The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
WELCOME As we enter autumn, and with the winter months ahead, we have been reflecting on how the year has developed. We have faced many challenges, with the Competition Commissionâ€™s investigation into the private healthcare market continuing to consume a great deal of our time and effort. However, with the completion of the analysis and recommendations due in April 2014, I am confident that The Wellington Hospital will benefit from that which has been a major investigation. This year we have welcomed many new doctors and staff members, joining us in delivering a high level of service to all our patients. Along with new colleagues, this year has also seen the acquisition of a wide range of advanced technology, equipment and programmes, including the O-arm imaging system (see page 18). As a hospital, we aim to share best practice and important information to assist GPs and patients. Mr William Bartlett answers frequently asked questions on hip replacements on page 10, offering in-depth information on all hip options. In this issue, Consultant Cardiologist Dr Romeo Vecht, who returned to consult at the Platinum Medical Centre in June this year, describes his six years of teaching and lecturing at the Carmel Medical Centre, Haifa. Learning is a key factor in developing our knowledge and understanding, and we have held many successful events this year, including our Foot and Ankle seminar at Lords, which you can read about on page 9. Also in this issue, Dr Nisith Sheth explores Mohs surgery and how it is shaping the future of treatment for skin cancer. Our regular Q&A feature introduces you to Mrs Vadney Fontaine- Waldron, Enquiry Helpline Supervisor, who explains the inner workings of our Enquiry Helpline service and all the work they do to support your calls and emails for appointments and bookings. As 2013 draws to a close, we reflect on this yearâ€™s achievements and look forward to all the developments we have planned for 2014. More on this in our winter edition due out in the New Year. Best wishes for the remainder of 2013,
Keith D Hague CEO
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Editor: Hannah Rogers Production & Distribution: Runwild Media Group
11 CONTENTS 04 | Surgical advances for kidney tumours Mr Omer Karim
05 | Mohs surgery â€“ the best in cure rates and cosmetic outcomes Dr Nisith Sheth
06 | My time in Israel Dr Romeo Vecht takes an in-depth look into medical practices, advances and culture during his time in Haifa
08 | Contemporary options in the management of diabetic eye disease Mr Hadi Zambarakji
09 | Masterclasses and events at The Wellington Hospital 10 | Common questions on hip replacement Mr William Bartlett
11 | Musiciansâ€™ hands: unique problems, bespoke solutions Mr Raj Ragoowansi
12 | Strive for excellence Mr Damian Muncaster introduces the new Sports Performance Programme available at The Wellington Hospital
14 | The perineum and the psyche Mr Nicholas H Morris
15 | Total knee replacement in 2013
Mr Martin Logan
16 | GP news Updates from the primary care sector
18 | Latest news and new consultants
14 www.practicemattersmag.co.uk 3
Surgical advances for
kidney tumours Index artery – the artery which is clamped during surgery
Consultant Urologists Mr Omer Karim and Mr Amrith Rao discuss the role of intra-operative ultrasound scans for precise da Vinci robot-assisted removal of kidney tumours
Kidney cancer accounts for three per cent of all cancers affecting patients in the UK and is the country’s eighth most commonly diagnosed cancer. With increasing use of ultrasound and CT scans for abdominal symptoms, growing numbers of kidney tumours are being picked up at an earlier stage. Tumours that are smaller than 4cms are designated as Small Renal Masses (SRM), with 7080 per cent showing as cancerous when removed. In the past, any tumour detected in the kidney would have been treated by radical nephrectomy (removal of the entire organ). However, further medical advances have shown that only the tumour needs to be removed (partial nephrectomy), along with a rim of normal surrounding tissue. Not only does this maintain good cancer-related outcomes, but also has an added advantage of better preservation of kidney function. Traditionally, SRMs were removed by an open operation as the kidney sits in the retroperitoneum and has large blood vessels that are difficult to access. However, advances in technology have meant that surgery is now less invasive, whilst maintaining a high level of precision. Over the last 20 years, laparoscopic removal of these tumours gained popularity but was restricted to very specialised centres. The advent of da Vinci Robotic surgery saw this technology replace laparoscopic surgery in most established centres; creating a new age in surgical advances. At present, robotic-assisted partial nephrectomy (RAPN) is the new “Gold Standard” in the United States and at certain centres in the UK.
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How does RAPN work? Robotic surgery involves the insertion of tiny wristed instruments into the patient. The precise movement of these robotic instruments is controlled by the operating surgeon while seated at the surgeon’s console. RAPN uses exact delineation of the tumour and its relationship with the complex anatomical structures within the kidney.
Robotic ultrasound probe in action
Recent media coverage about robotically assisted surgery suggests the machine is just an expensive toy for surgeons, however, past assessment of the tumour margins was based upon the surgeon’s memory, after having studied the CT scan images. Recently, with the availability of the drop-in ultrasound probes controlled by the operating surgeon, precise location of the tumour and its relation with important structures within the kidney is possible. This has the added advantage of removing as little normal kidney tissue as possible, along with the cancerous tumour. Developments in a novel technique to use contrast enhanced ultrasound scans (CEUS) can aid in identifying the precise nature of the blood supply to the tumour and its surrounding structures.
This unique technique, which we have developed, allows selective clamping of the kidney’s blood vessels, preserving maximum kidney function after RAPN. The images obtained by scanning the kidney are directly relayed to the operating surgeon’s console, showing exactly where to cut the kidney. As the ultrasound probe is directly on the surface of the kidney, the deeper aspect of the tumour can be clearly seen and removed, ensuring all cancerous tissue is caught. The drop-in ultrasound probe (recently acquired by The Wellington Hospital) has therefore revolutionized the way in which robotassisted kidney surgery is performed.
Ultrasound probe in action with the surgeon’s tile pro image
Advantages of the robotic drop-in ultrasound probe • It maps the margins of the tumour precisely • It allows the surgeon to assess the relationship of the tumour to important underlying structures • It maps the renal and tumour blood supply (CEUS technique)
To find out more information about Mr Omer Karim, please visit www.practicemattersmag. co.uk/website/contributors.php
Mohs surgery – the best in cure rates and cosmetic outcomes
The Wellington Hospital has recently invested in a new state-of-the-art Mohs laboratory at the Platinum Medical Centre. Here, Consultant Dermatologist Dr Nisith Sheth describes the technique and its uses
Skin cancer is the most common group of malignancies in the UK, with more than 100,000 new diagnoses each year. Cases make up 20 per cent of all cancer registrations, with the total number of instances more than doubling in the last 10 years. Some skin cancers can be deceptively large and more extensive under the skin than they appear on the surface. They may have roots in the skin, along blood vessels, nerves or cartilage. Those that have recurred after previous treatment may have extensions deep under the scar that has formed at the site. Conventional treatment with surgery or radiotherapy can often miss these roots, leading to recurrences that can be more aggressive than the original tumour. Conventional surgery can also lead to more tissue being removed than is necessary, resulting in an excessively large scar.
