Wellington Hospital Practice Matters Issue 4 by Runwild Media Group

WINTER 2011

www.thewellingtonhospital.com

The newsletter for GPs from The Wellington Hospital

Femoroacetabular Impingement and

Hip Arthroscopy The latest news, views and features from the largest independent hospital in the United Kingdom

WELCOME A very warm welcome to the 4th issue of Practice Matters; and I hope your start to the New Year has begun with promise. I would like to thank everyone who supported us last year, and we look forward to continuing to strengthen these relationships throughout 2011. 2011 heralds the completions of two major expansions to the hospital’s outpatient facilities - providing our patients access to more specialist services than ever before. The Platinum Medical Centre (PMC) based in Lodge Road, St Johns Wood, I’m happy to announce will open to its first patient on 3rd May 2011. The prestigious new facility comprises a comprehensive imaging department with low dose PET/CT, together with MRI capability at 1.5 tesla and 3 tesla. In addition, we have the usual array of radiology support in the form of plain film x-ray apparatus and ultrasound. There are 50 Consulting Rooms arranged over three floors together with 4 operating theatres, admission and recovery facilities built to very high standards of care and comfort. Perhaps more importantly we have partnered with the LOC (Leaders in Oncology Care) to develop with us a leading edge cancer strategy, commencing with a new style 10 bed day case chemotherapy suite. For the first time in 19 years the Wellington will also have Oncology inpatient beds to compliment the day care provision. This is clearly an exciting time in the Wellington’s history of medical expansion and development.

WINTER 2011

The expansion at the Wellington Diagnostic and Outpatient Centre (WDOC), our satellite centre in Golders Green, is now open. The contemporary facility includes a further 10 bright and spacious consulting rooms, access to additional imaging and diagnostic equipment and plans for a mammography screening service in the near future. On the subject of new services, I am pleased to confirm that since its arrival last October, the da Vinci robot Si has been used to undertake a number of highly successful operations. The first tranche of our patients were those needing Urology and Cardiac treatment; we are hoping to commence the second phase of the da Vinci’s wider use very soon - allowing our General surgery and Gynaecology patients the same cutting-edge surgical treatment. To keep our local GPs up-to-date with the latest advances and services we offer, the GP Liaison department has been busy cementing educational events for 2011. Education is a high priority at The Wellington, and last year we held a variety of masterclasses, study days and symposiums across London. This year promises the return of the popular Orthopaedic Masterclass, the continuation of GP seminars at both The Wellington boardroom and WDOC, as well as regular GP resuscitation training days and a selection of new mini masterclass series’ including: The Latest Advances in Cancer Management, amongst many others. Once again, many thanks for your continued support of The Wellington.

Keith D Hague CEO

INSIDE THIS ISSUE WHEN TO REFER TO THE ELECTROPHYSIOLOGIST?

Hints from the 12 lead ECG

5 THE DA VINCI SI ROBOT With the growing benefits of robotic surgery broadly documented and the increase of its use worldwide – The Wellington Hospital has recently acquired the da Vinci Robot

EDITORIAL TEAM Claire Allen Editor Tel 020 7483 5109 Email claire.allen@hcahealthcare.co.uk Jean Anderson Management & Distribution Tel 020 7483 5336 Email jean.anderson@hcahealthcare.co.uk Comments, personal views & opinions expressed by contributors are not necessarily those of The Wellington Hospital.

WHY IS MY PATIENT BREATHLESS? Pulmonary Arterial Hypertension is an uncommon and overlooked cause of breathlessness. The average time to diagnosis from onset of symptoms is 3 years.

PLUS: OUR REGULAR COLUMNS

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practicematters winter 2011

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WELLINGTON IN FOCUS

Dupuytren’s Disease Mr Neil Toft discusses this common hand affliction, its treatment, and when to refer patients to a specialist….. Dupuytren’s Disease is a common hand condition that predominantly affects middle-aged to elderly male patients. It has a range of presentations from a painless nodule in the palm of the hand to a debilitating progressive flexion contracture of the digits. If left untreated some patients may require amputation of the affected finger, with early recognition and treatment this is completely avoidable.

Clinically Dupuytren’s can present as nodules in the palm. Usually these are painless. A few are painful and patients often find improvement after surgical removal. More commonly Dupuytren’s affects the fingers especially the little and ring fingers, although it can affect all fingers including the thumb. Occasionally, it is present on the back of the fingers as knuckle pads. These lumps over the proximal interphalangeal joints (PIPJ) are known as Garrod’s pads.

Dupuytren’s Disease occurs in approximately 3% of the population. It is up to ten times more common in males, especially those from a Caucasian background. The commonest age of presentation is in the 5th and 6th decades of life, and there is a definite genetic risk of developing the disease with many patients having a positive family history. Dupuytren’s is thought to have originated from the Vikings in Northern Europe and spread through their descendants. Those patients with a strong family history tend to have an earlier onset of disease, more severe disease, bilateral disease, and sites other than the hand affected (e.g. Dupuytren’s in the foot is known as Ledderhose’s disease)

Conservative treatment of Dupuytren’s is usually ineffective. Surgical treatment is usually aimed at either simply dividing the Dupuytren’s tissue (fasciotomy) or complete removal of the diseased collagen (fasciectomy). Although the simpler operation of fasciotomy is popular in mainland Europe, it has a much higher recurrence rate of Dupuytren’s disease in the future and may be associated with concomitant injury to the digital nerves. For these two reasons the operation of fasciectomy and subsequent surgical removal of the Dupuytren’s tissue from the palm and digits is much more popular in the UK and is the treatment of choice.

The cause of Dupuytren’s is thought to be abnormal production of fibrous collagen within the palmar aponeurosis of the hand and hence it is classified as a “fibromatosis”. The cell responsible for this is known as a myofibroblast which is a mixture of a smooth muscle cell and a fibroblast. Although the exact mechanism of development of Dupuytren’s is unknown, dit is thought that these cells go into overdrive with production of excessive amounts of fibrous tissue, which subsequently undergoes contraction and shortening, resulting in the clinical findings.

Enquiry Helpline: 0207 483 5148

Mr Neil Toft is a Consultant Plastic Surgeon with a special interest in hand surgery at The Royal Free Hospital and The Wellington Hospital.

