Summer 2014 â€˘ Issue 17
A lump in the breast Is this cancer?
Womenâ€™s health Common conditions in the over 50s Epithelial ovarian Cancer Advanced treatment options
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
Welcome 2014 has been a year of big changes and developments here at The Wellington Hospital; a trend that is set to continue. In my first few months as CEO here at The Wellington Hospital, after moving from the same position at the Harley Street Clinic, I have seen the launch of new units and services , and have met many members of staff. This edition of Practice Matters highlights just some of the developments that have taken place, ensuring that The Wellington remains at the forefront of private healthcare in the UK. In this summer issue, The Acute Neurological Rehabilitation Unit announce their recent CARF re-accreditation which highlights the hard work of this invaluable service and is evident in the feedback on various areas of service in the CARF report (page 9). With cardiology being a hot topic in the media, we have been promoting our well-established and comprehensive cardiac services and information online and in the cardiac packs circulated by our GP Liaison Team. In conjunction with this, on pages 4-5, Consultant Cardiologists, Dr Fakhar Khan and Dr Syed Ahsan discuss SVT, explaining the symptoms and pioneering treatments available to our patients. With breast awareness month fast approaching, this issue also includes an in-depth analysis of breast cancer, providing further information on the diagnostic and treatment options. You can also find out more about our Breast Care Unit which recently moved to our Platinum Medical Centre building, enabling our patients to receive all their diagnostic care in one facility. With many more projects planned for the remainder of this year and into 2015, we look forward to the implementation of these upgrades to The Wellington Hospital. Best wishes,
Neil Buckley CEO
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Editor: Hannah Rogers Production & Distribution: Runwild Media Group
Contents 04 | Supraventricular tachycardia: modern diagnosis and management Dr Fakhar Khan and Dr Syed Ahsan
06 | Advances in the treatment of epithelial ovarian cancer
Ms Christina Fotopoulou
07 | Common conditions in the older female population Mrs Sarah Hussain
08 | The non-surgical management of obesity Dr Ray Shidrawi
09 | CARF re-accreditation awarded to our Acute Neurological Rehabilitation Unit 10 | The current state of hip replacement Mr Giles Stafford
11 | Introducing a new nonsurgical treatment for Dupuytren’s contracture Mr Rupert Eckersley
12 | A lump in the breast- Is this cancer? Miss Joanna Franks and Ms Jennifer Gattuso
14 | Advanced audiology services in North London 15 | Lipiflow – a new treatment for blepharitis Mr Simon Levy
16 | GP news 18 | Latest news and new consultants
www.practicemattersmag.co.uk PRACTICE MATTERs Summer 2014 • 3
Supraventricular tachycardia: modern diagnosis and management By Dr Syed Ahsan and Dr Fakhar Khan
What is a Supraventricular tachycardia?
What are the symptoms of SVT?
A supraventricular tachycardia (SVT) is an abnormally fast heartbeat that originates from the atria, but unlike atrial fibrillation, the heart rate is normally steady and regular. There are a number of different types of SVT, due to an abnormal electrical connection in the heart which can ‘short circuit’, triggering symptoms, or can be caused by an abnormal electrical focus within the atria (Fig 1).
The most common symptom of an SVT is palpitations, described as a rapid heartbeat and often characterised by abrupt onset and termination. In some patients, these palpitations may be associated with dizziness, breathlessness and chest tightness. Even though the heart can beat at very fast rates, SVTs are usually benign in the absence of structural heart disease. However, certain SVTs, caused by an accessory pathway allowing rapid electrical conduction between the atria and ventricles, carry a small risk of sudden death from potentially fatal ventricular arrhythmias.
There are three main types of SVT: 1) Atrio-ventricular nodal re-entrant tachycardia (AVNRT) 2) Atrio-ventricular re-entrant tachycardia (AVRT) 3) Atrial tachycardia SVTs can present in childhood and adolescence but certain types, such as AVNRT, are more commonly seen in adults. Extensive research and improved understanding of the basic mechanisms of these conditions has led to improvements in diagnosis and management.
How are SVTs diagnosed? The unpredictable nature of SVTs often presents a diagnostic challenge. It is difficult to establish when an episode will occur, how long it will last and when it will terminate. These problems can lead to some arrhythmias going undiagnosed, particularly if symptoms have abated before an ECG can be recorded. The diagnosis of these arrhythmias is made through a review of 12 lead ECG and ambulatory recordings. It often takes several episodes before the arrhythmia can be documented and, rarely, the arrhythmia may be elusive enough to escape recording. Continuous ECG recordings can also be obtained via small monitoring devices known
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as implantable cardiac or loop recorders. Newer implantable monitors are a third of the size of an AAA battery and can be easily implanted under local anaesthetic. This is done in the outpatient setting, via a skin incision of less than 1cm. The device can remain in place for up to three years and is particularly useful in patients experiencing infrequent episodes. Wireless technology allows for quick notifications of cardiac activity to physicians without the patient having to visit the hospital.
The diagnosis of these arrhythmias is made through a review of 12 lead ECG and ambulatory recordings Electrophysiology study An Electrophysiology study (EPS) is a minimally invasive procedure to investigate the electrical conduction system of the heart in which fine wires known as catheters are passed to the heart from the femoral veins. There are electrodes at the tip of the wires which detect electrical signals from different parts of the heart. An EPS is performed by a Heart Rhythm Specialist (Electrophysiologist) to assess the electrical activity
and conduction pathways within the heart. ItFig can 1 be performed if patients have recurrent symptoms but ECG recordings have failed to document the arrhythmia. It also helps identify the nature of the SVT and its exact anatomical location to determine the best method of treatment (Fig 2). Fig 2
SVTs can present in childhood and adolescence but certain types, such as AVNRT, are more commonly seen in adults.