Mohs micrographic surgery Mohs micrographic surgery is named after Dr. Frederick Mohs who developed the technique in the 1930s. Today, it is accepted as the single most effective technique for removing Basal Cell and Squamous Cell Carcinoma (BCCs and SCCs) and many other types of skin cancer, excluding all tumour types. It accomplishes sparing the greatest amount of healthy tissue whilst providing an almost total elimination of cancer cells . Cure rates can be an unparalleled 98 per cent (or higher) with Mohs, which is significantly better than the rates for standard excision or any other accepted method.
What does the process involve? Mohs involves a specific sequence of pathological investigation and surgery in which the visible portion of the tumour, including a small margin, is removed. The tissue is colour-coded with dyes, and a map of the surgical site and the sections of removed tissue are drawn. The sections are processed by a specialist histotechnologist and microscopically examined by a dermatologist for evidence of cancer cells. If these are found, their location is marked on the map and another layer of tissue can be carefully removed from the patient. By using this technique, only areas with cancer are sequentially removed and healthy tissue is preserved. The removal process continues layer by layer until microscopically there is no longer any evidence of cancer remaining in the surgical site. Depending on the size of the resulting wound, it may be left to heal on its own or reconstructed by direct closure, a skin graft or flap. This can be done in conjunction with other specialties such as plastic surgery or oculoplastics, if necessary. The procedure usually takes several hours to complete, but the exact time required can often be unpredictable. However, the patient is only being operated on for part of this time.
Some skin cancers can be deceptively large and more extensive under the skin than they appear on the surface
Why is Mohs surgery so accurate? In conventional surgery, skin cancer is processed by vertical sections where typically only two per cent of the margin is examined. This is one reason why tumours recur even when reported as being fully excised. Some surgeons carry out a margincontrolled procedure with standard ‘frozen-section histopathology’, but this does not have the same degree of accuracy as the Mohs process. In Mohs, 100 per cent of the margin is examined, with the surgeon studying the pathology and mapping the tumour precisely. The vast majority of doctors performing Mohs surgery are dermatologists with specialised skills in dermatological surgery and dermatopathology. Ideally, the surgeon should have completed a one year full-time intensive fellowship in Mohs surgery following dermatology training. To find out more information about Dr Nisith Sheth, please visit www.practicemattersmag. co.uk/website/contributors.php
My time in
Consultant Cardiologist Dr Romeo Vecht returns to The Wellington Hospital after spending six years at the Carmel Medical Centre in Haifa, Israel. Here he discusses his time spent teaching and lecturing, and the success of his Anglo-Israeli Cardiovascular Symposium PM: What prompted your move to Israel in 2007? RV: I was invited by Professor Danny Aravot, Head of Cardiac Surgery in Haifa, to join his unit. At that time, a position came up in the Carmel Cardiovascular Centre, where I was appointed Senior Consultant. My main contribution was to reorganise the ward rounds in English; however, I felt that I could offer more. So I began by organising an annual Anglo-Israeli Cardiovascular Symposium, whilst providing basic cardiology and bedside teaching at the Technion Medical School. Bedside teaching consisted of taking a proper history, followed by a thorough examination and discussion on diagnosis and management. This was rather different from the local teaching, which was USA-orientated with an approach that was more technological than clinical. The cardiology lectures took place at the medical school, where classes held
Extremely advanced scientific products from this area are used all over the world Enquiry Helpline: 020
up to 100 students from a mixture of Israeli and Arab backgrounds. I taught in English and, much to my surprise, was voted teacher of the year. PM: What were your aims for the trip? RV: I no longer wanted to be employed full time and I enjoyed spending my spare time reading about the country’s history and religion. We bought a house in Caesarea, the city built by Herod the Great, which became the centre of the Roman occupation of Palestine. The area is full of artefacts dating back 2000 years. I wanted to explore medicine and see how it worked in another country, and Israel offered me this opportunity. PM: What were the big differences with the practice of medicine in Israel compared to the UK? RV: On the medical side, I was interested to see how the local medicine compared with the NHS. There are numerous cardiologists in Israel, perhaps even more than in the UK, for a population of only seven million. Private practice is complicated owing to the numerous insurance companies involved. However, the amount of research emerging from that small country is just amazing.
Israel is a flourishing country, constantly expanding. A desert has metamorphosed over 65 years into an extended oasis. Tel Aviv is a cosmopolitan city with high rises, a Manhattan in miniature, boasting wonderful sunny beaches. Israel has a thriving economy and a large export market that has not suffered from the recent global austerity. Extremely advanced scientific products from this area are used all over the world.
Consultant Bahai temple in Haifa
PM: What were your first impressions of the Carmel Clinic? RV: The standards of practice were very high and research publications were abundant. Cardiology practice was aggressive, with interventions taking place at any time. Acute myocardial infarctions were stented round the clock. Cardiac surgery was also thriving as there is an ageing population and rheumatic heart disease is rather prevalent among the country’s population. On the downside, I learned that there was a limitation on available drugs. The Carmel Medical Centre was not equipped with a cardiac MRI, meaning patients had to be sent to Tel Aviv, a two hour ambulance journey. In addition, a common blood test known as BNP was not freely available owing to its cost.
Aerial view of the Carmel Medical Centre, Haifa
On the medical side, I was interested to see how the local medicine compared with the NHS
The standards of practice were very high and research publications were abundant
PM: Can you tell us a bit more about the Anglo-Israeli Cardiovascular Symposium? RV: The purpose of the symposium is to share the latest research between the UK and Israel. We have run four annual symposia since 2009, alternating between the two countries. The entire field of cardiology is covered, with eminent speakers selected according to their subject. Some attendees have reported that these have been the best meetings they have ever attended. PM: What prompted your move back to the UK? RV: The intense heat in the summer was one reason and there was also the complicated bureaucracy, all in Hebrew, which I could not master. My family, which now accounts for 12 grandchildren and four great-grandchildren, could not visit from London as much as we had hoped, meaning we missed them greatly. PM: Would you return to Israel to live or work? RV: Not to live, but certainly as a tourist. I am still involved with the Carmel Medical Centre and will join them whenever I visit the country. My time in Israel was a great adventure and one I am glad to have experienced. It was a valuable and enriching six years and I very much look forward to our next visit.
