A New Chapter in Cancer Care Introducing the Inpatient Oncology Ward
Taking it to the Max
Preparing for Rio 2016?
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
Welcome Once again another year has come round so quickly, January is a time to reflect on the year gone by, but above all it’s a time to be thankful. Firstly, I would like to say a huge thank you to everyone who took part in The Wellington £1 Million Appeal, raising money for two incredible charities – the British Red Cross and JDRF – and to all those who kindly donated and supported these charities last year. With your help we have raised an astounding £840,000 so far. If the season’s cheer has inspired you, donations can be made at www.thewellingtonappeal.org. I am pleased to say more plans for expansion are already in place for the hospital in 2013; but more on that in the next issue. Last issue we reintroduced you to the Endoscopy Centre, after it had undergone a redevelopment to reaffirm it as a state-of-the-art unit. I am happy to report that since its opening we have received an overall 99.1% patient satisfaction rate; with patients stating they would recommend us to family and friends. In this issue: Lung Function Lab Manager Damian Muncaster, anticipating the pre-marathon training your patients may be commencing, looks at breath and exercise. We showcase our Inpatient Oncology Unit which opened in September, and which brings us another step closer in providing some of the best oncology facilities in the UK. And on page 6, long standing member of staff, Carolyn Bull, tells us what happened when consultant Ciaran Healy noticed a cancerous growth on her forehead. Also covered in this issue: restless legs, carpal tunnel syndrome, meniscal tears and low FODMAP diets. As always we bring you interviews, updates from our GP Liaison team and news from world of primary care. I hope you’ll continue to read and enjoy Practice Matters as we move into 2013. We will be asking for your feedback towards the middle of the year, so we can take into consideration your thoughts and suggestions for coming issues. Practice Matters is a magazine created for our local GPs, so taking time to let us know your opinions really is invaluable. I would like to wish you a very warm season’s greetings and all the best for 2013.
Keith D Hague CEO
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Editor: Claire McKinson Production & Distribution: Runwild Media Group
Contents 04 | “All that tingles is not carpal tunnel syndrome” Ian Winspur urges us to think twice before a making a diagnosis
05 | FODMAP and IBS Catherine Cash reports on FODMAP diets
06 | Skin Cancer Case Study Ciaran Healy talks chance meetings and integrated care
08 | Meniscal Cartilage Tears David Sweetnam gives us the lowdown
09 | Taking it to the Max Damian Muncaster asks, are you ready for Rio 2016?
12 | Restless Leg Syndrome Shane Roche provides us with his key notes
14 | Four is the Floor Michael Feher updates us on the latest in Diabetes Mellitus
15 | Practice Managers’ News: Working past retirement: How you can support your staff
16 | GP News The latest news from the primary care sector and The Wellington Hospital
18 | Seminar Listings and New Consultants
Plus an interview with Inpatient Oncology Matron Laurie Thurlow
10 | A New Chapter in Cancer Care Introducing the Inpatient Oncology Unit
14 www.thewellingtonhospital.com 3
Hand and wrist
All that tingles
is not carpal tunnel syndrome
So spoke Professor Fritz Buchtal, the father of nerve conduction testing, advising me 30 years ago on why young pianists developed carpal tunnel syndrome-like symptoms after prolonged practice, but their nerve conduction tests were normal. He then explained that the cause of their median nerve dysfunction was oedema produced from the adjacent flexor tenosynovitis; the result of unaccustomed intense playing.
in the defined area of a specific peripheral nerve. Compression of the brachial plexus in the root of the neck, over an accessory rib or muscle band, will also produce distal symptoms, but is rare. Yet, similar symptoms can be produced from postural failings, and these patients will respond dramatically to physiotherapy. Compression of any of the peripheral nerves can take place in the arm, wrist or hand. The most common sites are the ulnar nerve at the elbow and the median nerve at the wrist – true carpal tunnel syndrome (CTS). The tingling and numbness will be in the distribution of each nerve with the little and ring finger involved in ulnar nerve compression and the thumb, index and middle fingers (and occasionally the ring and little as well) in median nerve compression. These nerves can also be compressed
The same phenomenon can exist in isolated digits when there is flexor tendon swelling or incipient triggering. The treatment for such cases (and this also applies to young, non-pregnant, female secretaries) is steroid injection into the carpal tunnel and not surgical release. These patients fair badly with surgical release, as compared with the older patient with clear compression of the median nerve, for whom the operation can offer a dramatic cure.
So, when faced with complaints of numbness and tingling in the arm or hand, it is important to remember not only the anatomical distribution of the symptoms and therefore the likely nerve involved, but also the possible patho-physiology of the condition – compression or inflammation – before coming up with a differential diagnosis and investigation. Nerve root irritation or compression in the neck will produce peripheral symptoms of tingling and numbness and is common. However, it is unusual to have such a situation without neck symptoms of stiffness or pain and the distribution of the tingling and numbness will be within a dermatome and not
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A history of night time or early morning tingling and numbness in the distribution of the median nerve should be highly suggestive of CTS. in other areas in the forearm and hand, but these are uncommon. Although unlikely, the radial nerve can also be compressed in the proximal forearm, often in association with tennis elbow, producing mostly pain and aching. Tingling and numbness in the radial nerve distribution on the dorsum of the hand is unusual. CTS is the most common distal nerve compression. If the diagnosis is in doubt, nerve conduction testing can be most helpful. Indeed in younger patients, in those with atypical symptoms and in work-related
cases, nerve conduction testing is essential. Professor Buchtal’s young musician will have normal nerve conduction tests and should not have surgical release. The correct treatment would be a reduction in playing, night splints, oral anti- inflammatory medication and steroid injection, if needed, into the carpal tunnel. This also applies to many young secretaries and data entry clerks. Keyboard usage has been incriminated in causing carpal tunnel syndrome. Certainly if a patient has incipient or mild CTS it will be dramatically worsened by typing or indeed knitting. But recent scientific and epidemiological studies from Sweden show that CTS is less common in computer users and secretaries than in the general population, and my experience is that CTS is less common in professional musicians than in the general public, raising grave doubts on the hypothesis that repetition causes injury.