Suitable patients for fasciectomy fall into three main categories: First, patients presenting with a painful palmar nodule. Second, patients who are unable to lay their hands flat on a table due to a contracture of the metacarpophalgeal joint (MCPJ) of 30 degrees or more. Third, any patient with advancing disease around the PIPJ of the finger with development of a contracture, should seek early treatment. If these joints are left bent and in a flexed position for any period of time, they respond poorly to future surgery and physiotherapy. Most surgery is performed as a day case procedure under regional nerve block or general anaesthetic. Physiotherapy and post-operative splinting begins at 48 hours to avoid operative stiffness and scar contracture. Sutures are removed at two weeks after the surgery, and a custom-made night splint is usually worn for three months. For patients to receive optimal treatment for Dupuytren’s disease early referral to a specialist hand surgeon is advisable.

Most surgery is performed as a day case procedure under regional nerve block or general anaesthetic.

winter 2011 practicematters

WELLINGTON IN FOCUS

Sudden Hearing Loss Mr Elliot Benjamin discusses the importance of an early referral and essential tests that can be performed in your surgery ......... A 25 year old man presents to your surgery, having woken unable to hear in his right ear. He had slight viral symptoms a few days ago, but no history of previous hearing loss or ear related problems. The majority of cases may be due to a URTI with an element of congestion and a middle ear effusion. But what if this is in fact a case of sudden sensorineural hearing loss, which maybe permanent if not picked up quickly, referred and treated? Sudden sensorineural hearing loss is quite rare, with an incidence of about 8 per 100,000 persons per year. Most cases are idiopathic and only 5-10% may have an identifiable cause i.e. infection, trauma, neoplasia, auto-immune, cardiovascular, neurological or metabolic. It may be the presenting symptom of an acoustic neuroma (3% of acoustics may present with sudden hearing loss). From the GPs point of view one must distinguish that this is sensorineural rather than conductive hearing loss and refer appropriately.

considered whether direct trauma, noise or pressure trauma. Previous infections such as herpes zoster, meningitis, measles, mumps and HIV can directly affect hearing, as can Lyme disease, for those with history of tick bites or recent foreign travel. The diagnosis of sensorineural deafness can be made in the surgery without complex audiological testing. Simple otoscopy will help rule out the common conductive causes of hearing loss such as: (complete occluding) wax, acute otitis media and a middle ear effusion or “glue ear”.

In the patients history there may be a prodromal illness and the loss is normally sudden. In 96-99% of cases it is unilateral; if bilateral one would seriously consider syphilis. Other symptoms may be associated such as: tinnitus, vertigo and fullness in the ear and this may well represent an acute endolymphatic hydrops or Meniere’s disease.

It is essential to perform the tuning fork tests; these will help distinguish between sensorineural and conductive hearing loss: For sensorineural loss, the Weber’s test (a 512Hz tuning fork placed on the forehead or the teeth) will be heard in the normal ear. If the Weber’s is referred to the bad ear – the diagnosis of a conductive loss is made.

Medical history may show signs of diabetes mellitus, hyperlipidaemia, auto-immune disease, sarcoidosis, multiple sclerosis and malignancy, (paraneoplastic syndrome or as a complication of chemotherapy) but rare for the sudden hearing loss to be a presenting symptom of such conditions.

Rinne’s test (again with a 512Hz tuning fork placed in front of the ear and then on the mastoid) will often be normal – i.e. the air conduction is better than bone conduction. If the reverse is true, definitely consider a conductive cause (unless the Weber’s test directs otherwise in which case this may be a false positive test).

A full drug history is important; various common treatments may be ototoxic, such as: aminoglycosides, loop diuretics and platinum containing chemotherapy drugs. Temporal bone trauma must be

Based on these tests the diagnosis can be made and an urgent referral to an ENT surgeon should be made where confirmatory hearing tests can be performed. The urgency of the referral is based on studies that show that early treatment is far more likely to be effective.

practicematters winter 2011

Many treatments have been tried for sudden sensorineural hearing loss including, IV fluids, dextran, vasodilators, carbogen (5% carbon dioxide -95% oxygen) ginko biloba and antivirals, all have shown little or no improvement in outcome compared with placebo. However, there is much evidence to support treatment with systemic steroids with doses of between 0.5-1mg/kg day of prednisolone for a week. If suitable progress is made, a prolonged decreasing steroid course over three weeks may be appropriate. In cases where systemic steroids maybe contraindicated or where hearing loss has been refractory to systemic treatment, there is case based evidence to support the use of intratympanic steroid injections. Performed in the clinic, under local anaesthetic, 1ml of methylprednisolone is injected through the tympanic membrane to bathe the round window (and the inner ear) with steroid. The evidence for intratympanic injections shows 47-100% of patients gaining significant improvement in their hearing thresholds – where treatment is started early following the onset of symptoms. Sudden onset sensorineural hearing loss should be considered as an otological emergency. If diagnosed in the surgery by simple tuning fork tests the patient can be referred early for hopefully hearing saving treatment. Mr Elliot Benjamin, is a Consultant ENT Surgeon, at Charing Cross Hospital, Chelsea & Westminster Hospital and The Wellington Hospital.

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The da Vinci Si Robot With the growing benefits of robotic surgery broadly documented and the increase of its use worldwide – The Wellington Hospital has recently acquired the da Vinci Robot Robotic surgery is by no means a new concept; it has been used in particular areas of surgery for the past two decades. The first surgical robot “Arthrobot” was first developed and used in Canada, in 1983. The da Vinci® Si™ however, is the most advanced form of surgical robotic technology to date. The Wellington is just one of four hospitals in the entire UK that have access to this super robot.

instruments by replicating their normal surgical techniques, by holding onto two hand sensors. The surgeon can view the procedure, by looking through the internal display and also on a larger screen above. The robot has a number of safety features meaning when the surgeon lifts his head from the display or his hands from the sensors, the robots halts; meaning the surgeon is in complete control at all times.

How it Works The da Vinci® Si™ consists of three components – the robot, the console and the operating workspace.

Surgeons at The Wellington Hospital using the robot have vast experience in robotic surgery, both in the NHS and the private sector; each surgeon must attend additional robotic training before they can operate.