Dr Romeo J Vecht MB. FRCP, FACC, FESC Consultant Cardiologist Dr Vecht completed his cardiology training at Hammersmith, National Heart, Royal Brompton and St Mary’s London. He spent one year in Cape Town with Chris Barnard at the time of first cardiac transplant. His following appointment was a year in Zurich with A Gruentzig and U Siegwart, innovators of angioplasty and coronary stenting. Further into his career, he became Honorary Consultant Cardiologist at St Mary’s, visiting Consultant Cardiologist at Royal Brompton and Consultant Cardiologist at Manor House Hospital. Dr Vecht has produced over 50 professional publications and three cardiology textbooks. Dr Vecht is currently practicing as Consultant Cardiologist at the Platinum Medical Centre and Senior Cardiologist at the Carmel Hospital in Haifa.
To find out more information about Dr Romeo Vecht, please visit www.practicemattersmag. co.uk/website/contributors.php
Contemporary options in the management of
diabetic eye disease Consultant Ophthalmologist Mr Hadi Zambarakji presents the symptoms of diabetic eye disease and the treatments available Vision loss in diabetic patients is predominantly due to retinopathy, which in the more advanced stages of disease results in new vessel growth known as proliferative diabetic retinopathy (PDR). Untreated PDR may lead to vitreal haemorrhage and retinal detachment, as well as rubeotic glaucoma, if new vessels invade the anterior segment of the eye. The UK national screening programmes have adopted a simple classification scheme based on which a grader identifies fundus features, aimed at detecting referable retinopathy. Referrals also include patients with cataract, but macular oedema remains the most important limiting factor to visual recovery. In relation to modifiable risk factors, the Royal College of Ophthalmologists (RCO) has recommended a target HbA1C of 48-58 mmol/ mol (6.5-7.5 per cent), a systolic BP of < 130 mmHg in those with established retinopathy and the consideration of statin therapy for the prevention of macrovascular disease. Furthermore, macular oedema has been associated with the use of thiazolidinediones and current recommendation is to withdraw pioglitazone in the presence of macular oedema.
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Figure 1: The optical coherence image (a) shows a colour-coded map of macular (retinal) thickness (MT) in an eye with diabetic macular oedema. The grid on the left (before treatment) shows white and red colours in the centre indicating a thickened macula (MT of 555 microns), whilst the grid on the right (after treatment) shows bluish/green colours in the centre indicating reduced macular thickening (MT of 321 microns). The cross section scans before (b: 02/2013) and after (c: 05/2013) treatment with Lucentis show significant resolution of cystic swellings following treatment. Figure 1b
Laser treatment Ophthalmologists have long been using lasers for the treatment of diabetic macular oedema (DMO) and PDR. Recent advances include the development of portable lasers, the sub-threshold infrared 810 nm diode laser and the multi-spot lasers. The main advantage of the sub-threshold diode is that it results in minimal structural damage to the outer retina as no absorption occurs by photoreceptors. The multispot lasers, however, are used because of the shorter laser pulse duration, which results in reduced pain during treatment.
Drug treatment DMO treatment is of particular interest because of the demonstrated superior benefits of intravitreal anti-vascular endothelial growth factor (VEGF) agents, including Bevacizumab (Avastin) and Ranibizumab (Lucentis) (figure 1). NICE approved the use of Ranibizumab for the treatment of DMO in February 2013. Bevacizumab, a drug that was originally marketed for the treatment of colorectal carcinoma, is not licensed for intraocular use, despite being used extensively to treat eye disease.
Steroid treatment Intravitreal steroid injections with Triamcinolone are rarely used nowadays but a Fluocinolone Acetonide intravitreal insert (Iluvien; Alimera Sciences), with sustained delivery for up to 36 months, has recently been approved by NICE for use in chronic DMO. Increased intraocular pressure and cataract are important side effects of steroids in the eye, but the use of the Iluvien insert may prove to be an attractive treatment option in eyes that are already pseudophakic.
What about surgery for diabetic eye disease? Pars plana vitrectomy (PPV) is primarily indicated when advanced PDR results in vitreal haemorrhage and traction retinal detachment. Whilst the advantages of surgery vs. observation are in favour of surgery, outcomes are limited by the extent of retinal disease and macular function. Major advances include small gauge surgical instruments, reducing the need for suturing, high-speed vitrectomy devices and the development of wider ranges of high quality disposable instruments. Improved visualization also improves outcomes and facilitates surgery, allowing reduced dependence on assistant help during surgery.
To find out more information about Mr Hadi Zambarakji, please visit www.practicemattersmag. co.uk/website/contributors.php
FOOT AND ANKLE
MASTERCLASS SERIES and events at The Wellington Hospital As part of our educational programme, each year we organise a wide range of events for our GPs, Embassy Doctors, Physiotherapists and other allied healthcare professionals. This provides us with a unique opportunity to share knowledge, discuss advances in areas of practice and network with other professionals. On Saturday 28th September, the Foot and Ankle Unit at The Wellington Hospital hosted the latest edition of the Orthopaedic Masterclass Series 2013. The consultants explored a whole range of topics, such as advances in ankle injuries, arthritis and sporting injuries. With over 90 attendees including GPs, physiotherapists and podiatrists, the event opened with registration and breakfast before talks on a range of topics that ran until 10:30am. Between the consultant-led talks, attendees were invited to ask questions and join discussions. After a coffee break and an opportunity to discuss the morningâ€™s seminars, delegates were split into three groups and attended various practical, hands-on sessions exploring Arthrex demonstrations, injection techniques and braces and boots. This included an egg and spoon race in which participants wore brace boots. There was also an opportunity to test some of the latest implant designs for treatment of acute ligament and tendon injury, alongside some of the newest splints and rehabilitation aids. The Wellington Hospital events run throughout the year and cover a variety of practices reflecting those available at our facilities. To find out more about our GP seminars, masterclasses and events, please visit the Healthcare Professionals section of The Wellington Hospital website.
