Winter 2014/15 • Issue 19
Gynaecology Options for improving the pelvic floor
Cardiology
The heartbeat of our cardiac services
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
Welcome Happy New Year to all, and what plans we have for 2015! Last year, I made the move from CEO of Harley Street Clinic to The Wellington Hospital, and began working with various departments on developing the already highly established services. The hospital’s ruby year brought with it new units, growth to services and the acquisition of advanced technology. In its 15th year since opening, the Acute Neurological Rehabilitation Unit was awarded CARF re-accreditation for a further three years. The award recognises the outstanding achievements of staff, services and the international team, all highlighted in a glowing report. You can read further information about the unit in their annual report, available on the main hospital website. February sees the start of our main events and begins with our cardiology GP seminar, running in conjunction with National Heart Month. We have an advanced cardiology department, supported by state-of-the-art technology and well regarded consultants. On pages 8-9 of this issue, we discuss the recent addition of a cardiology group, made up of four specialists, available to both our referred UK and overseas patients. This winter issue also features articles about the fascinating side of meniscal augmentation of the knee by Consultant Orthopaedic Surgeon, Mr Rahul Patel (pg 12-13), an insight into tailored treatment of vocal cord palsy (pg 14) and an overview of our balance and dizziness service, which has grown from strength to strength. We constantly strive to find ways in which we can improve services for our patients. The Wellington Diagnostics and Outpatients Service has received many developments to services over the past year, more of which you can read about on page 6 of this issue. So, as we kick off 2015, developments are already underway to keep The Wellington Hospital at the top of the UK private healthcare sector. Keep an eye out for future issues to find out more. Best wishes,
Neil Buckley CEO
Enquiry Helpline: 020
7483 5148
2 • PRACTICE MATTERs WINTER 2014/15
Editor: Hannah Rogers Production & Distribution: Runwild Media Group
PRACTICE MATTERS
Contents 04 | Addressing the ‘form’ to improve the function of the pelvic floor Mrs Joanne Hockey
04
06 | Services at The Wellington Diagnostics and Outpatients Centre
06
07 | The curious condition of cholesteatoma Mr Elliot Benjamin
08 | The London Cardiology Practice comes to The Wellington Hospital
1012
10 | Treatment options for skier’s thumb Mr Neil Toft
11 | The Balance and Dizziness Service Mrs Emma Warner
12 | Meniscal augmentation: scaffolds and stem cells Mr Rahul Patel
14 | Vocal cord palsy: tailored treatment for optimum voice restoration Professor Martin Birchall
15 | Irritable bowel syndrome: symptoms and treatments Dr Deepak Suri
16 | GP news
11
18 | Latest news and new consultants 18 | 60 Seconds with...
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 3
gynaecology
Addressing the ‘form’ to improve the
function of the pelvic floor By Mrs Joanne Hockey
Collection of interlacing symptoms
Urinary problems
Too often in routine practice, for both primary and secondary care, we concentrate on specific diseases or disorders, rather than looking at the whole woman in front of us. Usually, the patient will present with a medical term rather than a list of symptoms, such as ‘I have a cystocele’ or ‘I was told by the practice nurse at my smear that I have a prolapse’. Only on closer questioning will symptoms such as urinary or defecatory issues, and occasionally sexual function, be discussed.
These are often the result of some additional factors, especially in women who have had children. UTIs tend to persist for a while, recur once treated and are seriously debilitating. Untreated or low grade UTIs with acute flares can feature at the following times in a woman’s life:
However, there are usually one or two things that will underpin a generalised feP4eling of ‘not being quite right’ and having a sense of a urinary tract infection (UTI), The challenge is finding which problem can, if solved, have a knock on, positive effect on the whole.
• childhood • through their teenage years • after first intercourse • after the menopause
7483 5148
4 • PRACTICE MATTERs WINTER 2014/15
Topical oestrogen in post-menopausal women can also reduce the incidence of UTIs. This is because it helps to ‘plump up’ the vaginal and urethral mucosa, making it more resilient. In addition to this, the sub-urethral vascular layer at the bladder neck (which is also hormone sensitive) will improve, and as it does, the closure pressure of the urethral sphincter may enable a feeling of greater security with continence.
Such infections can lead to interstitial cystitis and painful bladder syndrome, with any sexual contact potentially leading to pain and urinary frequency. These need careful investigation, eradication of persistent bugs and assessment of function and flow. A poor urinary flow, determined with a flow meter or as part of a urodynamic assessment, together with a residual volume in the bladder, will predispose the particular patient to recurrent infections. The poor flow might be improved with elevating a cystocele, through inserting a ring pessary or performing an anterior repair of the vaginal wall. This particular problem will also respond to improving the urethral and vaginal mucosa with topical oestrogen (post menopause). By looking at more than just the residual urine,
Enquiry Helpline: 020
the whole area receives treatment, whilst other symptoms are also addressed.
Urinary incontinence Urinary incontinence affects up to half of all women at some stage of their lifes. The issue presents us with a problem to be solved, rather than an expression that this is ‘normal’ and an expected and natural consequence of having a family. The mobility of the bladder neck increases after pregnancy and childbirth, whether it is vaginal or abdominal. This mobility can be corrected with
Fig 1
Consultant
FOCUS
Mrs Joanne Hockey MD MRCOG
Consultant Gynaecologist
dedicated physiotherapy, followed by relatively simple surgery (mid urethral tape). But if the other symptoms of frequency, urgency, poor voiding and associated prolapse are forgotten, this can make the problems worse. As a result, careful history taking and investigation with urodynamics can highlight any other problems in patients presenting with more than one issue.
there is not a complete resolution of symptoms after a course of physiotherapy, surgery will usually be easier and result in a better outcome, if the pelvic floor muscles are strong. Continued effort prevents atrophy of the muscles after the menopause and can improve sexual function, all of which maintains any improvement achieved by surgery.