The robot has four arms that are able to hold surgical instruments and perform surgery better than a human hand, and can rotate at an astounding 720O. Offering heightened dexterity – they are able to negotiate more awkward, tighter spaces that could ordinarily present surgeons with complexity. One arm contains a microscopic high definition camera, and the other three arms are used to interchange surgical instruments. The surgeon performs the procedure via a console booth, sat just meters away from the patient. From this position the surgeon manipulates the

Benefits This extraordinary piece of equipment has huge advantages to offer patients and surgeons equally. Patients that under go robotic surgery are left with: •฀Smaller scars •฀Less pain •฀Lower risk of infection •฀Reduced bleeding •฀Faster healing All of which result in a shorter hospital stay and a quicker return to normal activities.

Mr Keith Hague, CEO welcomed the awaited arrival of the super robot and the options this created for patients. “We have been waiting for the newest version of the da Vinci so that patients could have the benefits of the latest robotic technology available”. Surgeons themselves are captivated with the latest robot’s addition features. Performing surgery in this way provides surgeons with greater ability and better control as the robot is able to sense any tremors in the surgeons’ hand movements. The new camera has superior 3D high-definition vision with up to 10x magnification. Commenting on the arrival of the robot, Mr Barry Maraj, Consultant Urologist highly praised these new features, “Because the machine has a fourth arm and with high definition 3D, we can be much more precise in our surgery; and being three dimensional, it takes the guesswork out of depth of measurement”. Mr Roberto Casula, Consultant Cardiothoracic surgeon firmly agreed, “…these new instruments can move in a way that my hands cannot. This is the new gold standard. With the acquisition of this machine we have the best technology, in the best hospital in the private sector.” The Future? Around the world, the da Vinci robot has been used to carry out a number of highly specialised surgeries since its development. It can be used for a multitude of procedures, including: coronary artery bypass, mitral valve repair, colorectal surgery, prostatectomy, hysterectomy, and myomectomy, but it isn’t limited to just these. Although The Wellington Hospital will focus initially on cardiac and urology cases, these procedures represent the scale of possibility that this type of surgery opens up to patients. This advance in surgical technology means that major and routine operations can now be performed with better outcomes than ever before, which is great news for surgeons and patients.

Enquiry Helpline: 0207 483 5148

winter 2011 practicematters

COVER FEATURE

Femoroacetabular Impingement and

Hip Arthroscopy Hip Arthroscopy Evolution In the past decades there has been a steady transition from open to arthroscopic surgery and although its use is now widespread for most large joints, the hip was the last one to join the list. Whilst complex arthroscopic treatment is well established in joints like the knee, shoulder and ankle, complex reconstructive hip arthroscopy is relatively new and therefore it is still a much subspecialised area. New techniques allow us to preserve the hip anatomy with the potential to delay or even prevent the evolution to osteoarthritis. For many years the deep, tight nature of the joint meant that more complex therapeutic hip arthroscopy was not possible. Replacement hip joints were the only real surgical option for painful joints. Over the last few years arthroscopic technology and techniques have evolved tremendously. Because nowadays, young and middle aged patients wish to remain active and practise sports for longer, hip arthroscopy is a welcome option, being a less invasive form of treatment, which usually offers a faster recovery. Hip Arthroscopy Today In 2003 the ‘discovery’ of the problem of ‘femoro-acetabular impingement’ (FAI) or hip

impingement unleashed hip arthroscopy’s true potential. We now know that hip impingement is the cause of arthritis in many patients, and there is hope that treatment of this condition at an early stage will potentially lessen the impact of osteoarthritis in the older population. For patients who have advanced osteoarthritis of the hip (which usually affects patients over 55) hip replacement remains the standard treatment. In patients with minimal or no degenerative changes, we can correct the bony abnormality responsible for the impingement. During the procedure the surgeon also addresses the articular cartilage and labral tears. History and clinical examination Patients usually present with groin and trochanter pain, some also with adductor or buttock pain. More than 50% of the patients have a limp and report a reduced walking distance. Half the patients also report pain with sitting. The pain initially tends to be intermittent. Your patient might have had a laparoscopy and still have symptoms. The pain might affect the more active and sportive patient earlier. Conservative management such as NSAIDs can help to take the edge off the pain, but doesn’t cure the condition. Patients also report

increasing stiffness of the hip and a reduced range of motion: e.g. they have difficulty putting on their socks and shoes in the morning. On clinical examination the GP can use two simple tests to diagnose hip impingement. The hip impingement test (fig 1a and 1b) and measurement of the Faber distance. The Faber distance is measured between the lateral joint line of the knee and the examination table and is increased in patients with FAI and reflects a reduced ROM of the hip. Figure 1a Hip X rays can be used to demonstrate bony abnormalities associated with FAI and to define the type. Patients usually become symptomatic with FAI when they have a labral tear or acetabular articular cartilage lesion and this can be demonstrated with an MRI of the hip. Procedure Hip arthroscopy is performed under a general anaesthesia and can be done as a day case or over night stay. In the majority of the cases two portals (small stab incisions) are used. There are two mechanisms of impingement: cam and pincer (fig 2). In cam there is an increased offset of bone at the head neck junction of the femur.

FAI in primary care: key points Professor Ernest Schilders is a Consultant Orthopaedic Surgeon, specialising in Hip Arthroscopy at Bradford Teaching Hospitals and The London Hip Arthroscopy Centre at The Wellington Hospital.

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n FAI is (10-15% of the population),

n Early referral is indicated

but relatively unknown n Young adults (15-55) with groin pain may have FAI or labral damage n Extensive investigations in primary care are neither necessary nor helpful

guide for referral n A plain x-ray true pelvis can be performed to rule out significant arthritis

n A positive impingement test is a simple

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For many years the deep, tight nature of the joint meant that more complex therapeutic hip arthroscopy was not possible

Figure 1a Impingement test Figure 1b Clinical tip: hip impingement test (FAI) •฀฀This฀test฀mimics฀the฀process฀of฀ impingement ฀ –฀฀Which฀occurs฀in฀Flexion,฀ Adduction฀and฀Internal฀Rotation •฀฀Pain฀=฀positive฀test •฀฀The฀clinician฀manoeuvres฀the฀hip฀into฀ an฀impinging฀position •฀฀Hold฀the฀lower฀leg฀with฀the฀knee฀lexed฀ and฀bring฀the฀hip฀into:฀ ฀ –฀฀Flexion฀ ฀ –฀฀Adduction฀ ฀ –฀฀Internal฀Rotation Figure 2 In pincer there is an acetabular overcoverage of the femoral head. Extra bone on the ball or around the socket ‘impinges’ or rubs, causing damage to the cartilage in and around the hip. The abnormality restricts movement with flexion and internal rotation. The abnormalities of the bones and soft-tissues can be treated simply by trimming away the extra bone and repairing or trimming away the damaged cartilage. To correct a pincer abnormality, a few mm of bone is removed from the acetabulum. To correct a cam the excessive bone is removed from the femoral head-neck junction. At ‘The London

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Hip Arthroscopy Centre’, a labral tear is usually repaired, and currently less than 1 in 10 patients require a labral resection. Rehabilitation Most patients require crutches partial weight bearing for two to four weeks. NSAIDs are recommended for 10 days to prevent ossifications of the hip capsule. Cycling is initiated from the first day postoperatively. Driving is allowed after three weeks. Return to sports depends on the level and the type of sport, but is on average after eight weeks for high level athletes and 15 weeks for recreational athletes.