Every year, approximately 450 patients per 100,000 population present to primary care with hip pain. What types of hip replacements are available?
Common questions on
As the number of patients undergoing hip surgery continues to rise, so does that of those seeking advice. Consultant Orthopaedic Surgeon, Mr William Bartlett addresses the most commonly posed questions Causes Every year, approximately 450 patients per 100,000 population present to primary care with hip pain. As a result, many of the same questions are asked regarding problems and treatments and, in particular, hip replacements. Of the 70,000 total hip replacements (THR) performed in England and Wales last year, over 90 per cent were to treat osteoarthritis. Conditions such as avascular necrosis, trauma, dysplasia and inflammatory arthritis are more common in younger patients. Hip pathology typically causes pain in the groin that radiates towards the knee. Pain in the outer thigh, buttock or emitting below the knee suggests an alternative cause such as the lumbar spine or proximal thigh musculature.
Osteoarthtis Radiological evidence of hip osteoarthritis is present in approximately 10 per cent of patients aged over 65. Risk factors include a genetic predisposition, female sex, obesity, previous hip injury, hip dysplasia and medical conditions such as diabetes and gout.
When should a hip replacement be considered? Usually when symptoms have a substantial impact on quality of life and are refractory to non-surgical treatment. The threshold for surgery depends on patient preference, age, functional requirements and medical co-morbidities. Early referral to discuss surgery is recommended, as the outcome of THR is better when performed before pain and impairment have become too severe.
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Is my patient too old or too young for THR? THR in the elderly can significantly improve quality of life and allow ongoing independence. However, patients should acknowledge that the risk of perioperative mortality in this group is higher (0.6 -1.3 per cent at 30 days). As our confidence in THR longevity and performance has grown, a young age is also no longer considered as a contraindication (2 per cent of cases are performed in patients under 40 years). In this group, the procedure should still be regarded as a ‘last resort’ and future revision surgery should be anticipated.
What is the alternative? Most patients can avoid surgery and manage with simple analgesics or NSAIDS. A walking stick held in the opposite hand reduces the weight on the hip and usually increases patient walking distance. Weight loss can significantly help symptoms and lower perioperative risks, if surgery is needed. Dietary supplements such as glucosamine, chondroitin, and vitamin D are not recommended for treating established disease.
Cemented hip replacements use polymethyl methacrylate to bond the femoral stem (made of cobalt-chromium or stainless steel) and acetabular cup (made of polyethylene) to bone. Uncemented hips are made from titanium with a surface treatment onto which the bone grows. The argument as to which form of implant fixation is better has raged for decades. In young patients, many surgeons prefer to use uncemented implants that create a robust biological bond between the bone and implant. Uncemented THRs also allow the use of ultra hardwearing ceramic bearings. In the elderly, however, cemented THR may be safer and more cost effective. The combination of minimally invasive surgical techniques and improved analgesic strategies now mean that often patients walk comfortably on the day of surgery. After three to five nights in hospital, patients can expect to return home, with post operative pain usually settling within six weeks.
How long will a new hip last? It is important to consider that there is a failure rate of one per cent a year. Patients undergoing surgery in their seventies have a 90 per cent chance of the original implants lasting their lifetime. Conversely, patients under 50 years at the time of primary surgery are likely to require revision. Outcome is also dependent on surgeon’s experience; a four-fold higher early revision rate is observed amongst ‘occasional’ surgeons compared to higher volume surgeons.
Is post operative specialist follow up needed? Whilst over 95 per cent of patients are satisfied with the outcome of their THR, there is still a risk of problems occurring at a later stage. Periprosthetic osteolysis can progress silently, which may lead to a fracture or unsalvageable bone loss. Patients should therefore liaise with their specialist and have an X-ray at one year, seven years and three yearly thereafter, even if there is no pain. Although ‘metal on metal’ THR were recently withdrawn from use in the UK, the majority of patients with these implants are at low risk of developing problems. Even though only a small number of patients with ‘metal on metal’ hips develop soft tissue reactions to the metal wear debris, annual follow-ups are still recommended for the life of the implant. To find out more information about Mr William Bartlett, please visit www.practicemattersmag. co.uk/website/contributors.php
HAND AND WRIST
Musicians’ hands: unique problems, bespoke solutions
Consultant Plastic & Hand Surgeon Mr Raj Ragoowansi discusses the frequent hand and wrist injuries experienced by musicians and the options available for treatment
Each musical instrument imposes its own unique physical demands on the musician’s hand. A variety of problems, such as flautist’s finger, bassoonist’s thumb and violinist’s palsy, inflammatory and degenerative, require a thorough understanding of patho-anatomy and physiology. In addition, a careful analysis of the instrument and playing technique should be carried out in close collaboration with a trained hand therapist, paying particular attention to ergonomics. Certain signs are pathognomonic as localised tenderness is a strong indicator of inflammation, injury or entrapment of a peripheral nerve. Diffuse and flitting tenderness in muscles of the forearm and hand often represent fatigue rather than injury. Sensory disturbances including dysaesthesia/paraesthesia are common in musicians and should not be attributed to nerve compression unless there is consistent anatomic distribution of the sensory disturbance, constant focal signs of the nerve in question and abnormal neurophysiological findings suggestive of delay.
Recognisable problems in order of descending frequency • Tenosynovitis – elbow, wrist, digits (trigger fingers) • Acute or acute-on-chronic trauma • De Quervain’s • Osteoarthritis – 1st CMCJ and PIPJ • Hand/wrist swellings including ganglions/ cysts/Dupuytren’s • Muscle fatigue/strain due to poor technique/ posture • Carpal tunnel/cubital tunnel syndrome • Emotional/psychological issues manifested as somatic symptoms • Focal dystonia
Only 20-25 per cent of these problems require surgery, with the remainder requiring supervised hand therapy, splintage and ultrasound, rest and appropriate analgesia (regional and systemic).
It is more common on the ‘ulnar’ side of the hand and wrist and specifically the thumb intrinsic. Treatment consists of sedatives, relaxants and specialist neuro-muscular rehabilitation.
Specific instruments and their demands The violinist holds the bow in the right hand in a variety of different positions, commonly using the thumb and middle finger. The violinist’s left hand holds strings in flexion whilst the chin, shoulder rest and cervical spine help in stability.