Dr Syed Ahsan
What are the treatments for SVT? Essentially, there are three types of treatment: Conservative measures: Initial management of an acute episode includes vagal manoeuvre. If these are unsuccessful, drugs such as adenosine or verapamil, or electrical cardioversion can be used in the emergency department.
to the heart via the femoral veins with radio waves used to create heat, destroying (ablating) the electrical signals that are responsible for triggering the SVT. The procedure can be performed as a day case in the cardiac catheter laboratory under sedation and local anaesthetic. It is usually a short and safe procedure. There are rare risks including the need for a pacemaker in less than 1 per cent of cases (fig 3).
Anti-arrhythmic medications: Medications can be taken to try to prevent episodes of SVT, although they are used infrequently for AVNRT and AVRT where ablation is now the first line treatment. Commonly used drugs include Beta-blockers, Verapamil, Flecainide and Sotalol. However these drugs have different side-effect profiles and may not be tolerated. If episodes are infrequent, a ‘pill-in-the-pocket’ approach can be adopted where the drug is taken after an episode has started, to try and limit the duration. Catheter ablation: Radiofrequency catheter ablation is a curative procedure for SVT and carries a >95 per cent chance of a permanent cure, after one procedure. Catheters are passed
BSc MD MRCP
Consultant Cardiologist and Heart Rhythm Specialist Dr Syed Ahsan is a Consultant Cardiologist and Heart Rhythm Specialist at the Heart Hospital, University College London, and North Middlesex University Hospital. He implants cardiac pacing and defibrillator devices and performs ablations for arrhythmias. He also manages patients with hypertension, blackouts, chest pains and heart failure.
Dr Fakhar Khan MRCP, MA, MD, CCDS, CEPS
Consultant Cardiologist and Electrophysiologist
To find out more information about our cardiac services, please visit: www.thewellingtoncardiacservices.com
Fakhar Khan is a Consultant Cardiologist and Electrophysiologist (heart rhythm specialist) based at The Heart (UCLH) and Royal Free Hospital. He trained in Cambridge, Oxford, London and Toronto in Canada.
www.practicemattersmag.co.uk PRACTICE MATTERs Summer 2014 • 5
Advances in the treatment of epithelial ovarian cancer By Ms Christina Fotopoulou After uterine cancer in the female population, epithelial ovarian cancer (EOC) is the second most common genital malignancy EOC accounts for the majority of deaths from gynaecologic malignancies in the western countries. The latest data shows that one in 43 women will develop EOC during their lifetime, with a risk rate of around 1.6 per cent. Women with a mutated BRCA1 or BRCA2 gene are at increased risk ranging between 25 and 60 per cent, depending on the specific mutation. Despite the continuous advances in diagnostics and imaging, more than 70 per cent of patients with newly diagnosed EOC will present with an advanced stage FIGO III or IV. This is mainly attributed to the unusual tumour biology and clinical behavior of the disease, which is typically associated with locoregional dissemination throughout the peritoneal cavity. Symptoms are often apparent at a later stage in an unspecific pattern of symptoms, including abdominal bloating and distention with pain, urinary frequency, loss of appetite and occasional rectal bleeding. This unusual natural history has generated unique therapeutic strategies that clarify the important contribution of locoregional control to optimise survival.
Treatment The last decades have brought a significant advance in the treatment of EOC, both in
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surgical and systemic aspects. These include the development of extensive cytoreductive techniques, refinement of surgical skills in the upper abdomen, dose dense cytotoxic regimes and novel targeted therapies. In recent years, targeted therapies based mainly on the principle of anti-angiogenesis, tyrosine kinase inhibition and homologous recombination repair have brought a significant efficacy in the fight against EOC. Various randomised trials have shown that maintenance strategy, during and/ or after successful cytotoxic chemotherapy, has a significant impact on survival. Despite all the advances brought by novel targeted agents, one of the strongest predictors of survival is still debulking surgery; even in advanced stages. Therefore, surgery aimed at maximal tumour reduction, ideally without any macroscopic tumour residual disease, combined with platinumbased adjuvant systemic chemotherapy, is currently the established gold-standard in the primary management of the disease; even at a peritoneally disseminated stage. The hypothesis underlying the value of surgery is mainly based on the removal of ‘bulks’ of tumour,
making the EOC more responsive to systemic chemotherapy. This enhancement of response to cytotoxic treatment may theoretically be achieved through the reduction of tumour masses critical for development of second resistance. This is done by minimising tumour areas with poor perfusion and the potential resecting of primary resistant tumour clones. Validated data shows that in the primary presentation of the disease, for each 10 per cent increase in cytoreduction, there is a direct correlation to a 5.5 per cent increase in median survival in a patient’s cohort. Increasing surgical effort and continuous education, along with practice and growing expertise, appear to be associated with improved rates of cytoreduction with no significant associate increase in overall morbidity. Nevertheless, in all aspects of care (both surgical and systemic) patient preferences, profile and, most importantly, quality of life should be the driver of every therapeutic decision. As a result of these decisions, the ultimate goal will be individualised treatment strategies, tailored to every patient and her needs.
To find out more information about Ms Christina Fotopoulou, please visit www.practicemattersmag.co.uk/ contributors
Common conditions in the older female population By Mrs Sarah Hussain
For many women aged 50 and over, the risk of certain health issues, such as breast and ovarian cancer and concerns over the menopause, become more prevalent. Frequent health awareness events and stories in the media have not only increased awareness but aided in the circulation of information regarding diagnostics and treatment. Many GPs and specialists can continue this practice by making female patients in this age bracket aware of symptoms and signs, advising on frequent screening tests and also making suggestions on healthy lifestyle choices for both physical and mental wellbeing. Menopause For many women the menopause is an easily managed period of time. However, some patients have a series of symptoms that leads them to seek help and treatment including hot flushes and night sweats, mood swings, irritability, loss of concentration and osteoporosis. Each of these women who seek health advice during the menopause will present with different symptoms and concerns. Although many symptoms can be controlled through a balance of a healthy diet and exercise, other treatment options should always be discussed with the patient. The Wellington Hospital Gynaecology Unit has one of the finest multi-disciplinary teams in the UK independent sector. Central to our approach to women’s health is a breadth of specialist expertise and support services for the range of
disorders, major and minor, affecting the female reproductive system. Our consultant gynaecologists and physicians are here to advise on any aspect of women’s health from fertility issues, contraception, gynaecological problems to difficulties associated with the menopause. We have at our disposal the very latest diagnostic and imaging technology. The unit, based in the South building of the hospital, has the most modern facilities including new operating theatres, treatment suites and a dedicated ten bedroom ward.