Who should be referred to The London Hip Arthroscopy Centre? Patients aged 15-55 with hip and groin pain. Booking an Appointment To arrange a referral to Professor Schilders / The London Hip Arthroscopy Centre at The Wellington Hospital please contact the Enquiry Helpline on 0207 483 5148 alternatively you can book online.

winter 2011 practicematters

WELLINGTON IN FOCUS

WHEN TO REFER TO THE ELECTROPHYSIOLOGIST? Hints from the 12 lead ECG The 12 lead ECG is (nearly always) essential Having a 12 lead ECG documentation of a given arrhythmia allows, in most cases, to narrow down the possible differential diagnosis: (e.g. atrial versus ventricular tachycardia).

These patients can benefit hugely from a diagnostic EP study, which can exclude the presence of an AP. In addition, the ability of the AV node to conduct the electrical impulse across two different AVN pathways (so called AVN duality) can be investigated. If a typical AVN reentrant tachycardia is inducible or if typical AVN echo beats are provocable, a careful ablation targeting the slow AVN pathway can be performed in the same session, to eliminate the arrhythmia (ESC guidelines).

Similar to the identification of an infarcted area, the 12 lead ECG allows understanding of the electrical activation of the heart (Figure 1). In patients with an antegradely conducting accessory pathway, the resting ECG already reveals the underlying substrate for the AV reentrant tachycardia. In other patients with narrow QRS complex tachycardia that typically starts and stops suddenly, the resting ECG is completely unremarkable. The typical history (mostly in young female patients) and the short duration of each tachycardia episode can make documentation occasionally very difficult. Serial Holter ECGs may fail to track the arrhythmia despite it posing a significant problem for the patient.

Importance of past medical history The young, and otherwise healthy woman, has different likelihood in developing any cardiac arrhythmia, than the elderly diabetic male with known coronary heart disease. While the most common cardiac arrhythmia is easily identified by its irregular ventricular activation: “arrhythmia absoluta” or atrial fibrillation, the differentiation towards atrial flutter or even atrial reentrant tachycardia needs more information. Again, a past medical history of cardiac surgery

Tachycardia with narrow QRS complex (<120 ms) Yes No

Regular tachycardia

Visible P waves? Yes Visible P waves?

Yes

Atrial flutter or atrial tachycardia

No Atrial fibrillation or atrial tachycardia with variable AV nodal conduction or multifocal atrial tachycardia

Analyze RP interval

Short (RP shorter than PR)

RP interval < 70 ms

RP interval > 70 ms

AVNRT

AVRT AVNRT Atrial tachycardia

Short (RP longer than PR)

Atrial tachycardia PJRT Atypical AVNRT

with cannulation of the right atrium for the cardio-pulmonary bypass, or an atrial atriotomy scar, points towards a scar-related tachycardia. Catheter ablation techniques Over 25 years ago, radiofrequency current ablation was introduced, offering a curative tool beyond the already established diagnostic procedures for cardiac arrhythmias. It replaced serial antiarrhythmic drug testing and made arrhythmia surgery no longer necessary. By sending current from the tip of the endocardially positioned ablation catheter, towards an indifferent electrode, the cardiac tissue in close contact is heated to temperatures of ~70°. The resulting scar is no longer able to conduct the activation wavefront. Exact navigation to the original site of a given tachycardia, is key to successful elimination of any arrhythmia. 3D mapping systems facilitate the understanding of the reentrant circuit and help to identify the important site.

Since the procedure is associated with rare, but potentially hazardous complications (such as stroke, PV stenosis, atrio-esophageal fistula formation, etc.) detailed information of the patient and careful balance of the risk benefit ratio is key.

Figure฀1.฀

practicematters winter 2011

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Serial Holter ECGs may fail to track the arrhythmia despite it posing a significant problem for the patient.

Dr. Sabine Ernst is a Consultant Electrophysiologist at Royal Brompton and Harefield Hospital and The Wellington Hospital

“Simple” ablation substrates While most supraventricular tachycardias are reproducibly amenable with catheter ablation, with success rates above 98% and with very low risk of adverse events (<2% for AV node block, tamponade, etc.), some can still be challenging. Especially in the presence of cardiac anomaly (such as Ebstein´s anomaly or a persistent left superior caval vein) even those “simple” substrates can be more demanding. Advanced technology such as remote navigation using magnetic fields to steer the ablation catheter, can help to approach these patients (Figure 2). Ventricular tachycardia does not, per se, qualify as a complex arrhythmia. Especially when the arrhythmia presents as monomorphic ventricular ectopy, the site of origin can be located fairly easily. Focal catheter ablation eliminates the source of arrhythmia and reverts the patient back to a sinus rhythm. “Complex” ablation substrates Electrophysiologic studies are classified “complex” when one or more of the following criteria apply: 1) Abnormal or operated cardiac anatomy (e.g. atrial surgery for transposition of the great arteries) 2) Cardiac ablation has a predictable success rate of ~70% 3) Presence of any additional circumstances (e.g. coagulopathy, severe heart failure, respiratory failure). While these conditions are not a contra indication against catheter ablation, careful planning of the procedure and close collaboration with the other expert teams (anaesthesia, heart failure, intensivists) is key to successful ablation. Atrial fibrillation (AF) ablation Being regarded as an incurable arrhythmia until recently, isolation of the triggering ectopy, from within the pulmonary veins by ablation from inside the left atrium, has become a daily performed ablation procedure in most ablation centres (Calkins Circ 2010). Depending on the

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I II aVF V4 ABL Figure฀2.฀ underlying cardiac disease, duration of the arrhythmia (paroxysmal versus persistent), left atrial size as a marker for remodelling (dilation) during AF, and the overall duration of the arrhythmia history, one or more ablation procedures are necessary to render a symptomatic patient arrhythmia free, without the need for further antiarrhythmic medication (ESC guidelines 2010, in print). Since the procedure is associated with rare, but potentially hazardous complications (such as stroke, PV stenosis, atrio-esophageal fistula formation, etc.) detailed information of the patient and careful balance of the risk benefit ratio is key. Serial Holter ECGs during follow-up are necessary to ascertain that the now asymptomatic patient is really arrhythmia-free.