But for the 50+ or older patient, with typical symptoms, the diagnosis of CTS can be made on clinical grounds alone. A history of night time or early morning tingling and numbness in the distribution of the median nerve should be highly suggestive of CTS. And confirmatory provocative testing using Phalen’s manoeuvre (reproducing the symptoms by holding the wrist fully flexed for 20 – 30 seconds), or finding a point over the nerve where tapping produces tingling or electric shock-like symptoms (Tinel’s sign) should complete the diagnosis. The results of surgical release are usually very satisfactory and lasting in this group of patients. However, the inappropriate release of the carpal tunnel for symptoms not arising from compression in the carpal tunnel will not be beneficial. Therefore, be guarded and remember Professor Buchtal’s wise words. Mr Ian Winspur, is a Consultant Hand and Plastic Surgeon at the London Hand and Wrist Unit.
Catherine Cash, Head of Dietetics at The Wellington Hospital, reports on low FODMAP diets, and how they are proving successful in treating patients with IBS.
Improving IBS the Low FODMAP Way
Irritable Bowel Syndrome reportedly affects 15% of the UK population. The main underlying cause is believed to reside in the enteric nervous system, presenting as visceral hypersensitivity where the GI tract nerve pathways become more sensitive to stimulation, causing over-reactivity and amplifying pain. This results in a variety of symptoms, such as: abdominal bloating and distension, flatulence, abdominal pain, nausea, changes in bowel habits, and other gastro-intestinal symptoms.
Treatment for IBS remains notoriously difficult to manage. Diet is perceived by many sufferers as the main cause of IBS symptom development, and consequently many patients restrict their diet which can in turn lead to nutritional deficiencies. Dietary recommendations vary depending on individual symptoms, and in the past focused on adjusting fibre intake, regular meal patterns and reducing fat, alcohol and caffeine intake. Whilst these recommendations remain important, and should be advised as first line dietary treatment, there is now a new treatment that is proving to be very successful in the treatment of IBS: the low FODMAP diet.
What are FODMAPs? FODMAPs is an acronym for: Fermentable Oligosaccharides (e.g. fructans and galactans) Disaccharides (e.g. lactose) Monosaccharides (e.g. excess fructose) and Polyols (e.g. sorbital, mannitol, maltitol, xylitol and isomalt)
Removing FODMAPs from the diet can be a highly effective means of improving the symptoms of irritable bowel syndrome. The low FODMAP diet was developed by a team at Monash University, Australia, following extensive research in 2001. It has now been successfully brought to the UK by researchers at King’s College, London, and we are pleased to offer this exciting new treatment at The Wellington Hospital. FODMAPs can be found in many of the foods we eat. These short chain carbohydrates can be poorly absorbed in some patients’ small intestine, leading to alterations in fluid content and bacterial fermentation in the colon; and this triggers functional gut symptoms in susceptible individuals. Removing FODMAPs from the diet can be a highly effective means of improving the symptoms of IBS. A recent evaluation by King’s College London has shown that 76% of patients who had seen a FODMAP-trained dietitian reported improvement in symptoms after being on the diet. Where are FODMAPs found? A few examples of very common food sources for each of the FODMAPs are listed below. This list is by no means exhaustive: • Excess fructose: apples, corn syrup solids, high fructose corn syrup, honey, mango, pear and watermelon. • Fructans: artichokes (globe and Jerusalem), asparagus, beetroot, chicory, dandelion leaves, garlic (in large quantities), leek, onion, raddichio lettuce, rye (in large amounts), spring onion, wheat (in large amounts), inulin and fructo-oligosaccharides.
• Galacto-Oligosaccharides (GOS): chickpeas, legume beans and lentils. • Lactose: milk, condensed and evaporated milk, custard, dairy desserts, ice-cream, margarine, milk powder, soft unripened cheeses and yoghurt. • Polyols: apples, apricots, avocado, cherries, longon, lychee, mushrooms, nectarines, pears, plums, prunes, sorbitol (420), mannitol (421), xylitol (967), maltitol (965) and isomalt (953). What can be eaten on a low FODMAP diet? The low FODMAP diet involves many dietary changes and the dietitians at The Wellington Hospital offer comprehensive nutritional advice, with detailed resources, to assist individuals with eliminating FODMAPs and then support through the reintroduction phase. Referring to the Dietetic Department: Outpatients are seen at the Platinum Medical Centre and referrals are accepted in writing or via email from consultants and GPs. Patients requiring the low FODMAP diet are recommended to have two consultations with our dietitians, and we offer telephone and email support between all appointments. The Dietetic Department welcomes any queries and can be contacted on 0207 483 5391 or wellington.dietitians@HCAHealthcare.co.uk.
As Would Have it
Mr Ciaran Healy talks to us about the Integrated Skin Cancer Service at the Platinum Medical Centre, and how a chance meeting led to swift intervention for one member of staff.
The London Skin Cancer Specialist Service at the Platinum Medical Centre is a fully integrated multidisciplinary programme, providing excellent comprehensive care throughout the disease continuum. This dedicated unit brings together dermatologists, plastic surgeons, pathologists and oncologists with specific expertise in the evolving techniques of diagnoses and treatment of basal and squamous cell carcinoma, melanoma, dermatofibrosarcoma and cutaneous lymphoma etc.
Chaired by Mr Ciaran Healy, Consultant Plastic Surgeon, the team at the PMC is lead by Prof Sean Whittaker in Dermatology, Dr Nick Francis in Dermato-Pathology, Dr Paul Nathan in Oncology, and co-ordinated by Charge Nurse Ali Bautista. Each participating consultant in the London Skin Cancer Specialist Service has held senior positions at NHS teaching hospitals and contributes to the ongoing development of the speciality.