Pelvic floor health
So, we must look at caring for all aspects of women’s urogynaecological health as after investigation, improving the form or position of the pelvic organs within the pelvic floor can improve their function. Consequently, although each of these are small benefits, they can have a larger overall boost to a woman’s quality of life.
Physiotherapy has the advantage of improving the global tone of the pelvic floor. Although it is good practice to offer physiotherapy for stress incontinence before contemplating surgery, women can benefit in other ways. For example, whilst undergoing a course of physiotherapy for stress incontinence, many women find that other areas feel better. Childbirth damage or strain after years of constipation can lead to posterior vaginal wall weakness; potentially further causing sexual dysfunction and defecatory problems. Even if
Mrs Joanne Hockey is a consultant gynaecologist and clinical lead for urogynaecology at the Royal Free Hospital, Hampstead. Her special interests include urogynaecology, urinary incontinence, bladder problems, urodynamics, prolapse and pelvic floor problems, as well as menstrual problems, fibroids and menopause. Mrs Hockey is also the lead for undergraduate Women’s Health for UCL students at the Royal Free. She is committed to understanding patients’ problems and ensuring that each individual woman is at the centre of her care.
To find out more information about Mrs Joanne Hockey please visit www.practicemattersmag.co.uk/ contributors
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 5
service update
Service update
The Wellington Diagnostics and Outpatients Centre The Wellington Diagnostics and Outpatients Centre (WDOC) in Golders Green has grown from strength to strength since opening in 2007. The centre provides private family general practice services and consultant care, in a variety of specialities. It has state-of-the-art imaging together with non-invasive facilities for patients with heart problems, digital breast screening and a pain management service.
Services include: • Breast screening • Cardiology and cardiac care • Child healthcare and paediatrics • Dermatology • Diabetology and endocrinology • Ear, nose and throat • Gastroenterology • General medicine • Geriatrics
• Gynaecology and obstetrics • Haematology • Hand, plastic and reconstruction medicine • Hepatobiliary and hepactic medicine • Neurology • Neurophysiology • North London Hearing • Orthopaedics • Pain management • Physiotherapy
Educational events In addition to our other facilities, the WDOC hosts a programme of GP seminars which run throughout the year. In 2015, we have put together a list of specialist events covering areas including urology, neurology, cardiology and IVF. The talks are led by The Wellington’s top consultants and hosted by Consultant Cardiologist and Medical Director for WDOC, Dr David Lipkin. All attendees receive an attendance certificate, which counts towards CPD points. For a list of events or further information on The Wellington Diagnostic and
Enquiry Helpline: 020
7483 5148
6 • PRACTICE MATTERs WINTER 2014/15
• Private GP service - JDoc 365 - Dr Ruth Whitby - Dr Miranda Abrahams - Dr Joanna Rustin • Renal medicine • Reproductive medicine and fertility • Respiratory • Rheumatology • Urology • Vascular medicine • Women’s and men’s health
Outpatients Centre, please visit:
www.wellingtondiagnosticscentre.com or contact the GP Liaison team on:
wellington.gpl@hcahealthcare.co.uk If a referred patient wishes to make an appointment at The Wellington Diagnostics and Outpatients Centre, or any of our other facilities, they can contact The Wellington Hospital Enquiry Helpline on 020 7483 5148. Further details of all services can be found online at www.thewellingtonhospital.co.uk
EAR, NOSE and THROAT
The curious condition of cholesteatoma By Mr Elliot Benjamin
Cholesteatoma is a condition unique to the ear, with only 1 in 1000 population of people referred with ear problems, diagnosed with the disease. GPs may only see a few cases in their whole career, but in view of the devastating effect it may have on hearing, balance, facial nerve function and possible intracranial complications, it is worth considering its diagnosis in a patient with chronic ear symptoms.
So what is cholesteatoma? It is a build-up of dead keratin (squamous epithelium) in the middle ear, which is normally lined by columnar epithelium. When in the middle ear, it takes on invasive properties, causing localised destruction. There are many theories as to its aetiology, the most accepted is that this keratin arrives from misplaced squamous epithelium from the outer surface of the tympanic membrane. It normally enters the middle ear via a slow forming retraction pocket, but may be occasionally implanted during surgery, or rarely even be congenital.
Fig 1. Cholesteatoma in the attic of a left ear
How does it present? The most classic way is with a persistent, smelly discharge form the ear, over a period of several weeks or months, which does not respond to topical or systemic antibiotics. The patients may have a conductive hearing loss (Rhinne’s test is negative, i.e. bone conduction better than air conduction and Weber’s test is lateralised to the symptomatic ear), but may of course have sensorineural hearing loss as well.
thrombosis are rare but still seen to this day as presenting signs of cholesteatoma.
What do you see inside the ear? The appearance can be quite variable and often present as a lot of infected discharge in the ear canal. On otoscopy, look upwards into the attic area for a retraction pocket with white keratin-like debris. It may be obscured by a hard lump of wax which is resistant to all attempts to remove it.
How do you treat cholesteatoma?
Fig 2. Tympanosclerosis
Occasionally, a patient may present with episodes of vertigo and imbalance (if the cholesteatoma has eroded into the semicircular canals). One should always be aware of the sudden facial nerve palsy. 99 per cent will be due to a Bell’s Palsy (idiopathic), but if there is a discharging ear, or even a big lump of wax, high up in the attic of the ear drum, be suspicious of an underlying cholesteatoma. A rare presentation may be with patients complaining of lack of taste, or a metallic taste as the disease damages the chord tympani nerve, which passes through the middle ear. Intracranial complications such as cerebral abscess, meningitis or lateral sinus
The mainstay of treatment is normally surgical. This may involve a mastoid exploration with removal of all the disease, and possible rebuilding of the ossicles of the middle ear to regain hearing. In this modern form of surgery, the ear canal is rebuilt and the ear drum closed and effectively looks normal in future examinations. It may involve the more traditional ‘canal wall down’ procedure, leaving the patient with a mastoid cavity, requiring long-term care and microsuction. If surgery is contraindicated (in the very elderly or medically unfit) then regular ear toileting with microsuction and treatment of secondary infections may be appropriate in some cases.