Figure 2. Example of an accessory pathway in lateral position of the mitral annulus. The lower panel shows the immediate effect of catheter ablation at the site of the accessory pathway insertion. Note the instant lost of the delta wave. Figure 1. Flow chart for differentiating the type of underlying arrhythmia in narrow complex tachyarrhythmia. (AVRT) Atrioventricular Reentrant Tachycardia, (AVNRT) Atrioventricular Nodal Reentrant Tachycardia, PJRT Permanent Junctional Reentrant Tachycardia

Summary Catheter ablation can cure most supraventricular arrhythmias, with a very small chance of recurrence (<2%). More complex arrhythmia (such as atrial fibrillation and ventricular tachycardia) can pose a greater challenge, but may also be addressable by ablation. winter 2011 practicematters

WELLINGTON IN FOCUS

Thyroid disease in a nutshell Disorders of the thyroid are very common Dr Asjid Qureshi summarises some key points for primary health care workers: Primary hypothyroidism This affects 2-4/1000 of the general population and the aetiology is most commonly autoimmune and onset is usually insidious. A raised serum TSH and low free thyroid hormones are characteristic. Further investigations including an ultrasound, and isotope scans are usually unnecessary. T o avoid side-effects and precipitating angina, Levothyroxine is best commenced at 25mcg daily and increased three weekly by 25mcg daily. TSH should be rechecked six weeks after a stable dose, aiming to maintain this at the lower end of the normal range. TSH levels should be monitored at least annually thereafter. Subclinical hypothyroidism Patients have raised TSH with normal free hormones; 40-60% are thyroid peroxidise (TPO) antibody positive. Untreated, subclinical hypothyroidism may have adverse metabolic consequences. Patients with a (i) TSH >10miu/l or (ii) Raised TSH, but <10miu/l and antibody positivity, should be treated with Levothyroxine. TPO antibody positivity Presence of TPO antibodies indicates a predilection to thyroid dysfunction; either hypo- or hyperthyroidism. Once detected, TPO titres need not be rechecked. In the presence of normal thyroid function, no therapy is indicated. Such patients are however, at a 3-5% per annum risk of developing hypothyroidism and should be screened annually. Hyperthyroidism Hyperthyroidism affects 0.8/1000 of the population and treatment is aetiology dependent (see below). Diagnosis is based on thyroid function; a thyroid ultrasound is usually unnecessary. Thyroid antibodies and/or a thyroid isotope scan may be beneficial in cases where the aetiology is clinically unclear. Graves disease 80% of hyperthyroid patients have Graves disease. Features include: young patients, family history of thyroid disease, eye signs and a diffusely 10

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Dr Asjid Qureshi is a Consultant in Endocrinology and Diabetes at Northwick Park Hospital and The Wellington Hospital.

raised. An early thyroid isotope scan is helpful and will classically demonstrate no uptake. Treatment is symptomatic with beta-blockers. Steroids may be of benefit, but antithyroid drugs are not indicated. Subacute thyroiditis patients may progress through hyper- and euthyroid states to hypothyroidism.

80%

of hyperthyroid patients have Graves disease.

enlarged goitre. In the first instance, Graves disease is usually treated with antithyroid medication for 6 to 18 months and there is a 50% risk of relapse following discontinuation. Some endocrinologists treat Graves disease with a large dose of anti-thyroid medication in combination with Levothyroxine (“block and replace”). Patients with relapsing Graves disease are treated with either radioiodine or a total thyroidectomy. Toxic multinodular goitre (TMNG) 15% of hyperthyroid patients have a TMNG which is more common in the elderly. Patients with a TMNG, although initially treated with antithyroid medication, will require definitive therapy (radioiodine or thyroidectomy). Toxic nodule 2% of hyperthyroid patients have a toxic thyroid nodule. Although initially treated with antithyroid medication, this is best managed with radioiodine. Radioiodine may render a toxic nodule nonfunctional with restoration of normal thyroid function from the remainder of the thyroid gland. Subacute thyroiditis 1% of hyperthyroid patients have a subacute thyroiditis. There may be a history of recent infection and raised inflammatory markers; TSH is suppressed and free thyroid hormones

Subclinical hyperthyroidism Patients have a suppressed TSH and normal free thyroid hormones. Thyroid function should be rechecked in three months. If persistent, treatment with radioiodine or antithyroid medication may be indicated, as this condition may be associated with osteoporosis and atrial fibrillation. Radioiodine versus total thyroidectomy Complications of a total thyroidectomy may include laryngeal nerve trauma and hypoparathyroidism. Ablative doses of radioiodine render 70% of treated patients hypothyroid. Hospital admission is avoided with radioiodine and there is no risk of hypoparathyroidism. Patients’ lifestyle is restricted for 3-4 weeks following therapy and radioiodine should be avoided in those planning to conceive in the next six months. Non-thyroidal illness (sick euthyroid) 50% of very ill patients have abnormal thyroid test results. Patients typically have a low TSH, free T3 and free T4. Theses results tend to normalise spontaneously. Thyroid nodules 5% of the population have a palpable thyroid nodule, but thyroid cancer is rare. Concerning factors may be: the young, old, those previously exposed to ionising radiation, male patients and in those with a solitary nodule. An ultrasound guided fine needle aspiration (FNA) is the investigation of choice. Thyroid function tests should also be performed, but a thyroid isotope scan is not usually required. A benign lesion on FNA should be re-sampled in three to six months. FNA evidence of malignancy necessitates surgery. An indeterminate FNA should be repeated, but if indeterminate again, surgery is usually recommended. Patients with thyroid cancer are treated with TSH suppressing doses of Levothyroxine.