This time last year I had what I thought was a gnat bite appear on the bridge of my nose. It started like a tiny whitehead but then turned into a red lump, because of its prominent position I did not touch it. Over the next week or so it grew larger and soon became an open sore. Just as I was beginning to think I would need to make a GP appointment, Mr Healy noticed my skin lesion whilst I was at my desk and arranged an appointment to see him promptly. It was just prior to Christmas when Mr Healy took a proper look and said it could be one of three things: 1. An infection 2. A self-healing lesion 3. Or a form of skin cancer We agreed that he should take a biopsy of a large enough area that would deal with the first two scenarios. I had the wound dressed and I then went back to work. It was my last day at work before the Christmas holiday, so meeting my sister at Heathrow the next
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morning I warned her that I had what looked like a mask covering my forehead and nose and resembled the Phantom of the Opera. The following week I learnt that I had a skin cancer and Mr Healy made a prompt appointment for me to have it removed completely, using a technique known as MOHS surgery. From then on everything happened in a whirl. Mr Healy clearly explained everything that was going to happen – and I was booked in for the procedure and overnight stay at The Wellington Hospital. I woke from surgery to the news that the skin cancer was completely removed. A flap of skin from my forehead was now covering the damage to my nose.
Christmas came and went and I had two further procedures in February and March to fix and tidy up my nose. Now it’s hard to even notice the join. Looking back it all happened so quickly. I didn’t have time to worry about what would happen – but now it scares me to think what could have happened. If it had been a mole that changed or became sore I would have gone to the GP straight away, but because I assumed it was a harmless bite, I delayed an initial GP appointment. Considering this all happened just before Christmas, my treatment was both efficient and effective. So I can only thank my lucky stars (and Mr Healy) for being in the right place at the right time.
Frontalis / Galea
Flap tip thinned
Skin cancer (SCC) – Carolyn presented with what proved to be a moderate differentiated SCC, which had grown rapidly.
Flap inset: The forehead flap is inset in the nasal defect.
Flap elevation : This illustrates the nasal cancer excisional defect with the forehead flap elevated and transposed.
Carolyn is pleased to be free of her tumour at one year.
This lady’s case is a good example of the integration of care this service provides, in that she had a rapid diagnosis of a life threatening skin cancer by what was ultimately a chance meeting with me.
As her squamous cell carcinoma was growing rapidly an initial biopsy, having confirmed the nature of the lesion, meant we were able to proceed rapidly to the complete removal of the cancer using micrographic surgery. This was performed under local anaesthetic and sedation, enabling the patient to remain comfortable throughout the procedure, while the pathologist confirmed the lesion had been completely removed. We proceeded with the first stage of her planned three stage nasal reconstruction using her forehead skin. This provides an ideal match in terms of colour, texture, and thickness for the nasal skin. Though the three stages may seem daunting, they do take up to several weeks to complete.
Carolyn’s long term progress has been excellent, she is completely clear of her skin cancer and has a more than satisfactory atheistic outcome from her reconstruction. Many people on the hospital staff, who have known her for many years, have failed to notice that she has had most of her nose removed and reconstructed. The London Skin Cancer Specialist Service are now in the position to offer rapid access to skin cancer patients with integrated, prompt and excellent service, both in terms of curing the tumour and reconstructing the often devastating defects.
general anaesthetic lasting 25-30 minutes. The objective of this surgery is to minimise the amount of damage to the knee in obtaining access to the cartilage inside.
David Sweetnam, Consultant Knee Surgeon gives us the lowdown on meniscal cartilage tears
The specialist is very careful to remove the minimum amount of cartilage and thus retain the function of the majority of tissue left behind. Surgeons will try to remove the absolute minimum amount of meniscus during the operation, usually around 20%. This removes the pain but retains as much of the shock absorbing capacity of the menisci as possible. This also minimises the chance of developing wear and tear arthritis in the future, compared to ‘open’ operations where the whole meniscus was removed. Despite this being considered a minor operation, patients need to rest the knee for the first few days, should not return to work for several days, and shouldn’t expect to return to full sporting activity for at least one month to six weeks post surgery.
rthroscopic menisectomy is the minimally invasive procedure required to treat meniscal cartilage tears within the knee. With thousands of these operations being performed each year in the UK, this is probably the most common operation performed on the knee. The most common way to damage or tear cartilages can be twisting whilst on a bent knee. These tears are commonly associated with a sporting accident; however, many patients cannot recall a distinct injury having ever occurred. Such injuries are thought to be a young person’s injury, but we see just as many in those 40+. In the older age group these tears are usually acquired after having participating in unaccustomed exercise, or perhaps having made an awkward twisting movement.
When examining someone with these types of injuries, we look for clues, such as: 1) Occasional swelling of the knee 2) A sense of collapsing or giving way 3) A new clicking or catching sensation 4) Intermittent sharp twinges felt at the sides of the joint associated with lingering aching Other clues include: extra fluid on the knee, pain on putting pressure along the joint margin and a new pain when kneeling or squatting.
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Physiotherapy treatment plays an important role after the operation; helping the patient to rehabilitate and improve knee function by reducing the swelling around the knee and getting the muscles working.
In order to confirm the diagnosis of a cartilage tear we prefer to use MRI scanning. An MRI produces a very detailed look inside the knee and surrounding soft tissue, and has almost 99% accuracy with such tears. If a meniscal cartilage tear is confirmed this by no means indicates that a patient requires surgery, but means the specialist can have a more informed discussion with the patient about the treatment options.
Continuing with non operative treatment (especially in the 60-70+ age group) is often better than risking irritating the knee with surgery. No hard and fast rules exist about when to operate, as each patient will present with their own unique situation.