To find out more information about Mr Elliot Benjamin please visit www.practicemattersmag.co.uk/ contributors
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 7
CARDIOLOGY
The London Cardiology Practice comes to The Wellington Hospital Cardiology has always been a leading specialist area at The Wellington Hospital. Our cardiac services include cardiac outpatient diagnostic testing, non-invasive cardiac imaging, invasive and interventional cardiology and cardiac surgery; all led by top cardiology consultants and supported by a multi-disciplinary team. The London Cardiology Practice joined our team of cardiology consultants at the end of 2014, offering a seamless service from diagnostic testing, through to treatment and comprehensive aftercare. The group have a specialist interest in interventional cardiology with minimally invasive procedures for all aspects of coronary artery and valvular heart disease. In addition to this, they have wide ranging expertise in the management of general cardiological conditions including heart failure, arrhythmias and hypertension.
Drs Patel, Kennon, Archbold and Smith each have their own sub-speciality expertise, in various areas of interventional cardiology. The team are particularly advanced in the delivery of complex coronary intervention and stenting, Trans Aortic Valve Intervention (TAVI), and have internationally recognised expertise in the latest coronary interventional techniques for chronically occluded coronary arteries. Until recently, for this particular set of patients, there were poor results and significant risks. The London Cardiology Practice began two years ago, and was built on a foundation of similar interests, yet with differing expertise and a strong desire to deliver the best possible care. These values not only apply to complex procedures, but also in the aftercare necessary for the best possible outcomes.
International patients As well as UK based cardiac patients, The Wellington Hospital sees many international cases. Often patients will come with very complex conditions and present with complicated cardiac history. Whether it is an assessment of a patient’s coronary circulation, a second opinion, or the need for a complex cardiac device such as a pacemaker, international patients will benefit from state-ofthe- art testing and treatment, as well as expert post-surgical care. Our cardiac services include both invasive and non-invasive procedures, performed by leading cardiologists and supported by specialist cardiac nursing staff, radiographers and physiologists. With three cardiac catheterisation laboratories, three operating theatres and intensive care facilities, we ensure our patients receive the best cardiac care. Our clinicians have state of the art diagnostic imaging at their disposal, including 3D echo, cardiac MRI, CT and myocardial perfusion scanning.
To find out more about The London Cardiology Practice, please visit www.thelondoncardiologypractice.co.uk For more information about cardiac services at The Wellington Hospital, please visit www.thewellingtoncardiacservices.com
Enquiry Helpline: 020
7483 5148
8 • PRACTICE MATTERs WINTER 2014/15
Consultant Focus Dr Simon Kennon MD FRCP Consultant Cardiologist I qualified from Manchester Medical School in 1992 and undertook postgraduate training in London, including research into acute coronary syndromes leading to the award of an MD. Following a fellowship in interventional cardiology at St Vincent’s Hospital, Melbourne, Australia, I was appointed consultant cardiologist in 2005. I work as an interventional cardiologist at Barts Health NHS Trust and the Royal Free Hospitals. I work as a general cardiologist at Barnet and Chase Farm Hospitals.
Dr Deven Patel MBBS, FRCP Consultant Cardiologist I trained at the Middlesex Hospital, qualifying with distinction in Pathology and merits in Medicine, Surgery and Pharmacology. My training in Cardiology was undertaken at internationally recognised London teaching hospitals, including The Royal Free, Royal Brompton and Harefield Hospitals. I have an active private practice, based at The Wellington Hospital since 1999. I have specialist expertise in diagnosing and treating patients with chest pain from suspected coronary artery disease as well as acute coronary syndromes. My coronary interventional work includes the techniques
My key areas of interest are the management of coronary artery disease and heart valve disease. I am an interventional cardiologist performing both elective and emergency coronary interventions at the Barts Health and the Royal Free Hospitals. I am an experienced Transcatheter Aortic Valve Implantation (TAVI) operator, having set up and led the TAVI programme at Barts Health for the last 6 years. In the private sector, as well as consulting at the Platinum Medical Centre, I also perform both coronary intervention and TAVI procedures in the cardiac catheter laboratories at The Wellington Hospital.
of rotablation, bifurcation, left main stenting and the use of intravascular ultrasound and optical coherence tomography. I also have a wide-ranging experience in general cardiology including the management of atrial fibrillation, heart failure, valvular heart disease and hypertension, as well as implantation of permanent pacemakers. My research interests have been in the evaluation and risk assessment of patients with acute coronary syndromes. My most recent research, undertaken in collaboration with The Wellington Hospital, was examining the diagnostic and economic benefits of CT coronary angiography, compared to conventional tests in patients with suspected cardiac chest pain.
Dr Elliot Smith BSc, MBBS, MD, MRCP Consultant Cardiologist I qualified as a doctor from Guy’s and St Thomas’ Hospitals in 1994, and trained in Cardiology at the Manchester Heart Centre and the London Chest Hospital. I became a consultant cardiologist in 2008, working at the London Chest Hospital (Barts Health NHS Trust), and the Royal Free Foundation Trust. I look after patients with all types of cardiac symptoms and diagnoses, including chest pain, breathlessness and palpitations and atrial fibrillation. I am also interested in the assessment of healthy patients who may be at risk of future heart disease. I have a specialist interest in the management of patients with
Dr Andrew Archbold MBBS, MD, FRCP Consultant Cardiologist
coronary artery disease. I am an interventional cardiologist specialising in coronary angioplasty and stenting. I have a particular focus on treating more complex types of coronary anatomy, especially arteries that have been blocked for a long period of time (chronic total occlusions or CTOs). I lead the CTO programme at Barts Health, and am a recognised expert in this field. I am also a European trainer (proctor) for the techniques used to unblock these vessels. I review patients who may previously have been informed that it is not possible to unblock their arteries minimally invasively. Some of my patients have previously undergone bypass surgery some years earlier, where a repeat bypass operation is not desirable.