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Ankle instability Mr Simon Moyes examines the common condition of ankle instability Ankle Instability Ankle ligament tears are extremely common, with approximately one in 10,000 people sustaining the injury per day; they are also the commonest ligament injury seen by surgeons. Repeated lateral ligament injuries interfere with normal daily life with chronic instability. A minor traumatic event can cause a significant inversion injury with an unpredictable outcome.

Brostrum repair of the ligaments. This involves a general anaesthetic and arthroscopic assessment of the joint with treatment of any intra articular lesions and anatomic reconstruction of the damage ligament.

Mr Simon Moyes is a Consultant Orthopaedic Surgeon, at The Wellington Hospital

In my practice this is followed by three weeks in an aircast walker and a three to six week physio programme. Success rates for this reconstructive surgery are good with 95% good or excellent results.

Cause Ankle injuries are caused by a twisting (inversion â&#x20AC;&#x201C; supranation) of the ankle and hind foot. The majority of ankle ligament injuries occur on the lateral side of the ankle joint. Symptoms Common features include pain, a snapping or tearing sensation, swelling and tenderness. Patients frequently fall to the ground and have difficulty weight bearing afterwards. Diagnosis After taking an accurate history examination usually reveals, in the acute situation, bruising and swelling anterolaterally in the presence of normal x-rays. A talar shift test is performed and this reveals excess antero posterior translation compared with the contralateral side. There is also excess internal rotation of the talus within the ankle joints. The anterior talar fibula ligament is almost always torn first. The calcaneo fibula ligament rupture is rare. With more chronic injuries far less bruising and swelling is seen. Imaging Plain x-rays exclude a fracture, and an MRI scan â&#x20AC;&#x201C; in the acute injuries confirms the diagnosis and can look for other intra articular injuries. Treatment Treatment can be non operative or operative; non operative treatment is tried first. This ranges from cast immobilisation to accelerated physiotherapy programmes. If patients fail to respond to these measures and cannot be symptomatic with pain and instability, they are offered an ankle arthroscopy and modified

Enquiry Helpline: 0207 483 5148

Success rates for this reconstructive surgery are good with

95%

good or excellent results

For more information or to arrange a referral, call the Enquiry Helpline on 0207 483 5148

winter 2011 practicematters

WELLINGTON IN FOCUS

WHY IS MY PATIENT

BREATHLESS? Dr Clive Handler is a Consultant Cardiologist at The Wellington Hospital, Consultant in Pulmonary Hypertension at the Royal Free Hospital, and Honorary Senior Lecturer in Medicine, UCL

Prognosis of PAH Although survival and functional class have improved with earlier diagnosis and new treatments, survival of PAH patients in WHO classes III and IV remains poor (<20% at 5 years).

Breathlessness is a common symptom in primary care; most causes can be diagnosed from clinical examination and some simple tests. The common causes of breathlessness are listed in table 1, and the tests to confirm the diagnosis in table 2. This article discusses pulmonary arterial hypertension, an uncommon and overlooked cause of breathlessness in patients of all ages.

TABLE 1: CAUSES OF BREATHLESSNESS HEART

Definitions of pulmonary arterial hypertension (PAH) and pulmonary hypertension (PH) PH is mean pulmonary artery pressure (mPAP) ≥ 25mm Hg. If the mPAP is ≥ 25 mm Hg and the pulmonary capillary wedge pressure (pcwp) is normal (≤15 mm Hg), this is called pulmonary arterial hypertension (PAH). This emphasises that the problem is in the lung arteries and the high pressure is not due to left heart disease.

severe anaemia, anxiety, obesity and being unfit

If the mPAP ≥ 25 mm Hg but the pcwp is ≥16 mm Hg, this is called PH, most commonly due to left heart diseases. 12

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hypertension, coronary heart disease, valvular disease, cardiomyopathy, arrhythmias LUNGS COPD, infections, interstitial lung diseases, pulmonary emboli, chest wall problems, pneumothorax, pleural disease and effusions

Pathology and pathobiology of PAH Vasoconstriction, fibrosis, thickening and thrombosis affect the smaller lung arteries. The pulmonary veins are not affected. The molecular and pathobiological triggers for these processes are unknown. There is up-regulation of endothelin, a potent vasoconstrictor and proliferative agent, and vasoconstriction with reduced nitric oxide levels and prostaglandin levels, the rationale for current PAH specific treatments.

OTHER

PULMONARY ARTERIAL HYPERTENSION (PAH) TABLE 2: TESTS TO EXCLUDE COMMON CAUSES OF BREATHLESSNESS • • • • • • •

Chest X-ray ECG Lung function Doppler echocardiography Stress testing Haematology, biochemistry, N-T proBNP V:Q scanning/CTPA

Epidemiology The prevalence of PAH in the population is between 6-50 per million. The majority of breathless patients with PH have left heart disease, 10% have lung disease, 0.6% have chronic thromboembolic disease, and the remainder have complex conditions. PAH is familial in a minority (<10%) of referrals. When to suspect PAH? In any patient of any age with unexplained breathlessness, tiredness, fatigue, without other heart or lung disease or other condition. Symptoms of advanced PAH with right heart failure include: angina and syncope. Signs on

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TABLE 3: SIMPLIFIED CLINICAL CLASSIFICATION AND TYPES OF PH

PH has been classified into six clinical groups according to pathology, pathobiology, genetics, epidemiology, and risk factors. PH and PAH are associated with a very wide spectrum of medical conditions spanning several specialties. The฀prognosis฀and฀management฀of฀each฀type฀ of฀PH฀depends฀on฀the฀cause฀or฀underlying฀ associated฀condition. 1. Pulmonary arterial hypertension (PAH) 1.1 Idiopathic (previously labeled “primary”) 1.3 Drugs and toxins induced 1.4 Associated with: 1.4.1 Connective tissue disease 1.4.2 HIV infection 1.4.3 Portal hypertension 1.4.4 Congenital heart disease and systemic to pulmonary shunts 1.4.5 Schistosomiasis 1.4.6 Chronic haemolytic anaemia 1.5 Persistent pulmonary hypertension of the newborn 2

Pulmonary hypertension due to left heart disease 2.1 Systolic dysfunction 2.1 Diastolic dysfunction 2.3 Valvular disease Pulmonary hypertension due to lung diseases and/or hypoxia 3.1 Chronic obstructive pulmonary disease 3.2 Interstitial lung disease 3.3 Other pulmonary diseases with mixed restrictive and obstructive pattern 3.4 Sleep-disordered breathing

Chronic thromboembolic pulmonary hypertension

PH with unclear and/or multifactorial mechanisms This diverse group includes haematological disorders (myeloproliferative disorders, splenectomy); systemic disorders (sarcoidosis, vasculitis), metabolic disorders: glycogen storage disease, Gaucher disease, thyroid disorders, chronic renal failure on dialysis.