Surgical principles Placement of the incisions is considered after evaluation of the interface between the hand, fingers and the instrument. The general techniques of posttrauma reconstruction apply, including meticulous/ microscopic surgical technique and restoration of structures with precision and fine balance. Fractures need early, sophisticated methods of fixation in order to allow early mobilisation and minimise swelling and stiffness.
The piano requires both thumbs in the fully flexed and rotated position, with the thumb lying across the palm in arpeggio. This is virtually the only activity where such extreme positioning of the thumb is essential. When playing the guitar, the fingers of the left hand are, at times, fully flexed in the playing position. The finger movements from string to string demand only slight additional adjustment by flexion or extension of the isolated distal joint. This requires very fine isolated flexion movements of the distal joint, with the fingers held in the fully flexed position In woodwinds/brass, the hand plays a secondary role in note-playing but is still important in maintaining stability and opening/closing holes, keys and valves. Focal dystonia This is a gradually progressive, painless disorder affecting the motor control of specific muscle groups due principally to overplay and fatigue, though it can be triggered by pain or trauma. Clinical signs may be limited apart from involuntary, compensatory movements and stress/anxiety with psychological overlay. It is prevalent in professional, male musicians, especially guitarists and violinists, with an average age of onset ranging from 32 to 38 years.
A thorough understanding of the ‘position of function’ is essential in rebalancing procedures. Reconstructive procedures for painful thumb base arthritis in pianists require careful restoration of joint mobility/stability with bespoke arthroplasty techniques. Recovery It is preferential to return as soon as possible to playing, in order to restore and maintain co-ordination and musculo-skeletal fitness. If, on clinical grounds, return to playing is delayed, then ‘air-playing’ followed by a graduated program of increasing playing with a trained hand therapist is essential. However, a premature return to full performance and repertoire can compromise recovery, encourage poor playing patterns and lead to secondary musculoskeletal problems. Therefore, a decision is often made on a case by case basis. To find out more information about Mr Raj Ragoowansi, please visit www.practicemattersmag. co.uk/website/contributors.php
SPORTS PERFORMANCE PROGRAMME
Strive for excellence The Wellington Hospital Sports Performance Programme is a bespoke screening and exercise prescription service providing positive changes to either lifestyle or athletic performance. Respiratory Physiologist Mr Damian Muncaster explains this unique service
Over the past five years, the boom in endurance sports participation has been extraordinary. The London triathlon has seen a 300 per cent increase in competitors, with over 11,000 people taking part last summer. This number is set to rise following the London Olympics and the success of British sportsmen and women, increasing the profile of sport even further.
If your patients are about to embark on a fitness programme for the first time, or are athletes looking to improve performance, The Wellington Hospital has launched a Sports Performance Programme that will be of immense benefit. The service provides assessments of strength and conditioning, cardio-respiratory function, motion analysis, general health and nutritional status. These scientifically underpinned measurements will then allow our Sports Doctors to provide a bespoke exercise prescription, tailored to individual patient goals. The service has brought together experts from each discipline to the hospital’s world-class facilities, to provide a seamless, one-stop shop for our patients.
The London triathlon has seen a 300 per cent increase in competitors Enquiry Helpline: 020
This Sports Performance Programme is a bespoke service and, though athletes make up a large proportion of our participants, it can be tailored to any sport at any level of exercise. We have classified the service into 3 main areas that fall neatly under the acronym SIR:
Safety Our extensive initial health screening, which includes cardio-respiratory diagnostics such as ECG, Lung Function and VO2max testing via gas analysis, will ensure that patients are healthy enough to meet training goals.
Improvement Using our scientific measurements we are able to produce training programmes to improve times, increase strength and develop endurance. We can track improvements in VO2max, AT and other physiological parameters that contribute to improved performance.
A large proportion of people who undergo a training regime often end up with injuries that are entirely preventable. These injuries often occur in people who have had previous sporting injuries, are embarking on exercise for the first time, or pushing themselves to a level or performance that they have never before achieved. The screening service aims to identify the athletes’ weaknesses, whether that be a joint restriction, a muscle imbalance or gait discrepancies, and then address them. This will ensure a high level of robustness and minimise the likelihood of injury. This Sports Performance Programme is a bespoke service and, though athletes make up a large proportion of our participants, it can be tailored to any sport at any level of exercise. We will be able to find a programme that ‘Suits you, SIR’.
The service has brought together experts from each discipline to the hospital’s world-class facilities You can get more information about the Sports Performance Programme by visiting www.thewellingtonhospital.com
SPORTS PERFORMANCE PROGRAMME
Case Study 1 – Mr X Mr X is a 42 year old fund manager in the City who was referred for an opinion regarding his knee. He had been an active rugby player until he ruptured his cruciate ligament back in the 1990s, and had since led a very sedentary lifestyle. An orthopaedic assessment and investigations determined that he was going to need surgery for his knee, but needed to improve his physical fitness before this. He was very overweight, suffered from hypertension and sleep apnoea, and was feeling nervous at the prospect of needing to get fit before the surgery. His main concern was that it might be ‘too risky’ for him to exercise. As a result, a full screening assessment was given, enabling him to understand exactly how his
cardiovascular and respiratory systems responded to exercise. This in turn, reassured him that it was healthy for him to feel exertion.
The service provides assessments of strength and conditioning, cardio-respiratory function, motion analysis, general health and nutritional status
Case Study 2 – Miss X A female runner in her 20s, who played football and netball, decided to take on the challenge of running the London Marathon. She was new to running, but went about training in what she thought was a sensible and structured progression, gradually increasing her mileage week by week.
any muscle imbalances or joint restrictions, Miss X could have carried out remedial strengthening and rebalancing work in the build up to the Marathon. These factors, combined with sports podiatry and a personally tailored training plan, would have enabled our runner to get to the start line in great shape and to pass the finish line in a good time.