I trained as a doctor at The London Hospital Medical College, qualifying in 1992. My higher specialist training was based at the London Chest Hospital and St Bartholomew’s Hospital. I was appointed as a consultant cardiologist at Barts Health NHS Trust in 2004.
I also have a particular interest in the assessment of patients who require non-cardiac surgery. Concerns about the heart usually arise in older patients, often scheduled for orthopaedic, cancer, prostate, bladder or vascular surgery. My aim in assessing these patients is to clarify whether or not there is an important heart problem, and to optimise their condition for surgery.
I am a general and interventional cardiologist, seeing patients who have all kinds of conditions from chest pain, breathlessness, palpitation and hypertension. My main sub-speciality area is the management of patients with coronary artery disease, either those with stable angina or acute coronary syndromes.
My role as one of the foundation training programme directors at Barts, helps to ensure standards of training for the specialists of the future. I am a member of several regional and national clinical leadership and expert advisory groups, and an elected member of the British Cardiovascular Society Guidelines & Practice Committee and its Clinical Standards Committee.
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 9
orthopaedics
Treatment options
for skier’s thumb By Mr Neil Toft
The majority of skiers (even those with ample experience) will fall at some point during their holiday, with the hands and wrists often taking the brunt of the impact. The thumb is especially vulnerable and ligament injuries are frequent. ‘Skier’s thumb’ is the common term used for either a sprain or rupture of the medial ligament to the large thumb knuckle, also known as the ulnar collateral ligament (UCL). If a patient delays or receives inadequate treatment, this can cause long-term problems with hand function.
Diagnostics Following a fall causing injury to the thumb, an X-ray is required to exclude a significant fracture. If the thumb is painful over the ligament, the surgeon needs to decipher whether the ligament is sprained or ruptured. This is best decided by testing for laxity of the thumb joint in clinic. Sprains have no laxity, whereas a full tear will have complete laxity on stretching the thumb to the side. More complex investigations such as ultrasound or MRI may be helpful, but can be difficult to interpret.
Enquiry Helpline: 020
7483 5148
10 • PRACTICE MATTERs WINTER 2014/15
Treatment A sprain of the UCL is best treated in a splint for four to six weeks, with the end joint of the thumb left free to mobilise. Patients will receive specialist physiotherapy by a dedicated hand therapist, who can supervise the splint making, and subsequent physiotherapy. Despite good treatment, patients can experience ongoing minor pain for a couple of months before the symptoms finally resolve. A tear of the UCL will require surgical intervention under general anaesthetic, with the ligament dissected free and reattached to the bone. Sometimes the ligament lies in an extraanatomical position, above one of the other small muscles of the hand. This is called a Stener lesion, and if missed in clinic, can cause long-term pain, instability and weakness of the thumb.
After successful surgery, the patient will be required to wear a custom-made splint for six weeks, and should avoid contact sport for 12 weeks. Incorrect diagnosis of thumb injuries after a heavy fall and during treatment can cause major problems with long-term thumb function. A painful thumb that is diagnosed as a sprain, when it is in fact a full tear of the ligament, is particularly worrisome. Worse still is a missed Stener lesion, with the ligament trying to heal itself; albeit in the wrong position. Late correction of the ligament may or may not be possible, and occasionally a fusion of the joint is the only option left to restore adequate thumb function.
The importance of early diagnosis and treatment After a painful thumb injury whilst skiing, it is essential that patients seek early medical advice from an experienced hand surgeon to rule out a complete tear of the ligament, which can easily be fixed in the initial stages. Patients presenting late with missed tears of the ligament are likely to develop into significant problems with their thumb in future.
To find out more information about Mr Neil Toft please visit www.practicemattersmag.co.uk/ contributors
NEUROLOGY
The Balance and
Dizziness service By Mrs Emma Warner
The Balance and Dizziness Service is a private treatment service, combining specialist medical, diagnostic and therapy services for the treatment of vestibular and balance problems. Members of the team are located in the Platinum Medical Centre on Lodge Road (consultants and audiologists) and the North Building, Outpatients Department on Circus Road (physiotherapy and neuropsychology). The purpose of the service is to diagnose the nature of the dizziness or balance disorder and provide appropriate rehabilitation. Assessment and diagnosis is made through a detailed consultation with a consultant, who may then refer the patient for further balance tests and rehabilitation.
Vestibular and Balance Rehabilitation Therapy (VBRT) Dizziness occurs for many reasons, including: Benign Paroxysmal Positional Vertigo (BPPV), vestibular neuritis, labyrinthitis, migraine, stroke and concussion. A detailed assessment assists in diagnosing what the cause is for a patient’s dizziness. This assessment will be carried out by the Balance and Dizziness Service team , which consists of: • Physiotherapists trained in the specialised skills of vestibular and balance • ENT Neuro-Otology Consultants
• Neurology Consultants • Audiologists Once a diagnosis is made and the clinical signs and outcome measures have been assessed, a customised programme of rehabilitation exercises is developed and taught to the patient. Some dizziness and balance disorders can be managed immediately in the clinic, whilst others may require longer-term treatment with medication and a customised rehabilitation programme. The rehabilitation programme consists of exercises specifically targeted for the individual and their problems. Advice and education about the dizziness and balance problem and how to manage it is included in the programme.