Due to the lack of blood supply to the meniscal cartilages, healing is quite unusual, however, there are a small group of cartilage tears that exist at the outer margin of the cartilage that do have a blood supply. Given time and rest, they can repair themselves. For the vast majority of these torn cartilages, symptoms persist despite conservative treatment, and surgery has to be considered. What can be confusing to patients is that the symptoms will often appear to get better, only for them to return. This cycle can continue for some time before a patient decides they need further help. In the presence of persistent symptoms, many younger patients opt for a minimally invasive operation to remove the damaged area of the torn meniscus. An arthroscopic meniscectomy is usually carried out as a day case procedure, using a light
“What can be quite confusing to patients is that the symptoms will often appear to get better, only for them to return. This cycle can continue for some time before a patient decides they need further help.
Complications that can arise from this operation include the possibility of irritating the knee; especially if wear and tear arthritis already exists. The process of having the arthroscopy and cartilage resection in itself can act as quite a significant irritant for such knees. As such, arthroscopic meniscectomy in the 60+ age group should be used far less often than in the younger age groups. To arrange a same-day appointment at The Knee Unit, please call 020 7483 5008.
Taking it to the
Damian Muncaster, Lung Function Laboratory Manager, discovers how Olympic fever has inspired more people than ever to participate in sport, but also how vital it is for amateurs to check their fitness first.
ver the past 30 years the participation rates in sport in the UK have continued to rise. The fitness industry has seen a steady growth in health and fitness club memberships and this increase in participation of sport looks set to continue to after the inspirational London Olympics. Cycling clubs have already seen an increase in membership, and British cycling has reported 500,000 extra memberships since Beijing 2008. Team Sky’s report into the ‘Olympic effect’ saw a 5.7% increase in bike sales and 30% of current cyclists have been motivated to cycle more and to take part in more cycling events since London 2012. Even more impressive has been the boom in triathlon participation, with a 300% increase in the past five years, with 11,000 competitors at this year’s London Triathlon. Add this to the ever popular London Marathon with its 35,000 entrants, and it’s clear to see that there are plenty of serious non-elite athletes amongst us. It has been proven that the motivation for the majority of athletes who dedicate so much time and effort to their training programmes is not about becoming healthier, but rather an intrinsic competitive or psychosocial goal. This leads to the athlete constantly striving to better their times and improve their fitness. This competitive spirit has given rise to the explosion of monitoring technology, from Google Strava apps with Garmin HR monitors to Nike
fuel bands, all providing the athlete with reams of information about their performance. Complex physiological testing can provide these athletes with further essential information about their cardio respiratory fitness. At The Wellington Hospital within the cardio respiratory department we provide a range of physiological tests that measure fitness. The cardio pulmonary exercise test is an excellent example. The test primarily measures respiratory gas exchange during maximal exercise. Allowing us to calculate, amongst other things, VO2 max and anaerobic threshold. VO2 max is a measure of the maximum amount of oxygen in millimeters that a person’s body can consume (or process) in one minute per kilogram of bodyweight. People with a higher VO2 max can exercise more intensely, because they can take in more oxygen, distribute it to their muscles through their blood, and convert it to use through their aerobic muscular energy system. VO2 max therefore is a measure of the maximum capacity of an athlete’s body. Importantly, training can improve VO2 max which in turns improves performance. Cross country skiers are recorded as having the highest VO2 max in the region of 85-95, the cyclist Miguel Indurain was measured at 88, whereas sports like football and rugby would see VO2 max in the region of 45-60. Anaerobic threshold is an excellent predictor for an athlete’s performance. The anaerobic threshold is reached when respiration starts to occur
anaerobically, as opposed to aerobically, to meet the muscles increasing demands for oxygen as exercise intensifies. A by-product of anaerobic respiration is lactic acid and the build up of lactic acid gives rise to the feeling of heavy or jelly legs and signals that the end of exercise is imminent. The higher the level of exercise before anaerobic threshold is reached the fitter an athlete is and as with VO2 max this can be improved markedly with training. Training also improves the ability of the body to break down and remove lactic acid, allowing the athletes to respire anaerobically for longer. Crucial for the likes of Bradley Wiggins in his time trails. Our laboratory is able to provide the serious athlete with these crucial measurements, along with parameters such as oxygen pulse, ventilation, end tidal CO2 and heart rate reserve. The range of testing that we provide in the lab is also of huge relevance when applied as means of health ‘risk management’. More and more people are embarking on exercise at a later stage in life, whether as means of disease prevention or to help manage conditions such as diabetes or high levels of cholesterol. In some cases it is to realise an ambition of completing a challenge, such as the marathon, before age really takes its toll. Whatever the reason, the testing that we provide at The Wellington Hospital is an excellent starting point to assess baseline fitness and investigate whether there are any underlying cardiorespiratory problems. Embarking on a rigorous training regime could put you at risk, if that is the case. ECG, echocardiogram and stress tests will ensure cardiac fitness, whilst basic lung function testing will assess respiratory health. These baseline measurements can then be used to provide you with the ideal exercise prescription for your desired goal.
Anyone fancy three weeks in Rio in 2016?
A New Chapter in
In 2011, when the Platinum Medical Centre opened, cancer care was reintroduced at The Wellington Hospital. Now, with the support of Leaders in Oncology Care (LOC), we proudly introduce the next phase â€“ our Inpatient Oncology Unit.
Opened in September 2012, the Inpatient Oncology Unit at The Wellington Hospital offers a cuttingedge service, providing bespoke care for all major oncology conditions. The Service Located on the 2nd floor, South Building, the unitâ€™s primary focus is to provide exemplary inpatient care for cancer patients. The unit offers treatment for complications of cancer and complications of treatment. It is also fully equipped to manage all oncology emergencies and the administration of inpatient chemotherapy. The service is developing strong links with already established palliative and supportive care services, enabling a more comprehensive approach to inpatient oncology care, and establishing a unique service for the North London area.