Mrs Sarah Hussain, Consultant Gynaecologist Treatment Appropriate treatment is available for menopausal women, which can significantly improve quality of life. Most women will benefit from simple lifestyle changes such as eating a healthy, well-balanced diet and regular exercise. However, if the symptoms begin to affect day-to-day living or are particularly severe, other treatment options should be discussed, which may be better suited to the patient’s needs. Almost a decade ago, research by the Women’s Health Initiative (WHI) published a report warning of the risks of hormone replacement therapy (HRT). As a result, many women were stopped from taking HRT, thus increasing anxiety and reluctance in taking HRT since. New data is emerging suggesting that healthy women, who begin taking HRT around the time of their menopause, actually benefit from reduced morbidity and mortality rates. Patients looking to begin a course of HRT should discuss this option with their GP. Such treatment is available in a variety of forms including cream, tablets and an implant, and helps to control menopausal symptoms by replacing the oestrogen in the body. Other options available include: tibolone (similar to HRT), clonidine, vaginal lubricants and anti-depressants. For more information on gynaecological services at The Wellington Hospital, please visit www.thewellingtongynaeunit.com. You can also find out more about Mrs Sarah Hussain by visiting mygynae.co.uk
www.practicemattersmag.co.uk PRACTICE MATTERs Summer 2014 • 7
management of obesity By Dr Ray Shidrawi
With two thirds of UK adults and children either overweight or obese, we are facing major challenges in obesity. Complications of morbid obesity including cancer, diabetes, hypertension and premature osteoarthritis requiring orthopaedic surgery have never been as high. So, what are the options available for patients with morbid obesity today? Pharmacological strategies are limited and generally ineffective. Orlistat is now available over the counter but most patients discontinue its use, due to its modest effect and poorly tolerated steatorrhoea. The explosion of bariatric, coined metabolic surgery with (a) restrictive options including surgical and band gastroplasty and sleeve gastrectomy and (b) diversionary options with the laparoscopic Roux-en-Y gastric bypass, are helping the super-obese lose weight rapidly and correcting their metabolic mayhem. Complications are not uncommon and include chronic anastomotic ulceration, strictures and leaks; and occasionally death. Some patients undergo technically successful bariatric surgery, but continue to report abdominal discomfort, nausea and vomiting for years. There is also a risk of regaining the weight lost following surgery, and a smaller cohort continue to lose weight after bypass surgery, which can cause malnourishment.
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For the patient who does not fulfil criteria for bariatric surgery, or is reluctant to undergo surgery, the following options are available: Endoscopic placement of a gastric balloon Available since the late 1990s, improvement in the quality of balloon manufacture has allowed reliable implantation and removal with minimal sedation, as day-case procedures. Newer balloons are licensed to remain in situ for longer periods and are adjustable in size. For patients who eat regular meals and avoid snacking, impressive short term weight reduction is seen. Short term weight loss rates (25-35% excess weight loss) are more impressive than longterm results, due to anatomical adaptation with time and restoration of gastric volumes. Ketogenic Enteral Nutrition (KEN) is a novel technique utilising a fine bore (6Fr) naso-gastric tube for continuous ambulatory enteral feeding of a protein/electrolyte solution without added calories that results in a protein-sparing modified fast. The continuous infusion of food results in humoral mechanisms which suppress hunger and stimulate satiety, allowing patients to last 10 days without feeling hungry. An average loss of seven per cent body weight, or a 10 point drop in BMI is achieved, with a 10 day gap between KEN therapy. KEN cycles are repeated until the desired target weight is achieved.
The Aspire-Assist device is a modification of the percutaneous endoscopic gastrostomy (PEG) principle, whereby a PEG tube is used for aspiration therapy to achieve weight loss. Patients are taught to chew their food thoroughly and twenty minutes after meals attach an aspiration device to allow an estimated 30 per cent of gastric contents to be drained. A counter fitted to the aspiration device limits the number of times the Aspire-Assist device can be used, and has to be replaced by the supervising clinician at regular five-weekly outpatient appointments. Thorough chewing produces feeding behaviour modification and earlier satiety, with early clinical trials having revealed promising results. Newer techniques, such as the EndoBarrier, involve the endoscopic placement of an impermeable sleeve attached to the duodenal bulb which lasts for a year. A significant reduction in weight and insulin requirements has been reported. Complications include stent migration and duodenal perforation on removal of the embedded stent. Current trials are underway with a modified version. Endoscopic suture devices are also being tried to produce gastric restriction and early trials are under way to measure their efficacy in weight management.
