pdf / 1.17MB - Bupa Cromwell Hospital

The Bupa Cromwell Hospital
magazine for General Practitioners
Issue 12
Published February 2015
In this issue
Pancreatic Cancer
Intracapsular Tonsillectomy
Irritable Bowel Syndrome
Breast Diseases
The Bupa Cromwell Hospital
magazine for General Practitioners
Issue 12
Published February 2015
REGULARS
We would love to
hear from you
03 Welcome and GP Liaison
04 News
In this issue
Pancreatic Cancer
Intracapsular Tonsillectomy
Irritable Bowel Syndrome
Breast Diseases
We always welcome feedback about MEDIscene. Please
let us know if there are any specific topics that you would
be interested to hear about in forthcoming issues. Email
your suggestions to [email protected].
New Biospheres
Diagnostic savings for self-pay patients
07
Intracapsular
tonsillectomy
Thank you
DEXA scanner upgrade
Multi-disciplinary teams
09 2015 Symposium Series
Follow us on Twitter
@BupaCromHosp
Like us on Facebook
facebook.com/BupaCromwell
FEATURES
BUPA CROMWELL HOSPITAL
07 Intracapsular tonsillectomy
WE OFFER
THE MOST
ADVANCED
RADIOTHERAPY
TREATMENTS
Mr Daniel Tweedie
11
Pancreatic cancer
Mr Andreas Prachalias
15 Breast diseases
Mr Ragheed Al Mufti
17 Irritable Bowel Syndrome
Dr Lisa Das
10 Consultant Q and A
Dr Matthew Wright
Consultant Cardiologist
13 New consultants
14 A conversation with...
A cancer diagnosis can be life-changing, wherever the disease is found. We understand the
challenges facing cancer patients, and have an international reputation for delivering exceptional
cancer care that is tailor-made for each patient.
An accurate diagnosis is essential to provide the most effective treatment. Our leading edge
diagnostic tests, from ultrasound to CT, ambient MRI and PET CT, can often be carried out on
the same day as an initial consultation with a Clinical Oncologist, and results given very quickly
afterwards. Treatment – whether chemotherapy, radiotherapy or surgery – is all carried out on-site,
so the whole patient journey takes place under one roof.
15
Breast
diseases
Bianca Parau, Dietitian for paediatrics and oncology
Front Cover: Pancreatic cancer, computer artwork.
SCIEPRO/SCIENCE PHOTO LIBRARY
We offer the most advanced radiotherapy treatments to give patients the greatest possible choice.
These include Gamma Knife - the gold standard for treating brain tumours - and TomoTherapy,
which is one of the most advanced, integrated cancer treatment systems available.
Our Gamma Knife centre was the first in London, and remains one of only seven across the UK. We
were the first in the UK to use TomoTherapy, and remain the only private hospital in the country to
use this leading technology.
We also offer high intensity focused ultrasound (HIFU) for prostate cancer, which uses sound
waves to heat up and kill cancer cells. This is a minimally invasive approach that has led to excellent
outcomes for prostate cancer patients.
For further information go to bupacromwellhospital.com or call 0800 783 9229.
01
MEDIscene - ISSUE 12
The opinions expressed in this magazine are the personal views of the
authors and do not necessarily reflect those of Bupa Cromwell Hospital.
cromwell direct 0800 783 9229
02
NEWS
New
Biospheres
THE
GP LIAISON
TEAM
Welcome to
MEDIscene
Welcome to MEDIscene issue 12, which includes four indepth articles from some of our leading consultants, staff
profiles and a number of exciting hospital updates. Articles
cover a new, minimally invasive form of tonsillectomy,
a breakdown of the different forms of bariatric surgery
and its role in treating diabetes, and guidance on how to
diagnose pancreatic cancer.
Last year was exceptionally busy at the Cromwell, and we
are looking to build on that success in 2015 by introducing
more services, continuing to develop our clinical multidisciplinary teams, and increasing our range of educational
events for GPs. We have also reviewed our prices for
self-pay outpatient diagnostics, and these are now highly
competitive (see page 4 for more information).
Our first GP symposium of the year took place in January
at our new venue, 30 Euston Square, and attracted almost
200 attendees for an overview of gastrointestinal and
colorectal conditions. Feedback on the speakers and
venue has been fantastic, so we look forward to seeing as
many of you as possible at future events (see the calendar
on page 9). Presentations from past events are available
in the ‘Doctors’ Lounge’ area of our website, so please
do sign up to access those – bupacromwellhospital.com/
doctorslounge.
As ever, do let me know if you have any feedback on the
magazine or on the hospital as a whole. I look forward to
seeing you at one of our educational or networking events
soon.
Three new ‘Biospheres’ have been installed
at the hospital; two in our Adult ICU and one
in our Paediatric ICU. These enable more
patients with compromised immunity to
infections such as hepatitis and MRSA to be
admitted.
The GP Liaison team provides a bespoke service for
GPs. We can assist you with any enquiries you may
have, and help facilitate patient referrals via Cromwell
Direct – 0800 783 9229. This is a dedicated line for GPs
wishing to refer patients (both children and adults) for
appointments with consultants, diagnostic tests and
admission to the hospital.
The units create an individually contained
environment, and this operates under a
negative airflow system to contain pathogens
and potential infections. They deliver
filtered air to the patient, and the air that
is re-circulated to the surrounding area is
fully conditioned to eliminate risks to fellow
patients.