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Providing a focus for cancer care in a hospital setting The Inpatient Oncology Unit benefits from The Wellington Hospital’s vast facilities, particularly, one of the most advanced imaging departments in the UK (including PET/CT, mammography and 3T MRI) and award-winning intensive care units. The unit also has access to an already established state-of-the-art Breast Care Unit and Acute Admissions Unit. As part of HCA International, the largest provider of private cancer care, we have access to a full, highly specialised radiotherapy service. We are also supported by and work closely with Leaders in Oncology Care (LOC) based at the Platinum Medical Centre as well as other HCA cancer facilities. Speaking about the opening of the new unit, Dr David Landau said, “Our aspiration is to create a comprehensive cancer centre of excellence. Through a unique combination of outpatients at LOC at the Platinum Medical Centre, the ground-breaking Acute Admissions Unit and the new Inpatient Unit, we are beginning to make this aspiration a reality.”
The Team Our specialised oncology trained staff are a young, dynamic team, working alongside some of the most experienced and internationally renowned oncology specialists, creating a multidisciplinary and clinically experienced team. This new service is led by Dr David Landau with the full support of the extensive clinical and medical oncology team at LOC (Leaders in Oncology Care). For further information please call the Enquiry Helpline, or to make a referral – please call the Inpatient Oncology Ward via switchboard 020 7586 5959, Ext 36002 or bleep 7802.
Known diagnosis – past or present
Oncologist / Consultant
Under the patient’s own Oncologist
Samir Agrawal Sarah Blagden Ekaterini Boleti Michael Brada John Bridgewater James Cavenagh Simon Chowdhury Susan Cleator Christopher Cottrill Angus Dalgleish Paul Ellis Paul Fields Hani Gabra Andrew Gaya Peter Harper Mark Harries Daniel Hochhauser Simon Hughes Alison Jones Rohit Lal David Landau
Jonathan Ledermann Martin Leslie James Mackay Nicholas Maisey Robert Marcus David Miles Paul Mulholland Paul Nathan Thomas Newsom-Davis Carlo Palmieri Katharine Pigott Nick Plowman Stephen Schey Jonathan Shamash Amen Sibtain Sarah Slater Maurice Slevin Justin Stebbing Jonathan Waxman Paula Wells
Seen by GP
Referral to AAU
List of Consultants
Under the care of Oncologist as per AAU rota
Under other Wellington consultant
Referral to an Oncologist
Admission to the Inpatient Oncology Unit at The Wellington Hospital
RESTLESS LEG SYNDROME
Restless Leg Syndrome Consultant
FOCUS Underlying Pathology:
Dr Shane Roche Dr Shane Roche, Consultant Physician, provides us with key notes on Restless Leg Syndrome. • Characteristically, RLS affects the legs, but can occasionally involve the arms • Patients will experience an urge to move, alongside feelings of burning, tingling, aching, fidgeting, throbbing, or tightness • Pain may also be a predominant feature • Symptoms tend to be worse in the evening or at night • It affects all age groups but increases with age • RLS is a common cause of insomnia, unrefreshing sleep and excessive day time sleepiness • And has a higher occurrence in women
1) An urge to move the legs usually with unpleasant sensations 2) The urge to move or the sensations worsen during periods of rest or inactivity 3) The urge to move or the sensations are partially or totally relieved by movement 4) The urge to move or sensations are worse in the evening or night
Low iron may be a contributory factor in pregnancy, although it is more likely a hormonal influence through the action of oestradiol or prolactin.
Possible underlying causes:
Effect of RLS:
1) Idiopathic. This has a strong genetic component with a family history of up to 60% in one study 2) Iron deficiency 3) Pregnancy. RLS becomes more severe over the duration of the pregnancy. The effect may be due to hormonal changes or iron deficiency anaemia 4) Chronic Kidney disease 5) Parkinson’s disease, diabetes, multiple sclerosis, peripheral neuropathy and spinal disease are all known associations
Restless leg syndrome can have a major effect on a patient’s quality of life. Difficulty getting to sleep, staying asleep and un-refreshing sleep can lead to excessive day time sleepiness and psychological problems. A recent extensive review showed that RLS is probably associated with diabetes, impaired glucose intolerance, and possibly heart disease.
Prevalence: 9-15% in some studies but lower in others. There is a wide variation in age of onset from childhood to older age. 38% have reported the disorder before the age of 20 years and 10% before the age of 10 years.
Routine screening should include a comprehensive drug history for exacerbating agents such as anti-depressants, anti-psychotics and some antihistamines.
The prevalence is two times higher in women than men and increases with age. It affects 13.5% 26.6% of pregnant women and worsens over the period of the pregnancy. There is a higher prevalence in Northern Europeans and North Americans than African, Middle Eastern, Asian, Hispanic or South Eastern Europeans.
Criteria for diagnosis:
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The effect on a hormone called Dopamine, which is produced in the base of the brain.
Pathophysiology: Dopamine is a neurotransmitter produced in several areas of the brain, including the substantia nigra. Desensitisation of dopamine receptors is highly implicated in RLS. Iron deficiency is also an important association as it has a role in dopamine metabolism. Iron stores in the brain have been found to be low in patients with restless leg syndrome.
Management: Evidence based guidelines have been published including the European Restless Legs Syndrome Study Group (EURLSSG).
Serum ferritin should always be checked, as anaemia may not always be present. Patients with a level of less than 50ug/l should be started on treatment. Only around 20% of patients will require drug treatment. Measures such as avoidance of alcohol, smoking and caffeine may help. Regular exercise, avoidance of stress, sleep deprivation, and over exertion should be advised. Summary: Restless leg syndrome is a common disorder which if ignored can lead to a poor quality of life for patients. It is important to follow the diagnostic criteria to make a diagnosis. Simple measures may help but drugs are also available to ease the misery of this condition.
When time is of the essence...
Acute Admissions Unit 020 7483 5999
This number is exclusively for Consultants and GPs
One Call Admission
24/7 Referral Service
The Wellington Hospital Wellington Place, St Johnâ€™s Wood, London NW8 9LE
Tel: 020 7483 5148 Fax: 020 7483 5618 email@example.com www.thewellingtonhospital.com
The Wellington Diagnostics & Outpatients Centre GOLDERS GREEN
Healthcare for all the family Based in the heart of the community, the Wellington Diagnostics & Outpatients Centre offers the very best in healthcare, for all the family.