To find out more information about Dr Ray Shidrawi, please visit www.practicemattersmag.co.uk/contributors
CARF re-accreditation awarded to our Acute Neurological Rehabilitation Unit The Acute Neurological Rehabilitation Unit is pleased to announce the recent CARF re-accreditation for a period of three years for its inpatient acute neurological rehabilitation programmes. What is CARF? CARF is an independent, non-profit accrediting body whose mission is to promote the quality, value, and optimal outcomes of services through a consultative accreditation process and continuous improvement services that centres on enhancing the lives of the persons served. Founded in 1966, as the Commission on Accreditation of Rehabilitation Facilities, and now known as CARF International, the accrediting body establishes consumer-focused standards to help organisations measure and improve the quality of their programmes and services. This accreditation decision represents the highest level of accreditation that can be awarded to an organisation and shows the organisation’s substantial conformance to the CARF standards. An organisation receiving a three-year accreditation has put itself through a rigorous peer review process. It has demonstrated to a team of surveyors during an on-site visit its commitment to offering programs and services that are measurable, accountable, and of the highest quality. The Rehabilitation Team l‘The organisation has a dedicated, enthusiastic group of well-qualified staff members who
have proven capable of meeting the needs of the persons served. Mutual respect for each other is very evident. The persons served benefit from the knowledge and collaboration of the interdisciplinary team and the consistency of services it provides.’ l‘The Wellington Acute Neurological Rehabilitation Unit is led by an experienced and respected team who value its employees and the persons served. The leadership staff members are enthusiastic, well qualified, and highly committed to providing optimum services, driving the upholding of quality standards.’ l‘The Wellington Hospital Acute Neurological Rehabilitation Unit provides services in a wellmaintained facility that is designed to meet the needs of the persons served. The inpatient rehabilitation programme offers spacious and well-designed rooms that promote a positive and respectful treatment environment for the persons served and their families. To further contribute to this environment, the organisation is investing in the refurbishment of its premises.’ The programme lThe organisation is commended for the recent implementation of evidence –based care paths and group sessions. Both have been positively received by stakeholders and are showing positive impact on patient outcomes.
l‘There is clear and strong evidence of cultural diversity in The Wellington Hospital Acute Neurological Rehabilitation Unit that demonstrates a high degree of distinction and singularity in relation to the persons served and staff members.’ International Relations l‘The Wellington Hospital Acute Neurological Rehabilitation Unit has developed an exemplary International Relations Department. The department is responsible for both the business office and international relations. A major focus of the department is to anticipate and respond to the needs of international stakeholders. The department is very interactive internationally, interacting with embassies and other stakeholders in assessing current and future needs. The information is used in programme development, such as the recent plan that employs therapy staff members outside of the UK to assist in the assessment of the persons served or to assist with the transition back to their home countries.’ For more information about the accreditation process, please visit the CARF website at www.carf.org.
To find out more information about The Acute Neurological Rehabilitation Unit, please visit www. thewellingtonrehabunit.com
www.practicemattersmag.co.uk PRACTICE MATTERs Summer 2014 • 9
The current state of
hip replacement surgery By Mr Giles Stafford
Consultant Orthopaedic Surgeon Mr Giles Stafford discusses the most recent options for both older and younger patients It has been passed through the generations of doctors and patients alike, that hip replacements are a treatment option reserved only for elderly people. However, it is not just the older population who suffer from hip pain and require surgical intervention. Countless unfortunate individuals are told they have to wait until they are at least 60 before they may qualify for a hip replacement; meaning years of painful symptoms. For those under the age of 60, hip resurfacing was offered, designed to be a ‘bone-conserving’ hip replacement for younger adults. Unfortunately, recent history has shown that these can cause adverse metal reactions, destroying local muscle and killing bone. Therefore, this has made the results of the ‘easy’ redo operation less secure and left patients with chronic pain and a limp. Due to the poor publicity around hip resurfacing results and the way it was introduced, there has been a huge swing to very conservative ‘tried and
The day of hip replacements only lasting 10-15 years are long gone! Enquiry Helpline: 020
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tested’ implants in the orthopaedic community. Rightly so, we now have a few femoral implants with 90 per cent, plus 20-year survivorship.
So why do we need something new? The answer to that is that the younger patient with hip arthritis has not gone away. There is still a need for a bone conserving option, as no matter what option is chosen, it is unlikely to last the 40- 50 years that it will be required. Each time a hip replacement is re-done, the surgeon tends to use a larger implant than previously. This gradual growth emphasises the importance of beginning with a smaller implant to allow for possible further surgery if ever needed. The main issue with the novel bone-conserving design is the length of time they have been available as a surgical option, meaning there is little long-term, follow-up data on their survival. With this in mind, problems following bone conserving hip replacement are unlikely as the materials used in their manufacture are well tested. With a ceramic on ceramic (CoC) bearing, there is no reason why they should not last as well as other designs. Ceramics do not produce biologically active debris, (something which all other hip bearing surfaces do) and wear extremely slowly. So, theoretically, they
should never wear out. In the older age groups, those of retirement age or higher, where bone quality may be an issue; we have implant options that may be more conventional but should last a lifetime. The days of hip replacements only lasting 10 -15 years are long gone! Implant designs are not the only things to have moved on over recent years. Improvements in anaesthetic and operative techniques mean that surgical time is usually only an hour. Blood loss is very low meaning the need for transfusion is minimal. Patients can be mobilised on the day of surgery (reducing DVT risk) and will usually be ready to go home after two to three nights.
To find out more information about Mr Giles Stafford, please visit www.practicemattersmag.co.uk/ contributors
Introducing a new non-surgical treatment for
Dupuytren’s contracture By Mr Rupert Eckersley
Dupuytren’s Contracture is a pathology of the hand which results in thickening and contracture of the palmar fascia. It typically affects the little and ring fingers restricting extension of these digits. In some cases it can affect both hands and even cause restriction in the thumb. Although the cause of Dupuytren’s is unknown, it is thought to be related to genes, as many cases run in the family.
Surgical options The traditional treatment for Dupuytren’s disease has been surgical excision of the affected fascia of the hand. Reserved for more severe cases, the two most common types of surgery are: Open fasciotomy – In this procedure, the shortened connective tissue is cut, relieving tension Fasciectomy – Surgery consists of removing the shortened connective tissue
Sometimes surgical intervention will not be successful in completely straightening the finger. In addition to this, there is also a risk of the contracture re-occurring or appearing somewhere else on the palm.
Non-surgical intervention Many cases are mild and will not need treatment, unless the symptoms are interfering with day-to-day living. There are a range of options available which can be discussed with a hand and wrist specialist.