We understand that GPs want to keep up to date with
new treatments, diagnostics and services, and work
closely with our consultants to coordinate our educational
programme. Please see the health professionals area of
our website for more information.
Amisha Patel is our GP Liaison Co-ordinator and will be
the first point of contact for educational events including
our symposium series.
We welcome our new GP Liaison Caireen Kelly, who is
looking forward to getting to know our GP community
over the coming months.
We would be happy to arrange a practice visit at a
convenient time for you in order to:
discuss the latest developments at the hospital
explore how we can work together more effectively
Reviewing diagnostic prices
for self-pay patients
introduce new consultants
If you would like to discuss your educational needs
and arrange a practice visit, or would like further
information about Bupa Cromwell Hospital, please
contact us:
Caireen Kelly
+44 (0)20 7460 5909
07714 368 680
caireen.kelly@
cromwellhospital.com
To provide the best possible service
for our patients through 2015, we
have reviewed the self-pay prices for
a number of key outpatient diagnostic
services, and these are highly
competitive.
Outpatient self-pay prices now offer
up to 30% savings on diagnostic
tests including: MRI, CT, PET CT and
ECG scans, physio appointments and
phlebotomy.
Amisha Patel
+44 (0)20 7460 5973
amisha.patel@
cromwellhospital.com
With warm regards,
Philippa Fieldhouse
General Manager
Bupa Cromwell Hospital
03
MEDIscene - ISSUE 12
We continually invest in the latest diagnostic technology,
and work with exceptional clinical teams and consultants
to analyse test results. These savings will enable even more
patients to access our excellent diagnostic services, all of
which are available under one roof.
In addition to diagnostic services, we have also been able
to apply a significant discount to a number of high cost
oncology drugs, and will continue to monitor costs to ensure
that patients are offered exceptional clinical and service
quality at a competitive price.
cromwell direct 0800 783 9229
04
NEWS
DEXA scanner upgrade
DEXA (Dual Energy X-ray Absorptiometry) scans are
used to diagnose osteoporosis and assess the risk of
osteoporosis developing in women aged over 50 and in
men over 60.
DEXA scans are preferable to routine X-rays in
assessing bone density, as they are more accurate
(a person would need to lose 20-30% of their bone
density before it will show on X-ray), and require less
radiation exposure than CT scans or plain X-rays. You
would be exposed to more radiation on a four hour
flight than during a DEXA scan.
BUPA CROMWELL HOSPITAL
ADVANCED
KIDNEY
DIALYSIS
We have recently upgraded our DEXA scanner with
the latest data sets, including the ability to calculate
both adult and paediatric bone density. This gives more
precise results regarding bone density and a WHO
classified risk of fracture (FRAX), resulting in better
treatment solutions for the patient.
NHS waiting times can be lengthy for DEXA scans and
Bupa Cromwell Hospital offers appointments at short
notice for £275.
To make an appointment call +44 (0)20 7460 5700
Multi-disciplinary Teams
Our clinical Multi-disciplinary Teams (MDTs) ensure that patients
receive the very best care at Bupa Cromwell Hospital.
Made up of a range of experts, from surgeons to radiologists,
oncologists and therapists, the MDTs ensure that patient cases
are discussed by a whole panel of experts to guarantee optimum
treatment guidance.
Our MDT meetings include:
breast
endocrine
Gamma Knife
heart
liver and
gastrointestinal
lung
neurosciences
prostate
“The MDTs provide us with a
fantastic opportunity to truly work
as an integrated team for the
ultimate benefit of our patients”
Kate Monaghan - Lung, Neuroscience and Sleep
Manager
05
MEDIscene - ISSUE 12
Our newly refurbished Dialysis Unit offers nine stations, with leading edge
technology that optimises patient comfort and frees up the operator to focus
on patient care. The unit is led by a Consultant Nephrologist and team of highly
experienced nurses.
We have installed the very latest Artis dialysis machines and a Spectra Optia
Apheresis machine. Bupa Cromwell Hospital is currently the only hospital
in London to use the Spectra Optia to its full capacity. This high tech blood
component separator can be used for plasma exchange, sickle cell, lipid cell
removal and stem cell harvesting. It offers a much more efficient service for
patients through: Continuous flow centrifugation technology with an Automated Interface
Management (AIM) system to improve patient safety
A single platform for customised procedures to satisfy unique patient needs
Easy data storage and retrieval, reducing manual data transcription and freeing
up staff for additional patient care
Bupa Cromwell Hospital provides isolation facilities and we are able to treat
patients with Blood Borne Virus. Our Dialysis Unit provides an exceptional quality
of service for patients.
To make an appointment call +44 (0)20 7460 5966
or email [email protected]
cromwell direct 0800 783 9229
06
FEATURES
FEATURE
Fig. 1: The Coblation®
wand gently ablates the
tonsil tissue in a highly
controlled fashion,
with minimal heat and
collateral tissue damage,
and no bleeding.
An effective, safe and minimally-invasive alternative to
traditional tonsil surgery, with much faster recovery
T
onsillectomy remains one of the most commonly
performed procedures in the UK, with over 50,000
carried out each year. This is particularly the case in the
paediatric population, with increasing recognition of its
value in the management of obstructive sleep apnoea
(OSA) in ever younger patients.