The Wellington Diagnostics & Outpatients Centre Roman House 296 Golders Green Road London NW11 9PY
Our new facilities include: Breast Screening Pain Management Reproductive Health (IVF)
The centre provides a state-of-the-art diagnostics and imaging department and specialist care in all major areas of medicine including: paediatrics, cardiac services, orthopaedics, gastroenterology, gynaecology, dermatology and many more.
Nerve Conduction Studies
Quick referrals, experienced consultants, and superb links to The Wellington Hospital and The Portland Hospital, are all on your doorstep.
For enquiries or information call our team today Tel 020 7483 5148
www.wellingtondiagnosticscentre.com all HFEA licensed treatments will take place at The Lister IVF Clinic
Four is the
A Group 2 driver (bus/lorry) with one or more episode(s) of hypoglycaemia requiring assistance of another person in the previous 12 months, must inform the DVLA and be advised not to drive. What is a reportable hypoglycaemic episode? Hypoglycaemia requiring assistance from another person at any time of day or night constitutes an episode for reporting purposes. The requirement of assistance includes: admission to A&E, treatment from paramedics, assistance from a partner/friend who has to administer glucagon or glucose because the person cannot do so themselves.
It does not include another person offering or giving assistance, in circumstances where the person was aware of his/her hypoglycaemia and able to take appropriate action independently.
Dr Michael Feher, Consultant in Diabetes and Clinical Pharmacology, updates us on the latest in Diabetes Mellitus. Looking at hypoglycaemia, new DVLA guidance, and statin issues. Hypoglycaemia Hypoglycaemia is a common treatment sideeffect of both insulin and oral (sulphonylurea and meglitinide) diabetes therapies. This can be the most distressing aspect of a patient’s care, particularly when associated with sudden incapacity. There is now increasing evidence that hypoglycaemia is a problem for individuals with type 2 diabetes, as well as those treated with insulin with type 1 diabetes. Definitions of hypoglycaemia The biochemical classification varies between a blood glucose below 3.1 mmol/l to 3.9 mmol/l. The variation in cutpoints have been used in different studies evaluating hypoglycaemia. A pragmatic approach has been proposed as ‘4 is the floor’. The clinical symptoms of hypoglycemia include autonomic (sweating, palpitations, tachycardia, shaking, hunger) from activation of counterregulatory hormones, and malaise due to either nausea or headache. The neuroglycopaenic symptoms comprise confusion, drowsiness, un-coordination, speech difficulties, fit, and coma. The clinical presentation of hypoglycaemia is described as either: • Minor or moderate hypoglycaemia associated with symptoms and where self management is possible or • Major or severe hypoglycaemia associated with neuroglycopenic symptoms, or reduced consciousness/symptoms and requiring third party or medical intervention
Enquiry Helpline: 020
Referral is recommended to a diabetes specialist for patients who have suffered a single hypoglycaemic attack requiring assistance, especially where a second episode might result in loss of employment. And self testing is advised before undertaken driving, with the recommendation for the glucose to be above 5 mmol/l.
Factors increasing risk of hypoglycaemia in diabetes • Type of oral diabetes therapy These include oral insulin secretagogue drug classes- sulphonylureas (glibenclamide has a greater hypoglycaemic potential than glipizide or gliclazide. Chlorpropramide is not in clinical use) and meglitinides (repaglinide, netaglinide). Hypoglycaemia is rarely observed with monotherapy metformin, pioglitazone, DPP-4 inhibitor or with GLP-1 agonist, but can occur when these drugs are combined with either sulphonylurea or meglitinide.
Statins and Diabetes Risk One of the first studies reporting a possible link between statin therapy and new onset diabetes was from the JUPITER trial. This trail was on 17,603 individuals without CVD, but with at least one major diabetes risk factor, where 134 CV events (93 first events) were avoided at a cost of 54 new diagnoses of diabetes (Lancet 2012;380:565-71).
• Insulin formulation ‘Older’ basal insulins -Isophane/NPH Insulinappear to have a slightly greater hypoglycaemic potential for the same achieved HbA1c compared to ‘newer’ analogue (insulin detemir and insulin glargine) insulins. • Incorrect dose or timing of drug/insulin • Irregular/reduced eating habits • Alcohol • Exercise • Lower HbA1c (tight glycaemic control) • Periods of fasting • Prior hypoglycaemia • Hypoglycemia unawareness • Older people • Long duration diabetes
New DVLA Guidance for Diabetes A Group 1 driver (car/motorcycle) who has had two or more episodes of hypoglycaemia requiring assistance from another person at any time (including when sleeping) in a year, must inform the DVLA and be advised not to drive.
There is now increasing evidence that hypoglycaemia is a problem for individuals with type 2 diabetes, as well as those treated with insulin with type 1 diabetes.
In the combined analysis of 13 statin trials involving 91,140 individuals, only 174 more cases of incident diabetes were found in those treated with statin compared with placebo or conventional care, this equated to a 9% increase in incident diabetes risk. (Lancet 2010; 375:735-42). The meta-analyses of statin based trials indicate that all statins are associated with a small increase in the development of type 2 diabetes, and that this risk is higher at higher statin doses. In absolute terms, the risk is low compared with the absolute benefit of statin therapy. Current cardiovascular guideline recommendations place statin therapy as the cornerstone of lipidmodifying therapy. The absolute benefits in preventing CVD are greater than the risk of incident diabetes. Dr Michael Feher is a consultant at The Wellington Hospital, Platinum Medical Centre and Chelsea and Westminster Healthcare NHS Fdn Trust, London.