Case study Mr W is a 67 year old man who suffered injuries during a motor vehicle accident one year ago. His car was hit from behind and he lost consciousness for a brief period of time. Since this accident, Mr W has been suffering from brief episodes of vertigo, usually related to specific head positions and mostly occurring in the mornings. He also reports feeling generally ‘off balance’ which worsens with head movements when in the dark. Mr W has had a few falls related to these episodes and is still receiving musculo-skeletal physiotherapy to manage the whiplash injury sustained in the accident. Mr W
was assessed by a consultant otolaryngologist and audiologist, who conducted MRI scans to rule out any tumours and with caloric tests to look for peripheral vestibular canal paresis. Audiology reported some mild symmetrical high frequency hearing loss which fits with agerelated changes. A specialised vestibular physiotherapy assessment revealed a positive Dix- Hallpike test, indicating left posterior canal BPPV. Other testing also indicated some problems with central integration of visual and vestibular cues for balance and reduced function of the vestibulo-ocular reflex (VOR), which indicates central causes. This was related to a post-concussion syndrome resulting from Mr W’s original accident. Repositioning manoeuvres for the BPPV were repeated three times to clear the particles in the left posterior canal. Following this, VOR/ gaze stabilisation, habituation and balance exercises were provided as part of a customised programme of rehabilitation. The programme was targeted to reduce Mr W’s symptoms of head movement provoked unsteadiness and improve his integration of all sensory cues for balance. Over a period of four months, his balance and gait in busy and dark environments improved and the function of his VOR returned to within normal limits. He is no longer experiencing episodes of BPPV.
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 11
orthopaedics
Meniscal augmentation
scaffolds and stem cells By Mr Rahul Patel
The meniscus
Surgical options
The meniscus is a specialised C-shaped disc of cartilage (fibrocartilage) that sits in between the two main bones that make up the knee joint: the femur and tibia (Fig.1). The primary role of the meniscus is to evenly distribute the load imparted across the joint compartment. Each contributes to joint stability, which applies more to the medial meniscus than the lateral. The meniscus is elastic and designed to do its job efficiently, but there are instances when the force and pressure that is on the meniscus is injurious. Classically, in the young, the mechanism is an awkward, violent twist of the knee, which results in a meniscal tear through healthy tissue. In the older patient, where the tissue has started to weaken through agerelated degenerative processes, more innocuous mechanisms will result in tearing the meniscal tissue. This includes sitting with the knees flexed for long periods of time e.g. on a flight. Tear
The meniscus is elastic and designed to do its job efficiently, but there are instances when the force and pressure that is on the meniscus is injurious patterns can be characteristic of the age groups. For example the horizontal cleavage tear is often associated with a degenerative meniscus. Unfortunately, the meniscus cannot heal itself when torn. The tear persists and can cause symptoms of pain (often localised to the side of the knee in which the meniscus is torn), intermittent or persistent swelling, and mechanical symptoms, such as clicking and catching. In larger tears, the knee can sometimes become temporarily locked in a position. Fig 2.
Synthetic biological scaffold
Fig 1. Meniscus
Enquiry Helpline: 020
7483 5148
12 • PRACTICE MATTERs WINTER 2014/15
Because the meniscus has such poor inherent healing capacity, the likelihood of surgical intervention for a torn meniscus is relatively high. In the older patient with a degenerative tear, the symptoms may become more manageable with strengthening over time. However, for the continually symptomatic knee, the traditional solution is to remove (resect) the torn fragment. This works well in the majority of cases, allowing swift return to work and sport, following complete resolution of symptoms. The trend in the last decade has been to try and save meniscal tissue, (especially in a young patient), by stitching the tear, hoping that it will heal. Meniscal repair is more successful if the tear is near the outer edge of the meniscus, where there is some blood supply and if the meniscal tissue is of good quality. The latter is often dependent on timely diagnosis and intervention and more likely to succeed in young individuals. However, most surgeons accept that there is an approximate 20 per cent failure rate with repairs. Current evidence suggests that the success of repair diminishes significantly in individuals over the age of 40. Losing meniscus, especially at a young age, may confer a slightly higher overall risk of developing osteoarthritis of the knee, compared with not losing any meniscal tissue. This is, of course, not the only variable that influences the development
Consultant
FOCUS
Mr Rahul Patel
MBBS MRCS(Eng) MD FRCS(Tr&Orth)
Consultant Orthopaedic Surgeon
of osteoarthritis of the knee. Studies that have evaluated the long-term outcome of knees after loss of meniscus suggest that a higher risk is conferred as a consequence, particularly if more than 50 per cent of the meniscal tissue is sacrificed. Therefore, new technology and surgical technique focuses on meniscal preservation and replacement. Repair techniques are sufficiently advanced to be reproducible, and attention has turned to enhancing the healing response of the native meniscus and biological solutions and replacing meniscus if it cannot be preserved. The latter has seen the arrival of synthetic biological scaffolds into clinical use (Fig. 2). This is where a synthetic scaffold substitute is implanted to reconstitute lost meniscus and over time, the scaffold is replaced by the patients’ own meniscal tissue that has grown from naturally occurring stem cells which have been harboured in the scaffold. This concept differs from previously used meniscal substitutes (e.g. collagen meniscal implants) and should not be confused with Meniscal allograft transplantation. The scaffold is typically a porous, biodegradable, anatomically-shaped implant which is cut to
size to fill the defect and sutured into place using meniscal repair techniques. Provided the peripheral blood supply from the synovium is accessed, the biological process of tissue regeneration ensues, harnessing the potential of the stem cells that populate the scaffold. However, this type of scaffold cannot be used if substantial meniscal tissue has been lost. The recovery from such a procedure is approximately six to nine months, and initially involves the patient wearing a knee brace to restrict range of motion and using crutches to restrict the full weight-bearing. The early results (two year published data) are very encouraging, allowing a full return to sporting activity without pain. Longer-term studies are required to demonstrate durability of the regenerated tissue, and the theoretical effect of preventing arthritis.