But traditional extracapsular tonsillectomy by various
methods still has high rates of morbidity, including pain,
delayed discharge, haemorrhage (3-5% of cases) and a
recognised mortality risk. This is because the underlying
pharyngeal muscle is exposed as the tonsils are stripped
off, together with the surrounding capsule. The muscle
is very sensitive and takes up to two weeks to heal, and
it is perforated by large blood vessels which have to be
cauterised or tied off during the surgery, and may bleed
profusely during or after the procedure.
With intracapsular tonsillectomy, which has been used
as an alternative in the USA and parts of Europe, the
tonsil tissue is removed from within the surrounding
fibrous capsule, which is left intact. Unlike traditional
methods, the remaining capsule protects the sensitive
underlying muscle and blood vessels from injury, with
benefits in terms of speeding up recovery, reducing
analgesic requirements and minimising the risks of
haemorrhage.
Underlying muscle and
blood vessels are not
encountered.
Diagram courtesy of
Arthrocare®.
The ablation of the tonsil tissue effectively dissolves it
away, until the inner fibrous capsule is reached and thin
islands of denatured tonsil tissue are all that remains. No
tonsil crypts are left to trap bacteria and cause tonsillitis,
and regrowth is also therefore highly unlikely. Additionally,
the underlying muscle and blood vessels are not exposed
at all, and intraoperative blood loss is typically negligible.
Local anaesthetic is applied topically at the end of
the procedure, which takes a total of 15-20 minutes.
Adenoidectomy can be performed in addition, using the
same equipment.
Fig.2: Appearances before
Coblation® intracapsular
tonsillectomy (left)
Here I present my experience of using Coblation®
(cold radiofrequency ablation) intracapsular
tonsillectomy at Evelina London Children’s Hospital;
the first and largest prospective series of its type in
the UK.
Patients and methods
I have prospectively evaluated 300 consecutive
paediatric patients undergoing Coblation®
intracapsular tonsillectomy (+/- adenoidectomy) for
obstructive and / or infective (tonsillitis) indications,
and experience from the first 100 cases has been
published (1).
All patients have open access in the event of
problems, and all are followed up after surgery.
Parents are asked to complete validated tonsil
symptom quality of life questionnaires before the
procedure and at follow up, and are also asked
about their children’s post-operative analgesic
requirements, return to normal activities and whether
or not they would recommend the surgery to other
parents.
Photo - © Science Photo Library
Surgical procedure
Coblation® refers to a range of “cold” radio frequency
ablation (RFA) equipment marketed by Arthrocare®
Corporation, part of Smith and Nephew®, which has
US FDA approval. Radio frequency current is delivered
by electrodes at the tip of a probe (“wand”), which also
incorporates a suction channel and saline irrigation. The
radio frequency energy excites electrolytes within the
saline to form a focused gas “plasma”. This ablates tissue
by breaking down molecular bonds, and fragmented
debris is aspirated via the suction channel.
07
Very precise removal of tissue is achieved at low
temperatures (40-50°C), with simultaneous coagulation
of small vessels and minimal collateral tissue injury. The
technology does not involve any charring, burning or
cauterisation, in contrast to traditional “hot” cauterisation
techniques (monopolar and bipolar diathermy, and laser).
MEDIscene - ISSUE 12
Otherwise, parents report that their children are able to
return to normal activities straight away, including playing
with friends, riding a bike or bouncing on a trampoline the
day after surgery. Patients are allowed to return to school
or nursery as soon as their parents feel that they are ready.
The current mean time to return to education is 5.6 days,
but some children return in as little as three days.
Complications and sequelae
There have been no delayed discharges or readmissions
because of pain in this series of 300 cases. None of the
patients has required additional opiate or other analgesia
at home, or via their GP. Nor have there been any primary
haemorrhages. Two cases had small-volume (50ml)
secondary haemorrhages after one week, but these settled
immediately without any intervention.
Symptomatic regrowth rates have been very low. Two
cases, both with severe OSA, who first underwent surgery
at one year of age, had modest regrowth and required
revision treatment. One child also had revision surgery
for recurrent tonsillitis in the tonsil residues. Interestingly,
the respective parents were still delighted with their
treatment, and would have undertaken the same original
surgery again, given the choice. The overwhelming
majority of cases have had no problems at all postoperatively.
Parental feedback
Over 99% of parents said that they would recommend the
procedure to others, and two sets of parents said they
were unsure. There has been an exceptionally positive
response, and in particular to the children’s rapid recovery
and absence of any significant post-operative problems.
Older teenagers and adult patients who were not part of
this study have also reported similar positive experiences,
with rapid recovery and minimal pain, and only simple
analgesia.
Conclusions
Coblation® intracapsular tonsillectomy has proved to be
an extremely effective and well-tolerated procedure in a
traditionally high-risk tertiary paediatric population. It has
allowed a rapid return to normal activities and education,
and complication rates have been very low to date.
The response from children and parents has been
overwhelmingly positive, and I anticipate that this
technique will have wider applications in both children and
adults, for obstructive and infective indications.
Appearances
immediately after
Coblation® intracapsular
tonsillectomy (right)
Nine months after treatment
(left). Minimal tonsil tissue
remains, there is negligible
blood loss and the
surrounding tissues are not
injured.
Post-operative recovery
The vast majority of patients, even very young children,
are able to eat and drink normally straight away and to go
home as day cases, unless circumstances are unfavourable
(age under three years, comorbidities, severe OSA, or
isolated home address).