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examination include a loud P2, a high jugular venous pressure, right ventricular hypertrophy and peripheral oedema. Features suggesting PAH: •฀ ฀Doppler฀echocardiography:฀a฀tricuspid฀ valve regurgitant velocity (TVR) ≥2.8 m/s, equating to a pulmonary artery systolic pressure of 40 mm Hg in a breathless patient. False positive results are quite common if a lower TVR cut off is used. The higher the TVR, the more probable is PAH; the converse applies. •฀ ฀Lung฀function฀tests:฀showing฀disproportionately฀ low transfer factor (DLCO) but normal lung volumes and no important obstructive ventilatory defect.

The average time to diagnosis from onset of symptoms is 3 years. Earlier diagnosis depends on awareness of the diagnosis and prompt referral to a PAH specialist.

•฀ ฀ECG:฀right฀ventricular฀hypertrophy฀and฀strain,฀ and big P waves of right atrial hypertrophy. •฀ ฀Chest฀X-ray:฀cardiac฀enlargement,฀big฀ pulmonary arteries and pruning of the distal vessels, with absence of other abnormalities. CXR and ECG may be normal in PAH. Diagnosing PAH Right heart catheterisation is essential for diagnosis of PAH and distinguishing it from PH. Invasive pulmonary angiography and coronary angiography may also be necessary and can be performed at the same time. The average time to diagnosis from onset of symptoms is 3 years. Earlier diagnosis depends on awareness of the diagnosis and prompt referral to a PAH specialist. Treatment of PAH Anticoagulants (to reduce the risk of thromboembolic disease), and digoxin and diuretics are generally prescribed for most patients. High dose calcium channel blockers may be effective in the minority of patients with a positive vasodilator test. Half of those who respond acutely will have a long term response. Currently three groups of drugs targeting three defective pathways are used to mitigate the vascular defects of vasoconstriction and proliferation: endothelin receptor antagonists,

PDE-5 antagonists (sildenafil etc), and prostanoids. They are also used in combination. They can be prescribed only by recognized PAH clinicians in PAH centres. The annual cost per patient for each drug is £25,000. In short-term randomized controlled trials, all three agents have been found to improve symptoms and functional class. Registry studies and meta analyses show improved survival in PAH patients over the last few years. General measures Moderate exercise is recommended. Immunization against flu and pneumococcus is recommended. Lung transplantation is recommended for patients in WHO class IV but the shortage of donor organs makes this an option for very few patients. Because of the high risk of maternal death, the WHO advises against pregnancy. Conclusions PAH฀is฀a฀rare฀but฀treatable฀cause฀of฀ breathlessness฀and฀fatigue,฀and฀prognosis฀ has฀improved.฀Patients฀should฀be฀referred฀ for฀early฀specialist฀diagnosis฀and฀treatment฀ in฀a฀multidisciplinary฀unit.฀฀

winter 2011 practicematters

GP COMMENT DEBATE The Wellington Hospital is dedicated to supporting GPs…

All change! In July 2010 the White Paper on health announced the plan to shift the responsibility of commissioning health services - from Primary Care Trusts to local GP consortia’s. Following a consultation period the Health and Social Care Bill was published last month: confirming the abolition of both PCTs and Strategic Health Authorities and the foundation of the NHS Commissioning Board. The intention is to provide the professionals - who have frequent contact and first hand knowledge of their patients, with responsibility for purchasing the services required for their care. The NHS Commissioning Board is a new national organisation which will oversee consortia and retain commissioning responsibility for General Practice, Dentists and

Eye Care along with some specialist services. The names of Andrew Lansley’s GP ‘Pathfinder’ Consortia have now been announced; and though the mood is generally a positive one; there are naturally questions and reservations surrounding the imminent changes. In the first wave a total of 52 pathfinder consortia throughout England were announced, the smallest of which will be in Hertfordshire, covering a population of 18,900 under one practice, ranging to 672,000 in Oxfordshire, comprising 83 practices. This diversity in patient numbers highlights the argument that there is a real necessity for individual areas to develop at different speeds, and in ways that best serve their communities. There is a feeling that a great deal of flexibility

is needed in order to make this reform really flourish. A second wave of another 89 consortia has already been accepted, suggesting that GPs are embracing the proposed changes. These plans are likely to commence as early as April this year. The overall objective is for the consortia firstly to shadow PCTs, and then in 2012 they will take over the responsibilities including budgets, before a complete handover is expected by 2013. Dr Clare Gerada, Chair of the Royal College of General Practitioners announced, “We firmly believe putting GPs at the centre of commissioning is the right way forward and we will continue to engage with the department to shape the policy.” Nick Bosanquet, Professor of Health Policy at Imperial College has declared his support for Lansley’s campaign, but harbours concerns about the speed in which the changes are to be implemented, stressing the importance of the role of PCTs in this period of uncertainty. “The Government ought to rethink its plan to abolish the primary care trusts by 2012-13. Rather than being so hasty, we should keep clusters of PCTs running for at least five years; they could act as development agencies for the GP consortiums.” The general consensus is that this reform is very much welcomed, though there are qualms over exactly how this change should be tackled, and the speed in which it is to be implemented. The key concerns are that such a huge reform is being embarked upon whilst the NHS is expected to produce large efficiency savings.

The Government ought to rethink its plan to abolish the primary care trusts by 2012-13. Rather than being so hasty, we should keep clusters of PCTs running for at least five years; they could act as development agencies for the GP consortiums. 14

practicematters winter 2011

Ultimately, there seems to be a lack of faith in the Government’s capabilities to provide enough support to make this the success it could potentially become.

www.thewellingtonhospital.com

Come and join us at The Wellington Hospital for breakfast and a morning seminar with one of our specialist Consultants. At the end of last year a selection of GPs joined Professor Ellis Downes for an early start and a talk on “Heart Break Gynaecology”. This talk was extremely well received and we have already had requests to roll out a series for 2011.