Two weeks prior to the Marathon, she presented with excruciating ankle pain, which kept her awake at night. Convinced that it was just a soft tissue problem, she tried to keep going but the pain continued. A stress fracture in her calcaneum (heel bone) was diagnosed, and the patient had to endure six weeks of crutches and a boot, creating difficulties with work, business travel and family life. A screening assessment would have been able to identify key biomechanical and training faults which could have been picked up and corrected well in advance of the race, avoiding any fractures or damage. Armed with the knowledge of her gait,
The perineum and the psyche
Women aged over 30 and giving birth for the first time, are at greater risk of vaginal prolapse
Sexual dysfunction in women with urogenital prolapse The actual presence of an obstructive bulge in the vagina or a sense of vaginal laxity may lead to sexual dysfunction, particularly in more severe degrees of prolapse. Common sexual dysfunctions include: • Urogenital atrophy (lack of oestrogen) • Obstruction caused by physical presence of the prolapse • Lack of physical sexual response, leading to discomfort/pain, often aggravated by lack of lubrication and genital swelling
Consultant Gynaecologist Mr Nicholas Morris discusses the common problem of prolapse in postnatal women and the treatments available Traumatic vaginal birth can lead to damage to the fascial and the ligamentous supports of the pelvic organs, weakening the perineal body and potentially triggering the development of vaginal prolapse. Such trauma can have a major impact on a woman’s quality of life, including the sexual relationship with her partner. There is a direct relationship between the first vaginal delivery childbirth and obstetric trauma. Subsequent vaginal deliveries, as well as the loss of oestrogen at the time of menopause, will reduce collagen bulk and result in worsening vaginal prolapse. Women aged over 30, giving birth for the first time, are at greater risk of vaginal prolapse. Further risk groups include women who are hyper mobile, smokers, overweight or obese and diabetics. There are also genetic risk factors with vaginal prolapse that are more prevalent in women from South Asia. Clitoris
Sphincter ani externus
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The fundamental changes in vaginal function result in the development of perineal weakness, rectocele and cystocele development. This can result in urinary or faecal incontinence and loss of the frictional sensation during sexual intercourse.
• A short or narrow vagina or a tense, contracted pelvic floor • A decreased vaginal length, width or reduced elasticity caused by prolapsed vaginal tissue, scarring from previous surgery or a mesh insertion, can cause dyspareunia.
Psychological symptoms that can develop from urogenital prolapse • Lack of libido • Negative thoughts associated with sex
What can a GP do?
General practitioners play a vital role, particularly at the time of postnatal visits. By making a full clinical evaluation of any pelvic floor damage, referring presenting patients to a perineal clinic and asking them about any postnatal sexual difficulties, these measures will help reduce subsequent morbidity.
• Fear of incontinence
Simple steps, such as assessing stool consistency using the Bristol chart, encouraging a high fibre diet and a daily two litre water intake, may make a difference in reducing symptoms and avoiding worsening pelvic floor disease.
Sexual dysfunction In a study from St Georges, 85 per cent of postnatal mothers experienced sexual problems at three months, dropping to 64 per cent at six months. However, the striking finding in this study is that only 15 per cent of mothers had discussed this with a health care professional. In women with pelvic organ prolapse [POP], the posterior compartment is affected in nearly 75 per cent. Patients with rectocele may present with an asymptomatic bulge or may have significant complaints ranging from “bulge” symptoms to defaecatory and sexual dysfunction. Some women also complain of the need to interdigitate during defecation. They often feel open and exposed and report air trapping during sex, resulting in psychological problems in relationships and sexual performance.
Medical treatment Depending on the severity of the case, certain women can benefit from a variety of medical options that can help with the symptoms of prolapse. These patients will gain from a multidisciplinary team approach, with dietary, physiotherapy and psychological support, prior to and post surgery.
Surgical treatments In regards to surgical treatment options, gynaecologists and many colorectal surgeons prefer the transvaginal approach (posterior colporrhaphy). Other options to consider include a transanal and perineal approach, with vaginal mesh not used in any primary procedure. Posterior colporrhaphy is commonly performed in conjunction with a perineoplasty to address a relaxed perineum and widened genital hiatus. This involves refashioning and placating the levator ani after mobilization of the rectum. This will improve defecation, and reduce the cavernous diameters of the vagina. Although surgery is effective, patients need to be aware of the risk of recurrence and vaginal scar-induced dyspareunia. To find out more information about Mr Nicholas H Morris, please visit www.practicemattersmag. co.uk/website/contributors.php
Total knee replacement in 2013 Consultant Orthopaedic Surgeon Mr Martin Logan discusses advances in total knee replacement and how this has made patient-specific surgery better than ever Custom implants and instrumentation
Many orthopaedic implant companies have developed the technology to allow patient-specific instrument guides and implants to be constructed utilising preoperative CT or MRI data. These technologies are the fourth generation of computer-assisted surgery.
In regards to best type, knee surgeons sit in two camps: the posterior stabilised (cruciate sacrificing) vs. the cruciate retaining philosophies. Both have produced broadly similar long-term outcomes but neither system has attempted a more authentic replication of normal knee motion. MRI-based knee kinematic studies have shown the medial side of the knee is more like a ball-in-socket joint, whereas the lateral side is far more mobile, allowing so-called ‘rollback’ of the femur and the tibia in flexion.
The images and the surgeon’s preferences are sent to the orthopaedic engineers, from which a pre-operative plan is constructed and agreed. Once the plan is agreed, the instruments and implants are built and delivered to the hospital in sterile packages, prior to the surgery date.
Figure 1: Custom matched guides inserted on the femur and tibia to allow accurate resections of the diseased bone.
In an attempt to replicate this movement more faithfully, there has been a move to design so-called medial pivot knee replacement systems. Patient satisfaction would appear to be higher from the medial pivot design, although the longevity of the implants does not appear to be any different. At present, most of the joint registries around the world that have long-term data are showing that, at 15 years, 95 per cent of implants are still working normally.
This technology has the advantage of reducing surgical instrumentation and therefore cutting potential for contamination. Patient-specific guides allow for less invasive surgery as the femoral and tibial intramedullary canals are not opened. Theoretically, this should lessen surgical time as many of the steps performed are done pre-operatively. Any form of custom fit technology only provides a measured resection of bone. The surgeon’s ability to adequately equal the flexion and extension gaps, with ligament tension balancing, remains the ‘art’ of the surgery.
Figure 3: Microscopic images of trabecular bone and the similarity of porous metal
New uncemented implants Cementing the total knee replacement components remains the gold standard in terms of implant survival. When a knee replacement fails due to aseptic loosening, it is usually due to the tibial component. In an attempt to improve the bond between the implant and the bone, new porous metal technology has been developed. This porous metal layer (see Figures 2 and 3) is on the lower surface of the tibial implant where it interfaces with the proximal tibial bone (see Figure 1), allowing biological fixation (growth between the two). This porous metal technology has also been developed with great success for total hip replacement systems. A biological fixation should, in theory, be better than a cement fixation. The femoral component rarely becomes loose in non-infected cases and cementation remains the best option. A cementless design requires good bone stock and better surgical alignment to prevent excessive point loading.