I offer only regular paracetamol and ibuprofen for one
week (opiates are not needed, even in teenagers),
together with co-amoxiclav to reduce halitosis as the
tissues heal.
The mean duration of analgesia in my series is 6.8 days.
Parents do not report a worsening of pain over several
days, as is often seen after traditional extracapsular
tonsillectomy.
1 - Hadjisymeou S, Modayil PC, Dean H, Jonas NE, Tweedie DJ.
Our experience. Coblation® intracapsular tonsillectomy (tonsillotomy)
in children: a prospective study of 100 consecutive cases. Clin
Otolaryngol. 2014 Oct;39(5):301-7.
Mr Daniel Tweedie MA(Cantab)
FRCS(ORL-HNS) DCH is a
Consultant Paediatric ENT, Head
and Neck Surgeon at Evelina
London Children’s Hospital, Guy’s
and St Thomas’ NHS Foundation
Trust and Bupa Cromwell Hospital.
To make an appointment please
call 0800 783 9229
cromwell direct 0800 783 9229
08
INTERVIEW
BUPA CROMWELL HOSPITAL
Dr Matt Wright
SYMPOSIUM
SERIES 2015
CCT Cardiology MRCP MB BS PhD, Consultant Cardiologist
Our 2015 lecture series continues at 30 Euston Square, the home
of the Royal College of General Practitioners. The series is led by
our renowned consultants, many of whom are from London’s top
teaching hospitals, to bring you the latest updates and advances in
healthcare. Topics have been tailored with primary care GPs in mind.
We hope to see you there.
Saturdays: 9.00am-2.00pm
30 Euston Square
London NW1 2FB
14 MARCH Neurosciences
25 APRILEndocrine
20 JUNELiver and renal
10 OCTOBER
Common concepts in primary care
21 NOVEMBER
Musculoskeletal
how to register
t: 020 7460 5973
e: [email protected]
w: register online at bupacromwellhospital.com/GPevents
Scan QR code to go directly to our registration page
Dr Matt Wright CCT Cardiology MRCP MB BS PhD, is a consultant cardiologist at Bupa
Cromwell Hospital and St Thomas’ Hospital. He has published over 70 scientific papers and
books and is regularly asked to speak at major international meetings. He performs ‘live’ AF
ablation cases to teach European electrophysiologists, has ongoing research collaborations
internationally, and acts as a proctor to electrophysiologists in Europe and the Middle East.
t: +44 (0)20 7460 5700 (appointments)
Clinics are on an ad-hoc basis.
Why did you study medicine?
I was in hospital for ten days following surgery when I
was 14, and it just seemed a fun place to be. The doctor
came round with a very friendly team of junior doctors
and nurses, cheered me up and went on to see the next
patient. I just thought that was far more interesting
that being stuck behind a desk, and it led me to pursue
medicine.
Can you tell us about a project that you consider to be
significant to your career?
What made you pursue your speciality?
I had a very enthusiastic
physiology teacher and
found that area particularly
interesting so did a second
year PhD course at UCL.
From then on I was doing
research within a cardiology
department and my route to
becoming a cardiologist was
set.
That was so informative because I was taught how
to achieve their very high
standards. Quality is very
important to me and it’s
hard to compare doctors
and hospitals because the
information isn’t available,
which is a travesty. Reputation
is via word of mouth and it’s
very difficult for a normal
professional to understand
academic and clinical
differences.
The PhD at UCL was very important in setting me on
my career path, and the next significant thing was
spending two years in Bordeaux with the world’s premier
electrophysiologists; Michel Hassiger and Professor Pierre
Giest. I was working 18 hour days, doing nothing but Atrial
Fibrillation (AF) – either operating or doing research.
Consultant
What is the most challenging
part of your job?
Trying to effect change,
because we can all do things
better. Trying to encourage
people to improve things
when they’ve been doing
something in a certain way
for a long time. Change
will come whether we like
it or not – especially with
medicine, where things
change rapidly due to
research, and encouraging
everyone to share a vision of
how to improve things can be
difficult.
What is the most rewarding
part of your job?
Clinically, it’s seeing patients a year after you’ve operated
on them, and having them tell you how grateful they are
that they went ahead with the operation after initially
having reservations about it. Academically, it’s when you
present work that makes a difference, and managerially it’s
effecting a change through positive patient feedback and
staff jumping on board.
Can you describe a typical working day at Bupa Cromwell?
I usually get up at about 6:00am and am at work until
around 7:00pm. I see patients in clinic, explain to them
what their problem is – they might come with a heart
rhythm disturbance, palpitations, dizziness or a loss
of consciousness that may result in extreme tiredness.
Typically I would also do an operation; either a minimally
invasive procedure like passing wires from the groin to see
how electricity passes through their heart, or inserting a
pacemaker or defibrillator.
What do you enjoy doing in
your spare time/hobbies?
I have two children, a three
year old and a 5 week old
– both boys. My hobby is
basically looking after them
as the rest of the time I’m
working! My other interest is
Bordeaux wine – I was there
for two years and got taken
out for quite a lot of dinners!
What is your most prized
possession?
My wife. We’ve been married
for 6 years.
Where is your favourite place in the world?
London. I love it here. You can always go to different
places and think this is amazing – but you’re on holiday.
London has it all - you can walk everywhere, there are
great theatres and restaurants, garden squares, amazing
parks – which I see a lot of with the boys.
The best soundtrack for a dinner party is...?
LTJ Bukem (jazzy drum and bass).