Xiapex Non-invasive options for patients include Xiapex, the commercial name for the collagenase clostridium histolyticum enzyme, which after extensive research, has demonstrated a safe release of the cord in Dupuytren’s, without surgery. If an interest in Xiapex is shown, it is important that a referral is made to a consultant who is experienced in this treatment. The consultant will decide whether or not Xiapex would be an appropriate form of treatment to use, as it is not applicable for all presentations of Dupuytren’s. Treatment involves an injection of the enzyme into the Dupuytren’s cord to break it down. Approximately 24 hours after the initial injection,
the patient will be seen again by the consultant to extend and release the cord, if this has not occurred spontaneously. Following the release, night splinting is recommended. A hand therapist will fabricate a removable night extension splint to wear while ensuring a good range of movement of the finger is regained.
Why consider non-surgical release? As surgical options do not necessarily guarantee a full recovery and include the risk of the contracture returning, non-surgical options should always be considered first. There are a number of benefits for the patient as with surgery, no time is required for wound healing and repeated dressing change, allowing earlier return to work and normal daily activities.
Mr Rupert Eckersley consults at The London Hand and Wrist Unit at The Wellington Hospital’s Platinum Medical Centre. His colleagues also provide Xiapex as a treatment option. For further information, please contact The London Hand and Wrist Unit and arrange an appointment or see our website www.londonhandandwrist.co.uk.
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A lump in the breast
is this cancer? By Miss Joanna Franks and Ms Jennifer Gattuso
Most women who are referred to the Breast Care Unit will present with an innocent lump or benign breast changes. Around one in eight women in the UK will be diagnosed with breast cancer during their lifetime. However, our knowledge of breast cancer has changed dramatically over the last decade. We now have a variety of medical and surgical treatment options which means we can offer individualised patient care. The NHS Breast Screening Programme, high profile celebrities sharing their personal stories and breast cancer campaigns, has raised the public profile of breast cancer. We hope that this will encourage patients to seek prompt medical attention, enabling an earlier diagnosis with an even greater improvement in prognosis.
The majority of biopsies are now achieved under imaging guidance-stereo-tactic core biopsy or ultrasound
Diagnostics In our clinics, patients with new symptoms are seen in a ‘one-stop’ diagnostic clinic. A detailed history and clinical examination is undertaken with any necessary imaging offered on the same day. The current guidelines state that mammography should be carried out from the age of 40, supported by ultrasound where necessary. In the under 40s, the first line of investigation is through ultrasound. Any discrete abnormality presented will require a biopsy, which is usually performed by either a fine needle aspiration cytology or core biopsy. The majority of biopsies are now achieved under imaging guidance-stereo-tactic core biopsy or ultrasound. These stages of diagnostics form a ‘triple assessment’. If a woman is found to have a cancer it is essential to obtain as much information as possible. Many patients will require MRI scans
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and further ultrasound assessment, potentially with more biopsies, before a personalised management plan can be finalised. Factors such as tumour type and receptor status, as well as the patient’s own views, must all be considered.
Surgical options Oncoplastic surgery prioritises excellent cancer management. These techniques can enable more women to keep their breasts, achieving greater rates of breast conserving surgery. For example, a cancer in a suitably large and ptotic breast may be best tackled via a breast reduction; a therapeutic mammoplasty. This can have the advantage of allowing a wider excision whilst reducing the overall breast volume, making post-operative radiotherapy easier to plan. However, it will often require symmetrisation of the contra-lateral side, either simultaneously or as a delayed procedure. If it is not possible to approach the cancer with breast conserving surgery or if the woman prefers a mastectomy, this can be combined with a breast reconstruction. This can be achieved either at the time of the cancer surgery or at a later date. The advantage of an immediate reconstruction (from the surgical point of view) is that much more of the skin envelope can be retained, improving the aesthetics. From the patient’s perspective, they are already on
The improved prognosis for women diagnosed with breast cancer has placed a much greater emphasis on survivorship
Consultant Oncologist Consultant Surgeon
Consultant Breast Surgeon
Radiographer Consultant Histopathologist
their treatment pathway and can achieve both good cancer management and maintain their body image.
After treatment The improved prognosis for women diagnosed with breast cancer has placed a much greater emphasis on survivorship. Choosing the right management for an individual patient has never been more important. Patients live for decades with the adverse effects of both their surgery and their medical treatments, meaning a poor cosmetic outcome can be a daily reminder whilst having life-altering psychosocial effects. Patients are now also likely to require extended follow-up. This will vary according to their disease, family history and treatment choices. A womanâ€™s breast changes considerably through her stages of life. Any patient or GP concerns should always be taken seriously and expert advice should be sought.
Ms Jennifer Gattuso MA, Mphil, FRCS (Gen Surg), MD
Breast MDT Breast Clinical Nurse Specialist
The Breast Care Unit The unit has recently moved to a new location in the PMC. You can still find all our top consultant breast specialist and support staff along with our state-of-the-art radiology department in one location, meaning all our diagnostic facilities are located in one building. The Breast Care Unit offers a sophisticated multi-disciplinary approach working closely with our oncology colleagues, clinical nurse specialists and patients. Every case is discussed at the MDT and after careful consideration, in consultation with the patient, an individual personalised treatment plan is determined.
To find out more information about Miss Joanna Franks and Ms Jennifer Gatusso, please visit www.practicemattersmag.co.uk/contributors
Miss Gattuso is a Consultant Oncoplastic Breast Surgeon at the Macmillan Cancer Centre, UCLH for the NHS. Specialisms include both benign breast disease and breast cancer management, including looking after high risk family history patients. Her interests are the use of oncoplastic techniques in breast conservation, the use of neoadjuvant treatments to achieve breast conservation, symmetrisation surgery and breast reconstruction.
Miss Joanna Franks MBBS(Hons), BSc(Hons), MSc, FRCS
Consultant Breast & Oncoplastic Surgeon Miss Joanna Franks is a Consultant Breast and Oncoplastic Surgeon at UCLH. Specialisms are the assessment and management of all conditions relating to the breast, including benign and malignant breast disease. Her particular interests are the detection of early breast cancers, oncoplastic breast conservation, where mastectomy is required immediate reconstruction and symmetrisation as well as family history, risk reduction and screening.