To find out more information about Mr Rahul Patel please visit www.practicemattersmag.co.uk/ contributors
Mr Rahul Patel is a Consultant Orthopaedic Surgeon specialising in the treatment of sports injuries of the hip, knee and shoulder, often using minimally invasive or keyhole surgery. He is a consultant at University College London Hospital, The Institute for Sport, Exercise & Health and at The Wellington Knee Unit, London. He is an honorary senior lecturer for the MSc in Sports Medicine, Exercise & Health at University College London. He also has a special interest in cartilage preservation and regeneration. Mr Rahul Patel is a member of The Wellington Knee Unit, which is based in the South building.
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 13
Ear, nose and throat
Vocal cord palsy:
tailored treatment for optimum voice restoration
By Professor Martin Birchall
Despite the increasing impact of electronic media on social and business life, the human voice remains the most important communication tool. Vocal cord paresis, whether of unknown origin or resulting from trauma, neurological disease or thoracic tumours, causes a weak and breathy voice, with aspiration, particularly of liquids. This is usually a major handicap for people at home and at work, who find that even modest levels of speaking leaves them with strained throats, breathlessness and tiredness. However, laryngologists have a wide range of highly effective treatments to restore people to an excellent and highly functional level of speaking.
Treatment The historical mainstay has been to inject the paralysed cord, placing it closer to the normally moving side. Teflon is no longer in
Enquiry Helpline: 020
7483 5148
14 • PRACTICE MATTERs WINTER 2014/15
use, as it is unwieldy, unpredictable and led to granulomas. However, we now have a range of injectable materials with varying absorption rates, and mechanical properties which allow us to personalise care. For example, calcium hydroxyapatite provides up to two years of voice restoration, whereas hyaluronic acid and collagen work for between three and eight months. These are ideal for circumstances where recovery may still be expected. Laryngologists can now offer the option of performing these injections in clinic. Under high resolution endoscopic control and with local anaesthetic, this saves time and cost for all concerned. This change is also considerably safer than performing injections under general anaesthesia, particularly in older or unwell patients, or those with lung tumours. With all of these techniques, the input of specialist speech and language therapists is essential for optimal results. Long-term exercises, effectively physiotherapy for the larynx, are also very important. The laryngologist and the speech therapist form a therapeutic team (in which the vocal cord palsy patient is an active participant, providing feedback) allowing rehabilitation. Internationally validated outcome measures, such as the Voice Handicap Index, and maximum phonation time, permit numerical assessment of progress and can now be applied
using mobile technology (e.g. OperaVOX). This allows for remote monitoring of surgical and speech therapy outcomes. Where a longer-term or permanent solution is desirable, two surgical options are available. The more established method is thyroplasty, using either a silastic or Gore-Tex implant, which can be combined with tailored ancillary procedures to tense up the cords further (approximation and arytenoid medialisation). Recently, vocal cord reinnervation surgery has been pioneered in many centres in the US, and is now available in London. This provides a more functional restoration of bulk and tone to the paralysed side. The present data shows that it is as good as thyroplasty, and better in younger patients. The future is looking very exciting with the application of pacing devices and soft robotics technology likely to emerge in the next 10 years. However, the range and effectiveness of today’s therapeutic options means that no-one with a vocal cord needs to be without a strong voice any more, and can return to work and society with confidence.
To find out more information about Professor Martin Birchall, please visit www.practicemattersmag.co.uk/ contributors
Gastroenterology
Irritable Bowel Syndrome
symptoms and treatments By Dr Deepak Suri
IBS has become a common condition, affecting nearly 15 per cent of the population. It is characterised by abdominal pain or discomfort associated with an unpredictable bowel habit, such as diarrhoea or constipation, or alternating between the two. Patients may also complain of urgency, bloating and difficulty in passing stools. In some cases, there may also be a urinary disorder, gynaecological symptoms and lethargy.
What causes IBS?
There is no single cause of IBS, but symptoms are usually due to: central processing (patient perception) • neurotransmitter imbalance • psychological factors (stress, affective disorder) • diet • anxiety This results in disorders of motility, and there is also visceral hypersensitivity.
Diagnostic testing
There is no one test that confirms or refutes IBS. Investigations are performed to exclude major digestive disorders; however, not all patients need or should have exhaustive investigations. Blood tests, including a wheat allergy, are required and a visualisation of the bowel should be considered in older patients or if symptoms (rectal bleeding, anaemia, weight loss) present.
What treatments are available?
Diet: Many of the foods we eat contain short-chain carbohydrates. If these
carbohydrates end up in the large intestine, they can ferment into hydrogen, carbon dioxide and short-chain fatty acids. These gases can cause the bloating, cramping and pain, which are often associated with IBS. Wheat, dairy, caffeine, chocolate, alcohol, carbonated drinks and fatty foods can all exacerbate symptoms. It is worth excluding these for a short period to see if symptoms improve, or keeping a diary to help pinpoint specific foods. A more restrictive diet, known as the low FODMAP diet, has also proved to be effective. Pro-biotics: These have shown some benefit and are often favoured by patients as they are natural treatments. Care is needed with fibre in patients with IBS, as where soluble fibre may benefit some, insoluble dietary fibre for others can cause pain and bloating.
Is stress the cause of IBS?
The colon is partly controlled by the nervous system. Stress management, such as relaxation training, therapies e.g. meditation, regular exercise and adequate sleep can be helpful. Formal Cognitive Behavioural Therapy (CBT) can be useful for some patients too. Medications No single drug uniformly works in everyone with IBS, so each patient needs an individualised approach. Drug treatment aims to alleviate
symptoms with medications to act on pain, constipation and diarrhoea. Antispasmodics: Gut spasms and cramps can respond to hyoscine, mebeverine, and peppermint oil capsules. Anti-diarrhoeals: Loperamide and codeine phosphate can be helpful with diarrhoea and urgency symptoms. Laxatives: Consider PEG-based laxatives to help with bowel emptying rather than aiming for a complete clearout. Nerve desensitisers Due to the key role the nervous system plays in the digestive tract, drugs such as amitriptyline (at very low doses) can be very effective. Newer medications: As the nervous system plays an important role in gut function, newer medications such as prucalopride, lubiprostone and linaclotide have been developed and licensed and help with constipation and bloating. In summary, IBS is a collection of symptoms that can prove to be troublesome for many patients. Treatment has to be individualised to each patient. Whilst symptoms can be difficult to treat there are several approaches using diet and medication that can help patients.