If you had one super power what would it be and why?
Flying – getting from A to B with no traffic. The efficiency
is appealing!
If you could be any biscuit, what biscuit would you be and
why?
Ginger snap – spicy, tough nut, interesting and a bit firey!
If you were a movie character who would you be?
James Bond.
cromwell direct 0800 783 9229
10
FEATURE
Possible risk factors
• diabetes mellitus, glucose metabolism, and insulin
resistance
• helicobacter pylori infection
• coffee and alcohol consumption
• diet (high intake of saturated fat and/or meat,
particularly smoked or processed meats)
• aspirin and NSAID use
CLINICAL PRESENTATION
The initial presentation of pancreatic
cancer varies according to tumour
location. 60 - 70% of tumours
are localised to the head of the
pancreas, while 20 – 25% are in
the body or tail and the remainder
involve the whole organ.
The most common presenting
symptoms in patients with head of
pancreas tumour are pain, jaundice,
steatorrhea, and weight loss. The
pain is usually insidious in onset,
and present for one to two months
at the time of presentation. It has
a typical gnawing visceral quality,
and is generally localised to the
upper abdomen, radiating to the
sides or through to the back. It may
be intermittent and made worse by
eating or lying supine. It is frequently
worse at night. Severe back pain
should raise suspicion of a tumour
arising in the body and tail of the
pancreas.
Jaundice, which is usually progressive,
is most often due to obstruction of
the common bile duct by a mass
in the head of the pancreas, which
causes hyperbilirubinemia, and
may be accompanied by pruritus,
darkening of the urine, and pale
stools. Jaundice secondary to a
tumour in the pancreas body or tail
typically occurs later in the course of
the disease, and may be secondary to
liver metastases.
A recent onset of atypical diabetes
mellitus may be noted. Unexplained
superficial thrombophlebitis,
which may be migratory (classic
Trousseau’s syndrome), is
sometimes present and reflects
the hypercoagulable state that
frequently accompanies pancreatic
cancer.
Skin manifestations occur as
paraneoplastic phenomena in some
patients (cicatricial and bullous
pemphigoid). Signs of metastatic
disease may be apparent at
presentation, and most commonly
affect the liver, peritoneum, lungs,
and (less frequently) bone.
The most frequent findings on examination are:
• jaundice
• Courvoisier’s sign (nontender but palpable distended
gallbladder at the right costal margin)
• hepatomegaly
• epigastric mass
• right upper quadrant mass
• ascites
• cachexia
DIAGNOSTIC APPROACH
CANCER
Pancreatic adenocarcinoma is a highly lethal malignancy. The commonly used term “pancreatic cancer” usually refers to
a ductal adenocarcinoma of the pancreas, which represents about 85 percent of all pancreatic neoplasms.
Photo - © Science Photo Library
EPIDEMIOLOGY
11
Worldwide, pancreatic cancer is the
eighth leading cause of cancer deaths
in men (138,100 deaths annually) and
the ninth in women (127,900 deaths
annually). In general the disease
affects more people in the developed
world, and whilst it is rare before the
age of 45, the incidence rises sharply
thereafter. The incidence is greater
in men than women (at a ratio of
1.3:1) and in those of African descent
compared to Caucasian populations
(14.8 per 100,000 of black males
compared to 8.8 per 100,000 in the
Caucasian male population).
The major risk factors for pancreatic cancer are:
• smoking
• high BMI and lack of physical activity
• familial pancreatic cancer
MEDIscene - ISSUE 12
• inherited cancer susceptibility syndromes (Hereditary
Breast and Ovarian Cancer, Peutz-Jeghers syndrome,
Familial atypical multiple-mole melanoma (FAMMM)
syndrome, Ataxia-telangiectasia Lynch syndrome
and Familial Adenomatous Polyposis, Li-Fraumeni
syndrome)
It is not possible to reliably diagnose
a patient with pancreatic cancer
based on symptoms and signs alone.
Awareness of risk factors may lead
to an earlier and more aggressive
evaluation in patients who present
with symptoms suspicious for the
disease. Specific tests used in the
initial evaluation include:Transabdominal ultrasound
The initial study in patients who
present with obstructive jaundice
or epigastric pain and weight loss
is often transabdominal ultrasound
(US). The reported sensitivity
for US in diagnosing pancreatic
cancer is 95% for tumours greater
than 3cm, but it is much less for
smaller tumours. Sensitivity is also
dependent on the expertise of the
ultrasonographer and the presence or
absence of bile duct obstruction.
Abdominal CT
The typical CT appearance of an
exocrine pancreatic cancer is an illdefined hypoattenuating mass within
the pancreas, although smaller lesions
may be isoattenuating. Secondary
signs of a pancreatic cancer include
a pancreatic duct cutoff, dilatation of
the pancreatic duct or common bile
duct (double duct sign) parenchymal
atrophy, and contour abnormalities.
Endoscopic retrograde
cholangiopancreatography (ERCP)
ERCP has a sensitivity of 92% and
specificity of 96% for diagnosing
cancer of the pancreas. Findings
suggestive of a malignant tumour
within the head of the pancreas
include superimposable strictures or
obstruction of the common bile and
pancreatic ducts, a pancreatic duct
stricture in excess of 1cm in length,
pancreatic duct obstruction, and the
absence of changes suggestive of
chronic pancreatitis. Furthermore,
ERCP provides an opportunity to
collect tissue samples for histologic
diagnosis.