Blood loss and total knee replacement Some studies have shown transfusion rates of over 40 per cent after uncomplicated total knee replacement. With all the risks and potential complications of blood transfusion, this level of transfusion is unacceptable. In order to minimise blood loss, we now routinely use intravenous tranexamic acid prior to release of tourniquet, reducing blood loss by up to 50 per cent and decreasing the risk of DVT. In the last 4 years, I have not been required to transfuse any joint replacement (primary or revision) and tranexamic has revolutionised this facet of knee surgery practice. Mr. Martin Logan consults at the Platinum Medical Centre of the Wellington Hospital on Mondays and Fridays. www.harleystreetkneeclinic.co.uk
Figure 2: Total knee replacement tibial tray undersurface showing porous metal (Biofoam®)
To find out more information about Mr Martin Logan, please visit www.practicemattersmag. co.uk/website/contributors.php
GP NEWS Round-up In the busy world of General Practice, we look at trending stories and interesting updates from the primary care sector
Government funding for online access GP practices across the country can apply for financial assistance from the new £240 million government fund dedicated to improved online access to services. The funding will allow patients to book online appointments, request repeat prescriptions and even access their GP records. The move comes as part of the movement to achieve a ‘paperless NHS’ by 2018, proposed by Health Secretary, Jeremy Hunt and the Department of Health. By moving processes online, patient notes will be readily available for clinicians, bringing an end to unnecessary diagnostic tests and prescribing the wrong medication. The 24 hour access service will also assist overnight A&E admission processes. However, not everybody believes that the ‘easy access’ service is the right way forward in streamlining GP practice inner workings. The Royal College of General Practitioners (RCGP) has highlighted in their report ‘Patient Online: The Road Map’ concerns with potential information governance risks and increased workloads for practice staff working on patient history information. The RCGP recommend that online access to patient records should be ‘prospective’, thus allowing only core medical information from ‘a date that the practice sets’. They have suggested that patients with complex diseases be allowed more in-depth access, though only on a ‘case-by-case’ basis. The GPC have backed concerns, calling for the online patient record scheme to be held until the issues of increased workload and data security have been properly addressed. You can read the ‘Patient Online: The Road Map’ by visiting www.rcgp.org.uk
First round of patient-led inspections put hospitals in their PLACE Following our story in the last issue of Practice Matters announcing the new CQC patient inspection approach, gov.uk has released the first round of results. The PLACE (Patient-Led Assessments of the Care Environment) team, comprising of around 5000 patients, have carried out more than 4,600 ward inspections since April, last year. There has already been a strong indication of changes being implemented by inspected hospitals, enforcing the CQC push for change. Targeted areas include services for the elderly and improvements to food, hygiene and dignity at all sites across the country. Some checked hospitals have improved signage around facilities to make it easier for patients to locate rooms and wards, and added extra seating for elderly and patients who struggle to walk long distances.
Comment and Debate How will the online GP services affect your local practice? Is full access to patient records a good idea, or does the risk of information security and increased workload make the ‘paperless’ move more of an inconvenience?
WHAT DO YOU THINK?
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Of the 1,300 sites checked so far, more than 200 have been from the independent sector, as part of the review of services ‘through the patient’s eyes’. Each inspected hospital will receive a rating on a range of areas that is later published online. The facilities are then given the opportunity to communicate any changes that will be implemented, as a result of these public scores. To read more on the first PLACE assessment programme, please visit www.hscic.gov.uk/PLACE
We are expanding: The Wellington Diagnostic and Outpatients Centre Centre Manager Ursula Stiemert discusses the recent changes in available services and clinic hours at The Wellington Diagnostic and Outpatient Centre (WDOC)
We are now open on Sundays
Breast Care Service at WDOC
As many healthcare professionals are aware (and as was highlighted in the GP Patient Survey 2012-2013), we work in a ‘weekday – nine to five’ society that requires maximum flexibility when it comes to healthcare. We are always listening to our patients and, in response to their call for extended surgery and healthcare facility hours, the WDOC is currently offering Sunday outpatient clinics to our patients from the North West London area and beyond.
The WDOC sits at the heart of the community; a local outreach facility providing the best Wellington healthcare services on offer to our neighbours in North London and beyond. We offer a relaxed yet professional service, developed through detailed community consultation, offering outstanding medical resources and fast access to consultants and specialist medical teams.
A private GP service is available, covering all forms of family medicine, thus ensuring that we are available to see all members of the family, even outside school, work and surgery hours. Here at the WDOC, patients have fast access to specialist healthcare, renowned consultants and state-of-the-art diagnostic facilities. Our Sunday service will include 24 and 48 hour ECG/BP monitoring, urinalysis, ECGs, taking bloods and changing dressings. The Sunday clinics currently supported by specialist consultants are ENT, rheumatology, gastro-enterology and orthopaedics. At present the WDOC will be open every Sunday from 0900-1300, with the exception of Bank Holiday weekends.
The centre runs in conjunction with the Breast Care Unit based at The Wellington Hospital, South Building, which provides a further breast screening service. Our mammography machine uses advanced technology, giving clear, high quality digital images, quickly and accurately. The state of the art digital scanner will ensure that patients are screened with minimal radiation and a quick one-stop service is guaranteed. Our team of breast surgeons, radiologists, clinical and medical oncologists, plastic surgeons, pathologists, mammographers and specialist nurses are available to provide patients with advice on health matters. If necessary, we can refer patients immediately to our specialist consultants managing breast care. Our WDOC screening service is available by appointment on Mondays from 0900-1230 and Wednesdays from 1300-1700. For more information on our Breast Care Unit and the services available, please visit www.wellingtonbreastcareunit.co.uk
If you would like to refer a patient for one of our services, please call the hospital’s Enquiry Helpline on 020 7483 5148, or visit www.wellingtondiagnosticscentre.com
The Wellington Hospital is constantly striving for excellence through advances in technology and new opportunities, in order to provide the very best standard healthcare in Londonâ€™s biggest private healthcare facility. This issue we discuss our first surgical successes using the pioneering O-arm, and our recent partnership with the new Jewish Centre, JW3
THE WELLINGTON HOSPITAL PARTNERS WITH JW3 The new Jewish Centre based on Finchley Road opened its doors at the end of September. JW3 houses a number of facilities, including a 270-seat auditorium, dance studios and classrooms. As part of our partnership, The Wellington Hospital will be housing a number of consulting rooms within the facility and inviting patients to visit our consultants and GPs. If your patient is not already seeing one of our consultants, they may need a GP referral prior to the initial consultation. These facilities are an excellent way to improve accessibility for all visitors to the centre, whilst providing the same level of first-class care patients receive at our hospitals. As an environment that encompasses culture, the arts and other areas, it presents a unique platform for our medical services. We will soon be offering the same fast-access service by way of private appointment through our enquiry helpline desk. Further details on the availability of consultations will be announced shortly on The Wellington Hospital website.
