. When it makes diagnoses and recommends treatments, it usually issues a series of possibilities, each with its own level of confidence attached.
What do you think?
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So how does the healthcare industry react to digital development? Mid-march saw the Department of Health hosting the Healthcare Innovation Expo 2013 with Health Secretary Jeremy Hunt. The Expo was a platform to launch ten new apps within the trusted health apps library designed by the NHS Commissioning Board.
‘‘
I want to give doctors and nurses the time and space to deliver patient-centred care – to do this we need to innovate. Jeremy Hunt
Some of the new apps include: • Patient Access Mobile: Patients can book a GP appointment and order repeat prescriptions • HealthFabric: Allows the sharing of online care plans aimed at patients with dementia and other long-term conditions • PatientKnowsBest: Currently being trialled in 20 hospitals, the app allows people to receive lab results and message a doctor or nurse securely. • Rallyround: A way for relatives and friends to communicate when organising their time to support a sick relative or friend. Ultimately, it is essential that technology or search engines are not used as a substitute for visiting a doctor but interactive online tools can help support health professionals and improve access to healthcare information for patients.
GP NEWS
Designed
For You
Virginia Wood | Practice Manager | The Clinic Virginia Wood is practice manager at The Clinic. She has witnessed first-hand the benefits of CPR training. PM: What does your role as practice manager at The Clinic entail? My role is to solely manage the practice. I do salaries, accounts, human resources and purchasing. All complaints come to me and I do about ten jobs at once. The most satisfying part of the role is seeing the practice progress and grow and being able to implement and develop new things. At the moment we are in the process of implementing a new resource centre that will be a room where patients can access a computer to find out more about ailments, download information via the internet and find local services. They will also be able to take their own BMI and blood pressure to update records and come along to expert patient talks, so if you have diabetes, for example, an expert talk can talk you through this. PM: Why is CPR training necessary for the practice? CPR training is important because it’s part of the GP contract that every GP must have it yearly and reception staff must have training every three years. We have had training from a number of different companies and when GP liaison officer Ricky McKinson visited from The Wellington Hospital to talk us through some offerings, he had such good energy and enthusiasm that we decided to do CPR training with them. PM: What does CPR training consist of? It doesn’t take very long. The reception staff were taught over lunchtime and for clinical staff, it took one evening. Training staff from The Wellington Hospital brought dummies along. You press down on the dummy’s chest, clear the airway and check if they’re breathing. The new recommendation of breathing has lowered the amount of breathing. I think it is 15 compressions followed by 1 ventilation. PM: Has the CPR training been useful? Yes! Two days after training, someone collapsed outside The Clinic. A GP was told and he went running outside to assist. There was a paramedic on site, but he needed someone to take over CPR so he could get his equipment and defibrillator ready. Two GPs who had just had training, took it in turns because you would be knackered if you did all the CPR yourself. The man had had a heart attack and through CPR they brought him around so he could get to hospital. They felt good that they had just done the refresher course and could put it into practice. You never know what’s going to happen.
Bon Voyage After four years we are bidding a fond farewell to Katy Cross from the GP Liaison team. Katy is leaving us for the distant shores of Thailand and with sun, sea, sand and diving, we don’t understand it ourselves! Stepping into the Central London liaison role, we welcome Supriya Taggar. We’ll provide a full introduction to Supriya in the next issue of Practice Matters.
Katy completing her abseil in a onesie for the Wellington Appeal!
PRACTICE
TALKS
Our ‘Consultant-Led Practice Talks’ bring the best of The Wellington Hospital’s educational programme straight to your practice, and at your convenience. There are currently over 70 Wellington consultants, across a range of specialties, who are part of this programme. These specialists are available to give talks at breakfast meetings, lunch breaks or evening discussions on topics of your choice.
Allergy Breast Care Cardiology Colorectal and General Surgery Dermatology ENT Gastroenterology General Medicine Gynaecology Liver Nephrology Neurology Ophthalmology Orthopaedics Plastics Respiratory Rheumatology Sports Medicine Urology Vascular A full list of topics is available to view via the health professionals section at www.thewellingtonhospital.com. If you are interested in arranging a practice talk, please contact the GP Liaison team via the Enquiry Helpline on 020 7483 5148, or via the individual GP Liaison Officer’s numbers listed on the back cover.
www.practicemattersmag.co.uk 17
NEWS from the
The Wellington Hospital is an advocate for education and professional development; our seminars and events cover a range of topics from a variety of distinguished and experienced specialists. All seminars are free of charge and a certificate of attendance is provided for CPD points.
The New
PRACTICE matters website
One element that we have been receiving frequent requests for is to make our Practice Matters magazine and our consultant’s articles more accessible online and via mobile devices. Launching shortly will be our new interactive and web-based magazine that provides you with access to all our past issues, and allows you to search for articles by speciality, condition or consultant. Finding specific information or reading around a subject will now be much easier. www.practicemattersmag.co.uk
Education, Education, Education Over the past four years, The Wellington Hospital has been busy supporting local GPs and physiotherapy practices with an array of educational seminars, to help obtain learning hours for professional development targets set by governing bodies. This year sees us progressing with a new format for our Orthopaedic Masterclass, aimed at physiotherapists and GPs with a special interest in orthopaedics. Moving away from our original set-up of an evening lecture style seminar, we designed a more interactive programme over a series of four Saturdays. Running simultaneously during the morning, our speakers provide a mixture
of lectures and practical workshops on one specialty. The delegates rotate between rooms throughout the morning so by the end of the morning each delegate has completed all sections, achieving three hours of learning. 2013 also sees the start of a new three-part cancer care series titled ‘Innovations in the World of Cancer Care’, with the first seminar focused on women’s health. This mini-series offers detailed treatment perspectives, from the physician, surgeon and the oncology specialists, who play a vital role in the multidisciplinary approach to treating patients with cancer.