MRCP
MRCP is more effective than CT in
defining the anatomy of the biliary
tree and pancreatic duct. It has the
capability to evaluate the bile ducts
both above and below a stricture.
Tumour markers (Ca 19-9)
Given the limited sensitivity and
specificity, the serum tumour marker
CA 19-9 should not be used as a
diagnostic test for pancreatic cancer.
Endoscopic ultrasound (EUS)
EUS may be more accurate for
smaller tumours and for predicting
vascular invasion.
Histologic confirmation is required
to establish a diagnosis of pancreatic
cancer. Patients who are fit for major
surgery and who appear to have
potentially resectable pancreatic
cancer do not necessarily need
a preoperative biopsy. When it is
indicated, biopsy of a pancreatic
mass can be accomplished either
percutaneously via radiology or via
EUS.
The preferred staging system for
pancreatic adenocarcimoma is the
tumour-node-metastasis system
TNM*.
TREATMENT
Surgical resection is the only
potentially curative treatment
for pancreatic adenocarcinoma.
Unfortunately, because of late
presentation, only 15 – 20%
of patients are candidates for
pancreatectomy. 40% have distant
metastases, and another 30 - 40%
have locally advanced unresectable
tumours.
Disease that is limited to the pancreas
and peripancreatic nodes is most
likely to be cured by resection.
Tumours with limited involvement
of the major peripancreatic vessels
such as the superior mesenteric
vein, portal vein, superior mesenteric
artery, or hepatic artery may be
technically resectable.
cromwell direct 0800 783 9229
12
INTERVIEW
Some cases are considered
“borderline” resectable, although the
definition is variable.
advanced nonmetastatic disease.
Patients with a good response may
become potential surgical candidates.
Absolute contraindications to
resection include the presence of
metastases in the liver, peritoneum,
omentum, or any extra-abdominal
site. Other indications include
encasement (more than half of
the vessel circumference) or
occlusion of the superior mesenteric
artery, unreconstructable superior
mesenteric vein (SMV) or direct
involvement of the inferior vena cava,
aorta, or celiac axis.
All patients with resected pancreatic
cancer, including those with T1N0
disease, should be offered adjuvant
therapy after resection. Palliative
treatment with or without systemic
chemotherapy is designed to control
the progression of unresectable or
recurrent pancreatic cancer, and can
provide relief of obstructive jaundice,
gastric outlet obstruction, pain, and
pancreatic exocrine insufficiency.
The conventional operation for
cancer of the head or uncinate
process of the pancreas is
pancreaticoduodenectomy. The
conventional form (known as
the Whipple procedure) involves
removal of the pancreatic head,
duodenum, first 15cm of the jejunum,
common bile duct and gallbladder,
and a partial gastrectomy. Pyloruspreserving pancreaticoduodenectomy
meanwhile preserves the gastric
antrum, pylorus, and the proximal
3-4cm of the duodenum.
PROGNOSIS
Five-year survival after
pancreaticoduodenectomy is about
25 - 30% for node-negative and 10%
for node-positive disease. The median
survival is 8 to 12 months for patients
with locally advanced, unresectable
pancreatic cancer and only three to
six months for those with metastatic
disease at presentation.
Surgical resection of cancers
located in the body or tail of
the pancreas consists of a distal
subtotal pancreatectomy, usually
combined with splenectomy. Total
pancreatectomy is sometimes
required to achieve a microscopically
negative resection margin or
for tumours involving the entire
pancreas.
Following the development of
combination chemotherapy,
many institutions have embraced
neoadjuvant combination
chemotherapy with or without
radiotherapy for patients with locally
Pancreatic Cancer
in the UK
5%
The three year
survival rate
8,800
The number of people
diagnosed with
pancreatic cancer in
2011 in the UK - that’s
24 people every day
5th
Pancreatic cancer
is the fifth most
common cause of
cancer death in men
in the UK with around
4,700 deaths in 2012
Mr Andreas Prachalias MBBS MD is a
Consultant Hepatobiliary Surgeon
at King’s College Hospital and Bupa
Cromwell Hospital.
To make an appointment please
call 0800 783 9229
75
and over - the age
of almost half of
all deaths from
pancreatic cancer
cancerresearchuk.org
NEW CONSULTANTS
Bupa Cromwell Hospital gives a warm welcome to the consultants below who were recently granted Practice Privileges.
Our consultants are committed to an extremely high level of care and provide an excellent service to our patients. We are
delighted to offer the innovation and expertise of the following new consultants at the hospital:
Dr Georg Auzinger
Consultant Intensivist (Liver Transplantation)
Adult Privileges
Dr Charl Jooste
Consultant Anaesthetist
Adult Privileges
Professor Julia Wendon
Consultant Intensivist (Liver Transplantation)
Adult Privileges
Dr Christopher Willars
Consultant Intensivist (Liver Transplantation)
Adult Privileges
The following two consultants have had their Practice Privileges updated:
Professor Loïc Lang-Lazdunski : Consultant Thoracic Surgeon (granted Paediatric Privileges)
Dr Ranjan Suri: Consultant in Respiratory Paediatrics (Paediatric age range increased from 16 year olds to 18 year olds)
13
MEDIscene - ISSUE 12
A CO N V E R SAT I O N W I T H
Our Dietitian for Paediatrics and Oncology
Bianca
Parau
W
hat made you want to become a
dietitian?