PRACTICE MANAGERS NEWS
With an ageing population which may continue to rise with each new generation, the old rules and regulations which saw employees retire at 65, or even before, has now been phased out. Now, the law stipulates that employees can stay working until they want to retire. Many employees when they reach the age of 65 still feel that they have a lot to offer, they still want the interaction of the workplace, and they may love the job they do. But there is a financial axis as to why many work past retirement too: many employees over 65 are not in the financial position to live without a full monthly wage. With devalued pensions to boot – prospects of retiring are not what they used to be. A recent study published by LV= showed that women over 50 are more likely than men to work past retirement, and that the number of over 50s expecting to work past the state retirement age has risen to 6.5 million. The report also revealed that the majority of these people say they are forced to do so to survive financially, but that over a third wanted to stay because they enjoyed what they do. LV=’s report also highlighted that in London, those who would stay past retirement age would stay on for an average of 7.4 years; longer than anywhere else in the country.
In many fields, and especially in healthcare, experience is paramount. These older employees are likely to have a handle on most situations that arise, and are much less likely that the rest of your workforce to move on to another job or company, and add diversity to your team.
FOCUS Useful Links: The Age and Employment Network www.taen.org.uk UK Government rules on retirement www.gov.uk/browse/employing-people Read LV=’s report in full: http://www.lv.com/adviser/workingwith-lv/news_detail/?articleid=3070853
What can you do to support these members of staff? • With high profile cases in the media, such as presenter Miriam O’Reilly’s, there is a feeling amongst the older workforce that they may be pushed out of their jobs because of their age. So, reassure them that they are a valued member of the team • If savings, as the LV= report suggest, are a real issue make sure that your staff who are over 65 know all the options that are open to them • Talk with these members of staff and find out what they want to do with their job, while some wish to slow down, others want to keep up the pace and responsibility
• Keep training your staff, many want to keep up to date with the latest technologies, in fact social media websites are now used just as frequently by older people as they are by young people As we mentioned in our last issue, the key points to keeping your staff happy are reassuring them of job security, providing the opportunity to train and develop, making sure they feel engaged and motivated, and to feel like they have respect and understanding from colleagues. This doesn’t change the older you become.
GP news Round Up
In the busy world of General Practice, we look at trending stories and interesting updates from the primary care sector.
Jeremy Hunt: GPs are ‘overstretched’ GP online have highlighted the big challenges that the new health secretary faces. In his first speech to Primary Care Leaders, he admitted that GPs were overstretched, but that part of this will be the responsibility of CCGs to restructure services and reduce GP workload. Mr Hunt suggested that CCGs could reduce workload pressures by putting pressure on poorer performing practices as well as reducing the variability found in practices up and down the country. And that using technology such as online appointments and repeat prescriptions, promoted by the NHS mandate, would also help. But questioned whether email consultations would help, or in fact hinder GPs. In his role as Health Secretary, Mr Hunt has decided to focus on four priorities:
RCGP President Steps Down As RCGP president Iona Heath steps down, if you haven’t already, head over to the Pulse website to read her latest interview, Fears for the next generation, or watch ‘the Big Interview’ where Dr Heath discusses dwindling GP morale and Government decisions.
• Dementia • Improving survival rates for killer diseases • Technology • Making sure that care is equally as important as treatment in the NHS
Changes to GP Contracts The DoH website outlines the proposed changes to the general medical services contract for 2013/2014, made by Dame Barbara Hakin, National Managing Director of Commissioning Development. These include: • New measures to improve care for patients with long term conditions and help prevent unnecessary emergency admissions to hospital • Ensuring that quality rewards for GPs reflect expert advice, from NICE, so that patients receive the very best care in line with the most up to date evidence • Stopping additional rewards for organisational tasks like good record keeping, which should be part of any good health organisation. This money will instead go into rewarding the quality of services that GPs offer patients • Ensuring that more patients benefit from best practice in areas such as keeping blood pressure low and reducing cholesterol levels, especially those in most need or hardest to reach These changes are vehemently opposed, but until the publication of the Statement of Financial Entitlements, negotiators have refrained from speaking in any great detail. In his article ‘If ever there was a time to fight’ Pulse editor Steve Nowottny , pointed out the likelihood that these negotiations are likely to push in to next year: with news that the BMA are planning roadshows around the country to discuss the changes in early 2013.
Comment and Debate GP out of hours care has long been a controversial topic since GPs lost responsibility in 2004. Dr Iona Heath in an interview with Pulse said, ‘There is a generation of doctors who came into general practice precisely because they didn’t want to do out-of-hours, and that is a problem’.
What do you think? Enquiry Helpline: 020
Our ‘Consultant Led Practice Talks’ bring the best of The Wellington Hospital’s educational programme straight to your practice, and at your convenience.
GP Liaison Offer You?
Whether you regularly refer to The Wellington Hospital, come along to our events and know our GP Liaison team very well, or you are new to us, we hope to offer you and your practice the support you need for 2013. Whether this is organising an event at breakfast, lunch or after hours, our events and training can be arranged at any time of the year, and at a time and place that suits you best. Below is a list of the educational events we currently run:
here are currently over 70 Wellington consultants, across a range of specialties, who are part of this programme. These specialists are available to give talks at breakfast meetings, lunch breaks or evening discussions on topics of your choice.
• CPR training
Liver Nephrology Neurology
Colorectal and General Surgery
A full list of topics is available to view via the health professionals section at www.thewellingtonhospital.com. If you are interested in arranging a practice talk, please contact the GP Liaison team via the Enquiry Helpline on 020 7483 5148, or via the individual GP Liaison Officer’s numbers listed on the back cover.
• Infection control training • Spirometry training • Breast awareness workshops • CQC symposiums • Monthly workshops, masterclasses and GP seminars in a number of London venues, across a wide range of ever-changing topics relevant to primary care • Consultant led talks at your surgery, or here at the hospital Although we largely offer support with educational and professional development, our main function is as a liaison between you and The Wellington Hospital. This may be assisting you with your referrals, answering any queries you may have or keeping you up to date with the developments and news at The Wellington Hospital. Whatever you need, the GP Liaison team are here, and happy to help. To get in contact with the GP Liaison officer for your area, please call the Enquiry Helpline on 020 7483 5148. Alternatively, contact details can be found on the back cover for each GP Liaison officer.