NEW CONSULTANTS Cardiology
General/Colorectal Surgery
Prof Anthony Mathur, Barts and The London NHS Trust
Mr Stephen Warren, Barnet & Chase Farm Hospital
Dr Shelley Rahman-Haley, Harefield Hospital Dr Andrew Wragg, London Chest Hospital
Dermatology Dr Ioulios Palamaras, Barnet & Chase Farm Hospital
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Histopathology Dr Jolanta McKenzie, Princess Alexandra Hospital
Medical Oncologist Dr Richard Ashford, Mount Vernon Hospital
‘
GP NEWS
‘‘
Q &A
Cancer facilities at The Wellington Hospital are expanding. In 2011, we partnered with Leaders in Oncology Care (LOC) to offer cancer treatment at the Platinum Medical Centre and now we have joined forces to create our new Inpatient Oncology Unit located at The Wellington South Jane Kirkby is a specialist oncology nurse at the Platinum Medical Centre. A perfectionist by nature, she is committed to making a difference and to making the patient’s cancer journey as comfortable as possible by focusing on the patient’s needs as a whole. PM: Can you tell us about your professional background?
JK: I trained and qualified in the 80s at a joint school – the Royal Masonic Hospital and Queen Mary’s Roehampton School of Nursing. I failed my final exams the first time round – that period of time between failing and retaking I got a bit disillusioned, so when I finished my training I quit being a nurse. I decided to try something completely different, but at the time I was sharing a flat with nurses, so it didn’t take long for me to get back into it. From there I went to the Lister Hospital where I worked in orthopaedics and then stepped into the oncology service, but not chemo at the time. When I started looking after these patients I thought – this is what I want to do. They started to develop the oncology service and members of staff were sent on training courses to become qualified in administering chemotherapy. PM: How would you describe your job to other people? JK: When you tell people you are an oncology nurse their first reaction is, ‘Oh, how difficult that must be. How sad.’ But it isn’t like that at all. If I could sum up what we do in a few words, ‘it’s to make a difference to someone in a very difficult time of their life’. It’s much more than just administering chemotherapy, it’s about being their advocate, listening and looking after the patient as a whole and their family. PM: Talk us through a typical day. JK: Our patients are all different, so no two days are ever the same and that’s the beauty of it. But we do have set routines and a ‘typical day’ would be coming in at 8am and getting things ready for the first patient who will arrive around 8.30–9am. We administer treatments and ensure that, if necessary, the patient gets appropriate support services in the community. It is also necessary to make sure
that the team is working well together, always keeping up with the ethos of LOC – because that‘s what makes us different. On the whole, I go home fairly satisfied knowing I have made a difference that day. But I am a perfectionist so if I can’t attain and achieve what I want for someone, that doesn’t sit well with me. PM: What happens once the treatment finishes and what other kind of supports are available? JK: In the last few years we have developed a service called ‘Living well’. It’s about enabling the patients to feel the best that they can while on treatment – looking after nutrition, psychological support, fitness and exercise, meditation and selfimage. We have a variety of specialists within LOC that we can refer patients to – homeopathic consultants, psychologists and psychiatrists. After the treatment there is also an intensive six-week programme available; each week focuses on something that will enable the patient to make a complete recovery from chemotherapy. To be a cancer survivor can be almost as difficult as being on treatment – you have been in this kind of cocoon where support is on hand and finishing treatment can also be quite challenging. There are also workshops available for patients and their carers during the time they are having treatment. PM: What piece of advice would you give to any young and aspiring nurse who wants to work with cancer patients? JK: It’s not a speciality you would consider just trying, there needs to be something special within you. As rewarding and practical as it is giving chemotherapy, there is a large aspect of it that is like being a social worker and there are lots of different things required to be an oncology nurse. Someone that comes into it with an open mind will be successful. The job is much more than giving chemo. It’s about having someone’s life in your hands and it’s so important that you respect that. It’s also about embracing the patient’s family so you also become a counsellor at times. You are not just a medical nurse, there are a lot of responsibilities that come with it. Interview conducted by Sandra Batista
Nephrology
Ophthalmology
Dr Alan Salama, Royal Free Hospital
Mr Avinash Kulkarni, King’s College Hospital
Neurology
Plastic and Reconstructive Surgery
Dr Dominic Mort, Barnet & Chase Farm Hospital
Mr Anthony MacQuillan, North Bristol NHS Trust
Oral, Maxillofacial & Dental
Radiology
Mr Wayne Halfpenny, Barnet and Chase Farm Hospital
Dr Barbara Faissola, St Mary’s Hospital
Dr Andrew Cantwell, Dentist/Specialist Prosthodontist, Private Practice
www.practicemattersmag.co.uk 19
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 Hertfordshire 07889 317 774
supriya.taggar@hcahealthcare.co.uk
ricky.mckinson@hcahealthcare.co.uk
ricardo.pereira@hcahealthcare.co.uk
veronica.brown@hcahealthcare.co.uk