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Ear, Nose and Throat
Advanced audiology services in north london By Mandy Lewis
The newest arrivals at The Wellington Diagnostic and Outpatients Centre (WDOC) are North London Hearing, a team of fully independent, highly trained healthcare professionals specialising in identifying, assessing and treating people with a range of audiological issues. This brand new service offers GPs and ear nose and throat (ENT) consultants a complete, on-demand audiological diagnostic and rehabilitation service. The service accepts direct GP referrals to audiology and patients are able to self-refer, according to guidelines set out by the Health and Care Professions Council (HCPC). Lead by Clinical Director, Paul Checkley, North London Hearing audiologists are trained on the complete range of digital hearing aids and hearing protection from all leading manufacturers. This ensures that every patient receives the best possible independent advice to reach their true hearing potential. A structured continuing professional
development (CPD) programme ensures that our audiologists are trained in the very latest technology, including invisible in-the-ear devices.
Lyric Centre North London Hearing are also the only authorised *Lyric Centre in North London, and were the first clinic in the UK to trial Lyric.
Fig 2 *Lyric is the world’s only revolutionary 100 per cent invisible change, no whistling and exceptional natural sound quality.
North London Hearing is part of the Harley Street Hearing group, including Musicians Hearing Service.
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Clinical Director of North London Hearing
“The team are trained in all areas of audiological rehabilitation, incorporating vestibular diagnostics & rehabilitation, hearing therapy and wax removal techniques including microsuction and irrigation” says Clinical Director, Paul Checkley. “We also work closely with orchestras and West End theatre productions to advise on hearing protection”.
hearing aid which can be worn 24/7 with no batteries to
For any audiological concerns, North London Hearing audiologists are trained to fully discuss with patients, using clear, easy-to-understand advice, the solution that is best for them. To find out more call North London Hearing on 020 8455 6361 or visit www.northlondonhearing.co.uk
Mr Paul Checkley
North London Hearing audiologists can also provide and advise on custom made ear plugs for the whole family for use with iPods and MP3 players, sleeping, swimming, shooting and for bike riders. “We understand that having any audiological symptom can be isolating and hard to accept, because of this we treat every patient with care and understanding, and pay particular attention to their individual needs”.
a new treatment for blepharitis By Simon G Levy
Blepharitis is an extremely common eye disorder in older adults causing redness, irritation, dryness and, paradoxically, also watering. Episodic flareups occur, with contact lenses and air conditioning worsen symptoms. Unsightly eyelid cysts called chalazia are common. Blepharitis is caused by malfunction of the meibomian glands of the eyelids which make lipid to lubricate the tear film. Eyelids contain 25-50 such glands whose pores open near the eyelash roots. Age-related increase in the lipid’s viscosity blocks the meibomian glands causing inflammation and secondary chronic infection. Once initiated, this process may be self-reinforcing as the damage done by blepharitis to the delicate architecture of the glands induces more inflammation and so on. Ultimately, the meibomian glands may largely disappear.
Why should an eyelid disorder cause eye symptoms? Inflammation of the eyelids spills onto the adjacent eye surface. Also, the lipid necessary for a normal tear film is stuck inside the eyelid glands - reduced lipid equates to less lubrication so the eyelids rub against the eye surface with every blink. Moreover the lipid normally reduces evaporation of the water component of the tear film so blepharitis causes secondary dry eye.
Treatment overview Blepharitis is a life-long condition that cannot be cured but symptoms can usually be suppressed to an acceptable level by effective emptying of the meibomian glands. Traditional advice to our patients has been to achieve this by daily or twice daily ‘eyelid toilet’: scrubbing the meibomian gland openings with a cotton bud soaked in baby shampoo or soda bicarbonate, a hot towel compress and then digital massage. The intention is to unblock the glands, melt the inspissated lipid and oblige the recalcitrant material to exit. Medication may be needed to settle exacerbations, including oral antibiotics, antibiotic and steroid eye drops and sometimes topical ciclosporin.
Unblocking the eyelid glands – the Lipiflow device Lipiflow is a sophisticated new device and a significant improvement in blepharitis management. An applicator warms the meibomian glands to the precise temperature (42.5°C) at which the blockage liquefies and mechanical rollers squeegee it out, unblocking the glands and allowing them to function again. It is safe, fast (treatment takes 12 minutes per eye) and painless. Symptoms often improve for 6-12 months. Lipiflow empties blocked eyelid glands much more effectively than home
methods and is more convenient – one or two outpatient’s treatments each year compared to a daily routine at home. Ophthalmologists are all too familiar with the depressing sight of eyelids in which practically all the meibomian glands have atrophied. Inevitably these patients will have troublesome symptoms. Superior eyelid gland emptying with Lipiflow may improve the long term prognosis of blepharitis by preserving functioning glands.
Consultant ophthalmologist, Simon G Levy (MD MRCP(UK) FRCS FRCOphth) provides Lipiflow therapy at the Platinum Medical Centre. His website, www.eyesite. org, has information for patients on blepharitis and its treatment.
www.practicemattersmag.co.uk PRACTICE MATTERs Summer 2014 • 15
GP news Round-up
In the busy world of General Practice, we look at trending stories and interesting updates from the primary care sector.
Out-of-hours care A recent survey by the National Audit Office (NAO) has reported that an estimated one in four people are unaware of out-of-hours GP services. In addition to this, of the 878 people who completed the survey in England, one in five were unaware of the 111 urgent phone service, launched last year. The survey was prompted by a wider review of patients using out-of-hours services, which had seen numbers drop by a third to 5.8 million, in the last six years. Although there has been a drop in the number of users of the out-ofhours service, there has also been an increase in admissions to A&E which the watchdog say may be as a result of lack of awareness or uncertainty about the value of the 111 service. The 111 service was implemented to help provide easier access to local NHS healthcare services in England for quick medical help in non-emergency cases. It also handles a number of out-of-hours calls in a bid to lift some of the stress on the A&E systems. Have you had any experience of the 111 service? Is it something you would recommend to your patients? In light of the growth in the call for better 24 hour healthcare access to services, The Wellington Hospital has now launched a 24 hour enquiry helpline service. More can be found online and in our 60 seconds with Janet Stowell interview, on page 19.