NEWS from the
The Wellington Hospital is an advocate for education and professional development; our seminars and events cover a range of topics from a variety of distinguished and experienced specialists. All seminars are free of charge and a certificate of attendance is provided for CPD points.
Events System This year we will be introducing a new way to book onto our events. This online system, which will act as an events calendar and booking system, means you can access information and book when it’s convenient for you - 24 hours a day, 7 days a week The new system is easy to use and makes booking much quicker. To start using this system all it takes is 5 easy steps: To open a new account visit www.twhevents.co.uk and then enter:
1. Your name, the practice you are based at, your job title and contact your details
2. How you would like to receive communication about our events
You’ll also be available to: • See a list of events that are available at The Wellington Hospital and confirm or cancel your attendance at chosen events. • Read a brief description about the talk/seminar, when and where it will be taking place, view the speakers’ profiles and the topics that will be covered. • See where the individual event is taking place, whether there is parking, disabled access and refreshments. You can also view or print a map, bring up information about the parking facilities, and even see live traffic conditions.
3. How you would like to receive attendance reminders, event
• Keep an eye on what events you have attended or are attending and how many seats are left for each event.
4. Accept our terms & conditions
• If there are spare seats and you think your colleagues may be interested - simply click on the Facebook, Twitter, RSS and LinkedIn icons to share information with them.
invitations and event news
5. Sign up to attend an event Once you have signed-up, you will be set up with your own profile, which you will be able to review and edit when you need.
The event system will be secure, so your personal details are safe. If you sign up and find the booking system isn’t for you, you have the option to close your account. And you can always book over the phone, by email or via fax. Tel: 020 7483 5031 Email: info@TWHevents.co.uk
NEW CONSULTANTS Cardiology
Professor Simon Redwood, Professor of Interventional Cardiology, Guys and St Thomas’
Dr Deepa Grover, Consultant Physician in HIV and Genito-Urinary Medicine, Royal Free Hospital
Dr Alisa Hart, Consultant Gastroenterologist, St Mark’s Hospital
Mr Daren Francis, Consultant General & Colorectal Surgeon, Chase Farm Hospital
Geriatric Medicine Dr Adam Webber, Consultant Geriatrician, Barnet Hospital
Enquiry Helpline: 020
Without a doubt the awareness and perceptions of cancer and oncology has been the most outstanding improvement. Cancer has become a subject that can be spoken about publicly and not in hushed tones. This openness has created a greater interest in nursing staff coming into the speciality and the general public becoming better informed. Laurie Thurlow, Modern Matron of the new Inpatient Oncology Unit, talks to us about oncology nursing and his time serving with the Royal Air Force Nursing Service. PM: What first drew you to nursing?
LT: I had enrolled at the Royal College of Art and Design to study threedimensional design, but my elder sister was already a nurse and had interested me in healthcare with her regaling stories of hospital life. Four weeks before I was due to come to London and begin my course I saw an advert for a pre-nursing course at a local college; I applied and was immediately accepted. Nine months later I had been accepted for student nurse training. PM: Why did oncology attract you? LT: I served for over 26 years with the Royal Air Force Nursing Service (PMRAFNS). The RAF medical service had been the lead in cancer care and I had been involved in looking after oncology patients on and off during my whole career. I later specialised in trauma and orthopaedics but retained special interest in bone tumours, innovative treatments utilising Endo Prosthetic Replacements in adolescents and the use of Ilizarov frames for massive bone loss. Innovative technologies in medicine really stimulate me to seek more knowledge about treatments that differ from standard oncological protocols. PM: What have been the biggest advances in oncology the last 10 years?
PM: Tell us about the new Inpatient Oncology Unit. LT: The unit comprises the main 12 bedded ward and is closely linked to the Breast Care Unit. Patients with cancer or oncological requirements who are admitted to The Wellington Hospital for surgical intervention can be transferred to the unit following their surgical procedure for continuation of their oncology treatment. PM: Being a modern matron is a demanding job, what do you enjoy the most about your job? LT: I’ve been a manager for many years in differing roles and in vastly different circumstances, but I find once you have developed certain skills they are transferable to so many roles, and I have enjoyed my own evolvement. Having spent so many years in military service I had picked up a particularly specialised set of skills that allowed for diverse and lateral thinking under extreme circumstances. The greatest comment I received was when a senior colleague chose me to go to a war zone and I asked ‘why me’? She said ‘it’s because you can flex in and flex out’; that ability gives me the greatest enjoyment in this role. PM: If you weren’t a Modern Matron, what would be doing? LT: I have often thought about this question and if it would be easy to pick up another role, especially when you perceive others having what looks like an easy life compared to you. But my greatest confidant (my Father) always told me that ‘even if it appears to be, the grass is never greener somewhere else’. So what would I be doing if I was not a Matron? I would be playing golf; I would be reading about Quantum Physics and I would be travelling a lot more.
LT: Without a doubt the awareness and perceptions of cancer and oncology has been the most outstanding improvement. Cancer has become a subject that can be spoken about publicly and not in hushed tones. This openness has created a greater interest in nursing staff coming into the speciality and the general public becoming better informed.
Dr Rob Stein, Consultant Medical Oncologist, UCLH
Mr Robert Lee, Consultant Orthopaedic Surgeon, RNOH Mr Giles Stafford, Consultant Orthopaedic Surgeon, Epsom General Hospital
Ophthalmology Mr Richard Bowman, Consultant Ophthalmologist, Great Ormond Street & Whipps Cross
Urology Mr Noor Buchholz, Consultant Urologist, The Royal London Mr Asif Muneer, Consultant Urologist, University College Hospital
For more information about the GP Liaison service, or to make a referral, please contact the GP Liaison Officer for your area: Katy Cross Central London
Ricky McKinson North & East London
Ricardo Pereira North West London
Veronica Brown Hertfordshire
07826 551 318 020 7483 5621
07889 317 769 020 7483 5620
07889 318 336 020 7483 5862
07889 317 774 020 7483 5863