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 15
GP NEWS
GP news Round-up
In the busy world of general practice, we look at trending stories and interesting updates from the primary care sector
2015 Events The Wellington Hospital programme of events will be running in conjunction with the national health awareness calendar for 2015. In February, this will begin with the our main GP event, ‘At the heart of healthcare - an update on cardiac care’, which takes place during National Heart Month. The educational seminar will include talks from The Wellington Hospital’s top cardiologists, covering updates on diagnostic and treatment options for heart disease. All of our events also include an opportunity to raise questions relevant to primary care. To find our more about our schedule of events, please contact your dedicated GP Liaison Officer, or visit www.thewellingtonhospital.com/health-professionals/eventsseminars-talks/
RCGP launches video to promote ‘care planning’ concept as aid to GPs The Royal College of General Practitioners (RCGP) has launched a three-minute animated video to promote the initiative of ‘care planning’ for patients with long-term conditions. Narrated by President Professor Mike Pringle, the animated short tells the story of elderly patient Rose, who is struggling to cope with her multiple health issues. Confined to the restrictions of a 10-minute consultation with her GP, Rose struggles to discuss her many issues, resulting in unfulfilling appointments for both Rose and her GP. The drawings then develop into asking ‘what more can be done?’ An independent inquiry on Patient Centred Care, commissioned by the RCGP, prompted a recommendation to all practices to implement a ‘care plan’ for patients in need, such as those with complex cases or long-term conditions. The aim of the programme is to involve a care planning team, based in GP surgeries, who will evaluate particular patients’ physical and mental needs and work towards a more effective, long-term care plan. This extra resource aims to improve the planning and implementation of care, through extra support in GP practices prior to consultations. In addition to this, the video release runs in conjunction with the RCGP’s launch of the Collaborative Care and Support Planning programme. Funded by the Health Foundation, it will work towards encouraging integrating the care planning approach into general practice. To find out more and to watch the animation, please visit www.rcgp.org.uk/care-planning.
COMMENT & DEBATE Are there any topics and educational seminars/training you would like to see in our 2015 calendar? You can contact your dedicated GP Liaison Officer to discuss future events (details on the back cover of this magazine).
Enquiry Helpline: 020
7483 5148
16 • PRACTICE MATTERs WINTER 2014/15
GP NEWS
services
update... CPR Training At The Wellington Hospital, we believe in the importance of education and sharing best practice. Each month in our boardroom we provide GPs, clinical and administration staff with a free, two-hour basic life support training session, with training certificates issued. For advanced training, we offer our GPs a further option to take part in an advanced clinical life skills training session. Not only do these sessions give attendees the knowledge and confidence to provide support in sudden situations, it also helps you to meet the requirements of the Health and Safety in Employment Act, whilst ensuring GP Practices are compliant with CQC requirements. Below, we speak to Ashley Stowell who is a trainer from TSS Development Group and conducts the in-house training sessions: PM: What does your role with CPR training at The Wellington involve? AS: I work with The Wellington GP Liaison Team to provide GPs and other healthcare professionals with cardiopulmonary resuscitation (CPR), automated external defibrillator (AED) and basic life support (BLS) training courses. I aim to make these training sessions informative and interesting, often working with a cardiac consultant, to provide an all-round update on essential lifesaving skills. Advanced airway management training is also available, where we focus on airway adjuncts and cannulation, and works as an extension to the BLS training for GPs and nurses. The benefit of this is the patency of an airway, allowing secure ventilation during CPR and IV access for drugs or fluid to be administered, if needed. Both courses are designed to be interactive, providing delegates with up-to-date protocols and procedures, so they can confidently manage emergency situations, both in and out of the surgery.
PM: Who can attend training? AS: For BLS and CPR, anyone who is capable of applying good and effective chest compressions. For every minute that nothing is done when someone is in cardiac arrest, there is a 7-10 per cent chance of success lost. Therefore, the sooner chest compressions are applied, the greater the chance of survival. The advanced course is for GPs and healthcare professionals only. PM: Can you tell us a bit about your working background? AS: I am qualified Advanced Paramedic Practitioner, registered with the Health and Care Professions Council (HCPC) with 30 years’ experience in the NHS and private sectors. I have worked with the East Sussex ambulance service, London ambulance service and private ambulance services. I obtained a degree in Health and Social Care, Paramedic Science at Birmingham City University. I studied Minor Injuries and Autonomous Practice at the University of Hertfordshire, and the Management of Minor Illness and Injury at Coventry University. I hold certificates in advanced cardiac life support (ACLS), paediatric advanced life support (PALS), and pre-hospital trauma and remote medicine. I am currently the International Lead Paramedic for Sky Angels, which is an international rescue air ambulance.
If you are interested in attending any of our advanced clinical life skills or basic life support training sessions at The Wellington Hospital, please let us know. Your dedicated GP Liaison Officer will keep you updated regarding training, or you can view upcoming scheduled events online at: www.thewellingtonhospital.com/health-professionals
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 17
News from The Wellington Hospital
news from The Wellington Hospital’s housekeeping team wins prestigious award Sunny Chada, Chief Operating Officer, said the award recognised the hard work and dedication of the housekeeping department. He said: “We’re delighted with this award win. To achieve a gold standard on our very first attempt, is proof of the attention to detail we bring to all aspects of the care we provide, here at The Wellington. “The award is a tribute to everyone in the housekeeping department who works tirelessly to ensure that the facilities are not only hygienic, but also warm and welcoming.” CAP inspectors were impressed with the way the housekeeping team dealt with the challenge of maintaining quality, across four separate buildings, on multiple floors, covering an almost 24/7 basis. At the end of 2014, the housekeeping team at The Wellington Hospital were awarded a major national award for cleanliness. The team won a Gold CAP Award, following an unannounced inspection into quality and standards, in October. The CAP Awards (the Continuous Advancement Programme) measure the quality of cleaning and housekeeping in healthcare facilities across the UK, and are regarded by patients and their families as a mark of high quality.