ADVANCES IN SPINAL SURGERY WITH THE O-ARM The Wellington Hospital has begun using the Medtronic O-arm, following the arrival of this revolutionary surgical tool earlier this year. It was first implemented in a patient case by Consultant Neurosurgeon, Mr Neil Dorward, who used the O-arm to perform a posterior spinal fusion at the beginning of September. The machine is a pioneering surgical imaging system, which can be used in complex cases of spinal surgery and trauma orthopaedic care. Treatment using the O-arm is painless and non-invasive, offering real-time 3D images, 2D multi plane and fluoroscopic (video x-ray) imaging of the patientâ€™s anatomy. The advanced system not only cuts surgery times and improves patient outcome results, but further increases the number of complex and specialised procedures on offer at The Wellington Hospital.
NEW CONSULTANTS Breast
Mr Robert Price, Kings College Hospital Mr Peng Tan, Whittington Hospital
Dr Kalpesh Besherdas, Chase Farm Hospital
Mr Stephen Brennan, Croydon University Hospital Mr Lee Dvorkin, North Middlesex Hospital
Mr Oliver Chappatte, Tunbridge Wells Hospital Ms Christina Fotopoulou, Imperial College Healthcare Trust Mr Clive Spence-Jones, Whittington Hospital
Dr Mark Mason, Harefield Hospital
General & Colorectal Surgery
Neurosurgery Mr Jonathan Bull, Barts and The London NHS Trust
Enquiry Helpline: 020
Q &A Vadney Fontaine-Waldron is the Enquiry Helpline Supervisor at The Wellington Hospital where she supports her team in providing excellent customer service. Here she discusses how she moved from training to be a nurse to her current role, and developing the services the Enquiry Helpline offers to GPs, consultants, patients and internal staff members PM: Can you tell me a bit about your professional background? VFW: I started my career in finance and customer service before deciding that I wanted to work helping people and began my nurse training. I liked the environment of the medical centre and chose to move from nursing to a secretarial role. I held this position for 10 years in Outpatients at the NHS Central Middlesex Hospital. I spent five years in gynaecology and five years in STDs. My working day involved one to one contact with patients, booking their appointments and following through with the tests; it was hands on and really enjoyable. After some time working as a pharmacy technician, I was offered a position on the orthopaedic ward at The Wellington Hospital, where I stayed for seven years. I did all the bookings at the desk, organising ECGs and X-rays. It was a very busy ward back then, dealing with 44 inpatients and 25 day cases a day. I then moved to the role of theatre secretary for plastics and ophthalmology and, after four years, to Endoscopy. During my time there, I saw an advert for the Enquiry Helpline (EHL) and I thought it might be time to settle down, so I applied and got the position. PM: Can you tell us a bit about the enquiry helpline? VFW: We provide a very good level of service to everyone who contacts the EHL. We make appointments for consultants and GPs wishing to refer patients to any of our facilities. We also handle admissions, finding a consultant to match the specialty, securing an appointment and ensuring there is an available bed for the patient. We deal with a lot of general enquiries, including patient parking or directions to any of our facilities. We can take up to 7000 calls a month and we can make in excess of 1500 appointments for consultations, radiology and admissions. We started making radiology appointments approximately three years ago and they currently account for around a third of our total appointments.
PM: How about your role specifically, what would a typical day involve? VFW: I remind my team on a daily basis that we need to deliver a service of excellence to all customers and I ensure all calls are dealt with in a professional manner. We also receive around 30 email enquiries a day in the form of radiology request forms and questions relating to patient appointments. I make courtesy calls to secretaries and others in the interests of building up good relations. I am proud of the work we do and my team do an excellent job. PM: Are there any new or exciting developments going on in EHL? VFW: I have experienced many changes since I began my role. We recently moved switchboard into EHL, so that we can offer our customers a more streamlined approach. We are upgrading elements of our telephony system and will be installing new telephones. The EHL started off with four members and now we are up to seven, so we are growing all the time. This is part of our constant effort to provide an improved service to all our GPs, consultants and patients. PM: What do you feel are the key qualities needed to work in EHL? VFW: As patients are often anxious, you need somebody who is going to take their call in a calm, professional manner and know how and when to empathise. The role suits someone who thrives on interacting with others and who is willing to learn. Although you donâ€™t need to be clinically trained, there is a lot to learn about, including all the different procedures offered by the hospital. PM: What do you like about your role? VFW: I like the team; they do a really good job. They are very supportive of me and they are extremely good with the patients. I love working for HCA as a whole and thatâ€™s why I am still here after 21 years. It is a caring environment and HCA care about their staff. PM: What do you like doing when you are not at work? VFW: Shopping. Handbags and shoes. I also write poetry. I actually won a poetry competition here at The Wellington. When I retire I want to spend my days in Barbados painting. I love to draw butterflies and could do so all day, but I have no talent for drawing, so I would love to learn more.
Dr Alison Jones, Royal Free Hospital
Mr Imad Sedki, RNOH Mr Raghubir Kankate, Wycombe General Hospital Mr Rajeev Sharma, Queen Elizabeth II Hospital Mr Rohit Shetty, Whittington Hospital
Dr Triet Hoang, Barnet & Chase Farm Hospital Dr Sashin Kaneria, North Middlesex Hospital Dr Sameer Khan, Imperial College Healthcare Trust Dr Maria Klusmann, UCLH Dr Hala Sbano, UCLH Dr Levansri Makalanda, Royal London Hospital
Mr Jonathan Simmons, Imperial College Healthcare Trust
Ophthalmology Professor Paul Foster, Moorfields Hospital Miss Rebecca Leitch, Epsom & Helier University Hospital
Mr Hamish Hamilton, Royal Free Hospital
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
Published on Dec 13, 2013