I have always been interested in
nutrition and come from a family who
are quite health conscious, so thinking
about what I eat comes naturally
to me. Nutrition and Dietetics is a
very versatile career offering many
avenues to pursue such as public
health speaking, clinical work in
hospital and community settings
as well as writing and publishing.
I trained in South Africa, where
I worked for three years before
relocating to England initially working
in the NHS and joining the Bupa
Cromwell team in 2010.
W
hat’s the best thing about your
job?
I love the variety of the work and
the fact that you can really make a
difference to somebody’s life. Eating
is a very sociable and emotional
aspect of life and people can become
miserable if their diet isn’t working
for them. Those with allergies or
intolerances can really struggle when
they don’t know what to eat, so it is
rewarding to be able to help them and
see that they are feeling better and
enjoying food again.
W
hat is the hardest thing about
your job?
Seeing patients who are clinically very
unwell, and there is not a lot you can
do nutritionally, sometimes it feels
that you are not able to help them
which can be hard.
H
ow would a patient end up seeing
a dietitian?
People can refer themselves, but
they are usually referred through
a GP, consultant or Allied Health
Professional. As a dietitian I would
typically see any patient diagnosed
with a medical condition where diet
manipulation and adjustment is
required in addition to disease specific
medication etc.
W
hat is an average day like for
you?
The day generally starts with
responding to emails and doing
administration. In-patient menus get
checked and altered every day, so I
go over these in the kitchen to ensure
that patients on specific diets have
ordered suitable foods before it is
prepared and served at mealtimes.
The majority of the morning will
be spent on ward rounds, where I
check on in-patients’ progress from
a nutritional perspective and deliver
nutritional supplements etc. My
out-patient clinics are usually in the
afternoon (although I occasionally see
patients in the mornings if required),
which involves consultations with
patients, supplying individually
tailored treatment plans and writing
up reports.
I
s this role different in the NHS to the
private sector?
We work with more international
patients here at Bupa Cromwell
Hospital than you normally would in
the NHS, and we are very lucky to
have dedicated interpreters onsite which makes things a lot easier.
Also our international patients have
different nutritional treatments and
products in their home countries, so
we spend a lot of time finding similar
treatments to what they are used to.
In the private sector you are not as
pressed for time as in the NHS, so
you can spend quality time with all
your patients, listening to their needs
without feeling rushed.
W
hat advice would you give to
someone hoping to follow in
your footsteps?
Becoming a dietitian is very enriching,
rewarding and never boring. Not only
will you be able to change patients’
lives but you will ultimately also
change your own. Being equipped
with this vast knowledge on nutrients
and your body inspires to live a
happier and healthier life. There are
also numerous courses and training
opportunities if you wish to specialise
in a specific area.
To make an appointment with the
dietitians please phone:
+44 (0)20 7460 5566
9:00am-5:00pm Monday to Friday
cromwell direct 0800 783 9229
14
Breast Diseases
Breast symptoms are very common, and the majority of patients presenting to the Breast Surgical Clinic have benign
conditions. The most common presenting symptoms (in over two-thirds of patients) are a specific breast lump or a painful
‘lumpiness’ of the breast.
When a patient presents at a GP surgery with a breast lump, lumpiness or nipple symptoms, the concern is always whether
this may be cancer rather than something that can be managed by the GP. National BASO Guidelines have been issued
concerning early referrals to the breast clinic (these are updated regularly), and urgent referral to the breast clinic is
needed in a significant number of cases.
Although benign breast lumps are far more common than malignant ones, breast cancer is the most common cancer for
women in the UK, with 1 in 8 women in England expected to develop the disease in their lifetime, and 1 in 20 to die as a
result. The rate of breast cancer diagnosis has more than tripled over the past three decades, but breast cancer mortality
has gone down from 69% in 1979 to 21% in 2010, mostly due to earlier diagnosis and better multi-disciplinary team
management.
The best historical example of a breast cancer was illustrated in the famous painting by Rembrandt, “Bathsheba bathing”.
The model was Rembrandt’s mistress, and he clearly demonstrated the lump and associated skin indentation from the
cancer in her left breast, as shown on the right.
When a patient presents to the GP with a breast lump, an assessment of the characteristics of the lump is necessary
to determine if it is discrete or a diffuse nodularity. A discrete lump stands out from the surrounding breast tissue, and
is usually felt with measurable borders, whilst a generalised nodularity is ill-defined lumpiness which changes with the
menstrual cycle and is often present in both breasts.
Over 90% of patients seen at the breast clinic with a lump have a benign lump, but a full urgent assessment of any lump is
important to rule out cancer. A cancerous lump can often look or feel the same as a benign one, and only triple assessment
in a rapid access breast clinic would make the diagnosis. Triple assessment includes a clinical surgical examination, breast
imaging (mammography and/or ultrasound) and cytology/ histology assessment.
Conditions that require referral to the Rapid Access
Breast clinic
Photo - ‘Bathsheba Bathing’ - Rembrandt © Agence Photographique de la Réunion des musées nationaux
All patients with a discrete breast mass or lump.
Fine needle aspiration by General Practitioners is not
recommended.
15
Any multi-duct nipple discharge in patients aged over 50
years.
Any single-duct nipple discharge in women of any age.
Bloodstained, persistent or troublesome discharge in
women of all ages.
Severe mastalgia that interferes with the patient’s
lifestyle or sleep, which has failed to respond to wearing
a well-fitted supporting bra and common analgesia
medications.