Growth of social media significantly impacts complaints A report by the General Medical Council prompted by a rise in complaints which has seen figures double over a five year period, has identified social media platforms as one of the main factors behind the surge. Patients have taken to social media, including Facebook and Twitter, to discuss treatment and also exchange information on how to complain about services. Although the majority of the 6000 annual complaints have not been GP specific but rather more about standards of care, results have shown confusion amongst patients about the right route to take to make a complaint. Service users are opting more and more for the independent GMC as opposed to the organisation responsible or CQC, suggesting a better awareness of complaints procedures is needed. Speaking on the findings, Dr Julian Archer, lead author of the report, said: ‘[The] rise in complaints against doctors are hugely complex and reflect a combination of increased public awareness, media influence, the role of social media technology and wider changes in society.’ To read more on this story, please visit http://www.telegraph. co.uk/journalists/rebecca-smith/10978904/Social-mediadriving-rise-in-complaints-to-GMC-report.htmlx
COMMENT & DEBATE How does your practice engage with patients online? Have you found that the rise in social media has been beneficial in the patient/GP relationship?
Enquiry Helpline: 020
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update... JAG Accreditation- Endoscopy Centre In May this year, the centre achieved JAG accreditation from the Joint Advisory Group on GI Endoscopy; the first private hospital in Central London to be awarded this gold standard in Endoscopy care. JAG is the Joint Advisory Group on GI Endoscopy and in order to attain accreditation, the Centre must complete the JAG pathway. The process to gaining accreditation includes completion of the GRS census, an online assessment tool that enables endoscopy units to assess how well they provide a patient centred service. The JAG Accreditation Scheme is a patient centred and workforce focused scheme based on the principle of independent assessment against recognised standards. The JAG accreditation not only represents the high standard of the service we provide for patients but also the hard work of our multi-disciplinary team. However, the hard work does not stop here. In order to maintain annual accreditation, the centre must continue to complete the GRS Census every six months and have another inspection in five yearsâ€™ time. The Endoscopy Centre is able to offer the full range of upper and lower GI endoscopic investigations and treatments, including endoscopic ultrasound, and is led by a renowned team of gastroenterologists, leading GI surgeons and respiratory physicians. As part of our promotional literature, we have created a glossy brochure and referral pathway on the recently awarded JAG accredited Endoscopy Centre here at The Wellington Hospital. If you are a GP interested in finding out more about our Endoscopy services or would like a brochure, please contact the GP Liaison Team.
The Enquiry Helpline The Enquiry Helpline officially opened in 2007, providing an easy way for GPs and patients to access our services. With originally only two members of staff, the Enquiry Helpline now boasts of a team of seven. In June 2014, the Enquiry Helpline became available 24 hours a day, 7 days a week, making services at The Wellington Hospital easier for patients to access when referred by their GPs. The Enquiry Helpline allows the patient to choose from over 400 lead consultants who are specialists in their field.
The Endoscopy Centre is able to offer the full range of upper and lower GI endoscopic investigations and treatments, including endoscopic ultrasound, and is led by a renowned team of gastroenterologists, leading GI surgeons and respiratory physicians. This new service ensures rapid access for the patient and referring GP, whilst helping to reduce waiting times and enabling a highly convenient means of communication. The Enquiry Helpline also organises radiology bookings for all Wellington Hospital sites, including The Wellington Diagnostics & Outpatients Centre in Golders Green. Should you need to refer any patients please call the Enquiry Helpline on 020 7483 5148. Alternatively, you can call your dedicated GP Liaison Officer who would be more than happy to organise any appointments. More can be found online and in our 60 seconds with Janet Stowell interview, on page 19.
www.practicemattersmag.co.uk PRACTICE MATTERs Summer 2014 â€˘ 17
News from The Wellington Hospital
wellnet unit launches This exclusive, state-of-the-art independent service is unlike anything else in the independent sector. Adhering to the ‘centre of excellence’ guidelines and linked as a partner with the Royal Free Hospital, the WellNet Unit ensures all NET patients will be offered the highest standard of care and receive optimum treatment.
What is a Neuroendocrine Tumour? Neuroendocrine tumours (NET) develop from cells able to make hormones and can be located anywhere in the body. A NET develops when the cells begin to grow abnormally, most commonly in the stomach, lungs, pancreas and intestine. A NET is a slow growing tumour (although some can grow aggressively), frequently growing without symptoms, meaning patients tend to present when the disease is quite advanced.
In 2013, The Wellington Hospital received over 100 NET cases,
prompting a growing need for a dedicated unit specialising in this area. We are now proud to introduce the WellNet Unit at The Wellington Hospital, which offers private care to patients in the UK and overseas.
Excellence in Practice A patient with a NET tumour needs highly-specialised care and treatment which requires a multidisciplinary approach. The unit, led by Professor Martyn Caplin, is linked as a partner with the ‘European Centre of Excellence’ established at the Royal Free Hospital, London (also led by Prof. Caplin – the Chairman of the European Neuroendocrine Tumour Society). Transferring the European ‘centre of excellence’ standards to the private sector, the WellNet Unit ensures patients will receive an expert service, going above and beyond with access to the very latest cuttingedge opportunities. This service is all supported by our highly-experienced multidisciplinary NET team, consisting of the finest: • GI surgeons • Hepatobillary/ pancreatic surgeons • Oncologists • Gastroenterologists • Endocrinologists • Thoracic physicians
• Cardiologists • Cardiothoracic surgeons • Radiologists • Nuclear medicine physicians • Pathologists • Specialist nursing team
With a US Advisory Board which includes: Dr Matthew Kulke (Dana-Farber Cancer Institute) and Dr Rodney Pommier (Oregon Health & Science University)
WellNet Facilities Patients will need to stay overnight for observation in the WellNet Unit’s dedicated patient room on the 2nd floor, South Building. This room has been carefully designed so it is bright and spacious, with great views looking over St John’s Wood, ensuring our NETs patients are as comfortable and relaxed as possible.