Ian Jackson, Managing Director of the CAP Awards, said: “We were hugely impressed with the strong departmental organisation, the robust training and support for the housekeeping team. “The Wellington had the confidence to attempt a gold award on first inspection – a sure sign that standards at the hospital are consistently high. “Well done to the members of the housekeeping team – this a thoroughly deserved award win.”
NEW CONSULTANTS Cardiology
Neurology
Plastic surgery
Dr Tim Lockie, Royal Free Hospital
Dr Balwinder Athwal, Barnet Hospital, NHS Trust
Mr Shadi Ghali, Royal Free Hospital
Dermatology
Neurosurgical
Dr Anjali Mahto, North West London Hospitals
Miss Mary Murphy, National Hospital for Neurology and Neurosurgery
General/Vascular surgery Mr Mohammad Keshtgar, Royal Free Hospital
Enquiry Helpline: 020
Ophthalmic Professor Charles Claoué, Queen’s Hospital
7483 5148
18 • PRACTICE MATTERs WINTER 2014/15
60 seconds with...
60
seconds with...
We get a real variety of people with inner ear disorders and balance problems; it can affect anybody at any age. Vestibular rehabilitation therapy is proven to be beneficial in the recovery of these conditions
Q&A- Mrs Emma Warner – Senior Physiotherapist for Vestibular and Balance
PM: How did you get into your role of Senior Physiotherapist? EW: Back home in Brisbane, Australia, I started university doing a science degree, as I originally wanted to do medicine. But then half way through, I decided I wanted to do physiotherapy. So, after finishing a post-graduate honours in science, I started my undergraduate physiotherapy degree. After eight years at university, I started working in the public health system in Australia and eventually headed up a rehab unit in a metropolitan hospital in Brisbane. I got a scholarship to do my masters in physiotherapy (neurology), which I did part-time whilst working in community rehab full-time. I have an ancestry visa, so I decided to come to the UK in 2006 and go travelling. I went back to my job in rehab in Brisbane, but decided to return to the UK in 2010. After my masters I knew I wanted to do more vestibular work, so I applied for a job at the Balance Centre at The Wellington Hospital. After a successful interview, I worked part-time at the Balance Centre and at two other London hospitals until the end of 2012. I then decided to go back to Australia, where I taught physiotherapy at one of the universities. I was getting into research, particularly on all the balance and vestibular problems that can occur with concussion. Then personal life took over and it has brought me back here to London. A job at The Wellington Balance and Dizziness Service became available again, where I am now working full-time. PM: What does your job entail? EW: The Balance Service covers a lot of conditions where the inner ear has been affected by a virus, disease or something else. We work very closely with audiologists at the Platinum Medical Centre and the ENT consultants. Balance problems affect people in different ways including: vertigo, feelings of imbalance or unsteadiness. These conditions are life changing and can be disruptive to a person’s quality of life. We get a real variety of people with inner ear disorders and balance problems, as it can affect anybody at any age. Vestibular rehab is proven to be beneficial in the recovery through these conditions. We get a lot of referrals from neurologists for people with balance problems caused by something wrong in the central nervous system. It may be a brain or connection problem, such as concussion or multiple sclerosis, and I find that my background in neurology really supports this. I am quite holistic in my approach and I try to make sure that I am addressing all the client’s needs. I will see what the patient wants out of our sessions and what their goals are, whilst working on improving their quality of life.
PM: What developments have you seen during your time at The Wellington? EW: The fact that it is now a full-time service is a big bonus because it means reduced waiting times. I am also starting to see an increase in referral numbers as well, which is really good. We have the Posturography machine, which not every hospital with a vestibular service has access to. The machine looks at how the sensory systems for balance are integrated as well as other useful details and can be used in other neurological conditions, not just vestibular conditions. It is quite versatile, so the rehabilitation unit physiotherapists can use it too. PM: Who makes up the Balance and Dizziness team? EW: Physiotherapy is based in the North Building and is currently run by me. There are a few people with some experience who want to learn more, so I am keen to get them trained. At the Platinum Medical Centre, we have got Isobel, who is the Audiologist. She does all the vestibular function testing, hearing tests and caloric tests. Then you have the ENT and neurology consultants, with the ENT consultants being the main referrers. In addition to this, we get a lot of referrals from consultants across London and from our sister hospitals. PM: What would you be doing if you weren’t in your current role? EW: When I was younger, I wanted to be in the Royal Flying Doctor Service in Australia, which is for remote area healthcare. The medical teams fly to remote properties for clinics, as well as emergency services for the outback. I come from a medical family so healthcare is very much in my blood! If I wasn’t in physiotherapy, I’m sure my role would still be medically based. PM: What do you like doing in your spare time? EW: I enjoy swimming, cycling and getting out, exploring places. I love travelling and the UK is great because it is so accessible to go off and do small trips. One of my favourite places is Norway. My grandmother is actually Norwegian and I have a lot of friends from my masters course who live there. The last time I was over there, I actually met my grandmother’s cousin who was a retired physiotherapist! I also love skiing, but growing up in the tropics, I didn’t start until I was 30, so I’m not very good at it! PM: What would you like to do in the future? EW: In the next few years, I would like to move back to Australia or New Zealand, where my husband is from. Eventually, I would like to do my PhD, which I started in 2014 but stopped when I moved to the UK. I think getting back into some research and teaching is another aspect I would like to explore because I enjoyed it for the 18 months that I did it, as I am still quite interested in clinical research.
www.practicemattersmag.co.uk PRACTICE MATTERs WINTER 2014/15 • 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 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