The Wellington Breakfast Club will take place on the 5th floor Board Room in the South building. Breakfast will be served at 7:45am and the presentation will start shortly thereafter. We wouldn’t want anyone being late back to work, so to allow you adequate time, meetings conclude by 8:25am. Please note parking is free on a meter or yellow line prior to 8:30am.

At The Wellington we appreciate it can be tricky to get to our evening events due to work commitments, so to make sure you don’t miss out we would like to offer a variety of times, dates and venues to suit all. So if you have missed a date just let us know and we will endeavour to hold a breakfast talk around that topic.

... AND BY THE WAY, I LIKE MINE SUNNY SIDE UP! Got a burning issue? Want more information on a particular topic? Sign up to our breakfast club and let us know the things you want to hear! For further information or queries please feel free to contact: Katy Cross Tel: 07826551318 E-mail: katy.cross@hcahealthcare.co.uk

Enquiry Helpline: 0207 483 5148

HOW DO YOU LIKE YOUR EGGS IN THE MORNING?

Consultant Led Talks Cardiology Dr R Rakhit Dr C Handler Dr A Chow Dr A Ghuran Colorectal / General Surgery Mr P Mathur Mr C Elton Mr R Navaratnam Mr A Obichere Mr K Moorthy Dermatology Dr S Mansoor ENT Dr H Kariyawasam Prof S Saeed Gastroenterology Dr V Wong Dr C Onnie Dr D Suri Dr B Prasad General Medicine Dr A Qureshi Dr S Robinson Dr D Noimark Dr J Birns Gynaecology Prof E Downes Liver Mr G Fusai Neurology Dr D Heaney Ophthalmology Mr H Zambarakji Orthopaedics Mr M Herron (Foot & Ankle) Mr N Cullen (Foot & Ankle) Mr R Carrington (Hip & Knee) Mr R Patel (Hip, Knee & Shoulder) Mr W Aston (Hip & Knee) Prof E Schilders (Hip) Mr N Toft (Hand & Wrist) Plastics Mr N Toft Respiratory Dr B O’Connor Dr M Beckles Sports Medicine Dr C Speed Urology Mr T Lane Mr J Ockrim Mr L Ajayi Mr R Hamid Mr B Maraj Mr A Ballaro Vascular Mr H Flora Mr C Bicknell

GP LIAISON UPDATE

B = breakfast L = lunchtime E = evening To take advantage฀of฀these฀talks:฀choose฀a฀consultant,฀ pick฀a฀time฀&฀we’ll฀bring฀these฀talks฀to฀your฀surgery.฀Email฀ our฀GP฀Liaison฀Oficers฀or฀call฀The฀Enquiry฀Helpline฀to฀book.

winter 2011 practicematters

NURSES CORNER

EVENTS DIARY Educational events scheduled for the next three months are outlined below. For further information and booking details please see our website: www.wellingtonevents.co.uk

New GM in Theatre spot light Miranda Dodd is The Wellington Hospital’s General Manger of Theatres. New to The Wellington, Miranda has been in this post for five months. Her previous role was Physiotherapy Manager and Clinical Governance Lead at Spire Bushey Hospital. Miranda spared us 10 minutes to tell us what her job involves and how she’s quickly adapted to her new role. PM: Tell us about your role as General Manager of Theatres: MD: My role is to manage the 11 (soon to be 15) theatres at The Wellington holding overall responsibility for all staffing, operational, financial and clinical aspects of the department. This involves working with the consultants to support their practices and ensuring we provide the highest standards of care and service. PM: What is your clinical background? MD: My clinical background is in Physiotherapy. I qualified in 1995 and specialised in musculoskeletal outpatients, later sub specialising in Shoulder rehabilitation. I completed an

MSc in Sports Medicine in 2003 before moving into management and governance. I have been working in the independent sector for the last 11 years. PM: What are the challenges that you face day to day? MD: The challenge is to run all aspects of the theatres at The Wellington to the highest standards of efficiency and effectiveness – both clinically and from a business perspective. Staff requirements change by the minute, and for each procedure different consultants have different instrument preferences and with new consultants and new procedures continually coming into play keeping pace means life is never dull.

PM: What do you enjoy most about your new role? MD: The challenges! I have learnt a tremendous amount in the five months I have been in post and I love the fact that every day poses new issues and opportunities. PM: If you weren’t Theatre Manager, what would you be? MD: I’m still getting my head round not being a Physio anymore and I am loving my job as a General Manager, so I’d have to say I’m good where I am at the moment – In another life I think I’d give Law a go.

Dr Malcolm Persey Consultant Rheumatologist Dr Fiona Watt Consultant Rheumatologist

15.2 Orthopaedic Masterclass 2: London Hip Arthroscopy Centre – Huxley Lecture Theatre, London Zoo 17.2 GP Seminar: An Update in the Treatment of Functional Bowel Problems – WDOC Golders Green 23.2 GP Resuscitation Training – Board Room 03.3 GP Seminar: Diabetic Nephropathy: Pathogenesis and Management – Board Room 15.3 Orthopaedic Masterclass 3: Shoulder – Huxley Lecture Theatre, London Zoo 16.3 GP Seminar: Paediatric ENT – WDOC Golders Green 23.3 GP Resuscitation Training – Board Room 05.4 Orthopaedic Masterclass 4: Hand and Wrist – Huxley Lecture Theatre, London Zoo 07.4 GP Seminar: Thyroid and Parathyroid Disease: An Integrated Approach – Board Room

NEW CONSULTANTS Dr Nida Chammas Consultant in Acute Medicine, Diabetes & Endocrinology

03.2 GP Seminar: Patients with Palpitations: Who to Refer and Who to Worry About – Board Room

Mr George Fowlis Consultant Urologist

12.4 GP Seminar: Fat, Fibrosis or Fosters Larger – WDOC Golders Green

Mr Prokar Dasgupta Consultant Urologist Mr Zahid Salim Consultant Gynaecologist

Dr Abdul Shlebak Consultant Haematologist

Dr Priyajit (Bobby) Prasad Consultant Gastroenterologist

Mr Matthew Sala Consultant Orthopaedic Surgeon

Mr Christopher Chan Consultant Surgeon

Mr Sameer Gidwani Consultant Orthopaedic/ Hand Surgeon

Dr Afrina Alam Consultant Dermatologist

27.4 GP Resuscitation Training – Board Room

Professor Sunil Shah Consultant Ophthalmic Surgeon

www.thewellingtonhospital.com Enquiry Helpline: 0207 483 5148