More Information To arrange an appointment or for further information about the WellNet Unit, please visit www.wellnetlondon.co.uk. You can also contact the WellNet Unit on 020 7483 5854 or email firstname.lastname@example.org
NEW CONSULTANTS Cardiologist
Dr Fakhar Khan, Heart Hospital and Royal Free
Miss Maria Kyrgiou, Hammersmith
Mr Gurpreet Sandhu, Charing Cross
Dr Manivannan Srinivasan, East & North Herts NHS Trust
Miss Iman Riad, Frimley Park
Neurosurgeon Mr Jonathan Bull, Barts & The London
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Dr Nikolas Fotiadis, The Royal Marsden
Gynaecologist Mr Joseph Yazbek, Queen Charlotte & Chelsea
60 seconds with...
Every day brings new challenges, it is very rewarding to know that at the end of a hard week we have managed to help hundreds of people on the start of their patient journey.
Q&A- Janet Stowell- Enquiry Helpline, Marketing and GP Liaison Manager
PM: Tell us about your working background? JS: I joined The Wellington Hospital back in 1983, and have worked in a variety of departments, from finance to CEO assistant, PA and patient administration. My current role is leading three of our services, GP Liaison, Marketing and the Enquiry Helpline. It is a diverse role with no two days being the same. It’s really interesting to be part of a business that is developing at such an incredible pace. PM: What does your job role entail? JS: My role is to look at the overall running of what we do and spot the gaps that are preventing the service from moving to the next level. With such a large number of departments, it is very important for me to select team members who not only have the knowledge for the role but also the right types of people who are dedicated to the roles and have the vision to want to move forward these types of projects. PM: What do your different services offer? JS: In the last 6 years I have developed our sales and marketing teams to offer three thorough services. We now have four GP Liaison Officers that interact with GPs across the Greater London area. They offer all GPs a comprehensive range of training opportunities and provide one-to-one support to help any GPs or Practices with queries regarding our hospital services. We have developed supportive information packs for GPs on all our main service areas including cardiac care, endoscopy, critical care, neurosurgery, spinal surgery and our very wide range of diagnostics services. We are always happy to receive feedback and look to continue to develop any areas to assist our GPs in the future. Our marketing activities were very minimal up until about 5 years ago when it was realised that in order to remain ahead we needed to engage with our market more. We started to develop our marketing strategies and improve our information for our customers and B2B market, ensuring we move forward in line with the technology and ideas of the healthcare market as a whole. Over the last 5 years we have successful launched the Platinum Medical Centre and developed a large educational programme for different healthcare professional groups. We are now working with future technologies to improve the service we offer our patients and business associates. Our enquiry helpline was initially established as a self-pay quoting line but it soon became apparent that the enquiry side of it was tremendously important. It developed into a general enquiries line and, in line with the new GP service, a booking service to assist the GPs to make the consultant appointments for their patients. Within the first month of this newly integrated service, we had 20 calls. Now, five years down the line, we are averaging about 9,000 calls a month. These calls are not all booking calls;
enquiry helpline prides itself on being there to help, from giving information about parking to making an appointment. PM: What changes have you seen unfold since you began in your role? JS: Many changes have unfolded as my time in these roles has grown. Previously, the Enquiry Helpline was a service only available until 6pm, meaning patients who contacted us after this time received an inferior service. Healthcare is a 24 hour business and we wanted to ensure that our patients received that same service 24/7. Our 24 hour service was launched at the beginning of June offering a dedicated service at all hours. We have also been working on the developments of an acute admissions app which is due to launch within the next month. GP’s can submit a referral form within a matter of minutes and work with a dedicated bookings team who will liaise with the AAU to ensure that all patients are assisted in an efficient and speedy manner. Along with the new 24 hour service, Enquiry Helpline are also now making radiology bookings and are now able to share diaries with our consultants. With a lot of hard work the team learnt all of the processes to enable them to make bookings in a seamless manner for consultants GPs and patients. Since taking that up almost two years ago, over 90 per cent of our bookings are now made through CWS. Earlier this year we also successfully integrated a switchboard service into our Enquiry Helpline. We are working towards offering a streamlined switchboard service to all incoming calls. PM: What do you enjoy most about your role? JS: The growth of services over the past 5 years and still being able to look at improvements and continue to further the services that we offer to our GPs and patients. Every day brings new challenges and together with the excellent teams, it is very rewarding to know that at the end of a hard week we have managed to help hundreds of people on the start of their patient journey. PM: What would you be doing if you weren’t at TWH? JS: I’d like to run a stables in the country. I rode horses since the age of about 5 and did a lot of competing and one day eventing. I had my own horse and my own yard for a little while but when I had my son, I had to lessen my time with the horses. If I could have had my dream job, I would have liked to compete in an Olympics. PM: What do you like doing when you are not at work? JS: I look forward to lovely holidays; I go on at least one holiday abroad and try to get away in England as well. I have spent a lot of time over the last 15 years watching my son develop in sports, including long days at cricket matches, and cold mornings at football and hockey matches. I spend a lot of time on the school parents committee, organising wonderful leavers balls which I have just done for my own son who left this summer. I will be looking for more challenges and hobbies as he develops into the next stage of his life.
www.practicemattersmag.co.uk PRACTICE MATTERs Summer 2014 • 19
www.practicemattersmag.co.uk For more information about the GP Liaison service, or to make a referral, please contact the GP Liaison Officer for your area: Supriya Taggar Central London 07826 551 318
Ricky McKinson North & East London 07889 317 769
Ricardo Pereira North West London 07889 318 336
Veronica Brown Beds, Herts, Bucks & Middx 07889 317 774
Published on Sep 5, 2014