Nipple retraction and distortion, changes in skin contour
or any nipple eczema.
Asymmetrical nodularity that persists after menstruation.
Request for assessment of a patient with high risk family
history of breast cancer.
Patients who have tested positive for the breast cancer
gene mutation (BRCA 1&2).
Patients with developmental and congenital breast
abnormality.
Patients with macromastia, especially causing neck and
back pain.
The differences between NHS and private breast clinics
Breast clinics in the NHS have been established to run as
“One-Stop / Rapid Access” clinics, in which patients are
seen urgently and receive a full breast assessment (history,
clinical examination, breast imaging and cytology/
histology). Until recent years, the set-up in the NHS was
well organised, but financial restraints have put pressure
on the NHS Rapid Access Clinics, and diagnosis and
assessment can often be delayed (taking up to three
or four weeks before the final diagnosis is made), up to
three visits required instead of one-stop assessments, and
appointments required. The rise of high quality ‘Rapid
MEDIscene - ISSUE 12
Access’ breast assessment clinics in the private sector
offers an attractive alternative for many patients.
allowing patients with cancer to proceed to treatment very
quickly, and offering swift reassurance for patients with a
benign lump or condition. It can establish a diagnosis of
a cancerous breast lump in a high proportion of patients,
although they may require further tests to confirm the
breast cancer diagnosis.
The Family Breast Cancer Clinic
The One-Stop breast clinics at Bupa Cromwell Hospital
are supported by a specialist breast multi-disciplinary
team, where leading breast surgeons, radiologists, cytopathologists and the breast care specialist nurse discuss all
patient cases to ensure the highest quality clinical service.
It is recommended that any patient who has a very
strong family history of breast cancer should be referred
to a specialist family breast cancer clinic (part of Bupa
Cromwell Hospital’s Rapid Access Breast Clinic), as they
will require a special breast screening programme and
genetic counselling to identify any inherited or genetic
predisposition.
The concept of the One-Stop clinic is summarised below:
Patient with a breast lump or symptoms of concern
Patients with a family history of breast cancer fall into
three categories; low, moderate and high risk. Thankfully
90-95% of patients with a family history of breast cancer
fall into the low cancer risk category, and only a very small
minority have a high risk of developing breast cancer.
Referred to the One-Stop Rapid-Access Breast Clinic
The patient is seen by a Specialist Consultant Breast
Surgeon
Clinical Examination
Breast Imaging by a Specialist Radiologist
(e.g. Mammogram, Ultrasound Scan)
Breast Assessment Services at Bupa Cromwell Hospital
Patients coming to Bupa Cromwell Hospital’s Breast Clinic
are seen within a couple of days of the referral, are offered
a triple assessment during the first appointment, and
usually given the diagnosis and treatment plans in a onestop clinical set-up.
Fine Needle Aspiration Cytology and/or Core Biopsy
Patient seen again at the same clinic by the Specialist Surgeon
to discuss the results and plan any necessary treatment
The BASO (British Association of Surgical Oncology)
guidelines indicate that all patients with breast symptoms
that require a One-Stop clinic assessment should be seen
within two weeks, and that treatment for cancer should
be scheduled within four weeks. However, in view of the
limited staff, facilities and resources in the NHS, these time
limits are only met in up to 85% of clinic waiting times and
70% of treatment waiting times across the country.
Thus why some patients who get their initial assessment
carried out at a One-Stop NHS clinic then opt to have
their treatment carried out privately. They can have their
treatment or surgery for the cancer carried out urgently,
by a senior consultant onco-plastic specialist breast
surgeon. All subsequent specialist scans and tests are
carried out very quickly (within a couple of days), without
any delay in the patient’s management (an MRI scan for
example is done within 1-2 days, instead of 2-3 weeks in
the NHS).
Mr Ragheed Al Mufti MB
BCh BAO MSc,MD(QUB)
FRCS(Eng) FRCSEd(GenSurg)
is a Consultant Breast/General
Surgeon at Bupa Cromwell Hospital
and St Mary’s Hospital.
To make an appointment please
call 0800 783 9229
The One-Stop Breast Assessment Clinic at Bupa
Cromwell Hospital
Bupa Cromwell’s One-Stop breast clinic offers a
comprehensive assessment of patients with any breast
symptoms in a safe, rapid and caring environment. An initial
clinical assessment is carried out by a consultant breast
surgeon, who would then request an urgent mammogram,
ultrasound scan, MRI, cytology or a core biopsy.
Tests are carried out during the same visit wherever
possible (subject to availability) and a diagnosis made
within a couple of hours (or within 48 hours of the patient’s
initial assessment). The service offers speed and accuracy,
cromwell direct 0800 783 9229
16
Irritable
BOWEL
Irritable bowel syndrome (IBS) is a
complex disorder that is associated
with altered gastrointestinal motility,
secretion and sensation. IBS has
a significant impact on quality of
life and healthcare utilisation, and
it remains a clinical challenge even
in 2015. It is the most commonly
diagnosed gastrointestinal condition,
and the most common reason for
referral to our clinics. The prevalence
is worldwide, and it may affect up to
one in five people at some point in
their lives.
Why is this disorder so challenging
when many describe it as ‘just IBS’?
The conundrum lies in the many
manifestations of IBS, and the fact
that it cannot be confirmed by a
specific test or structural abnormality.
Photo - © Science Photo Library
Gastroenterologists diagnose IBS
clinically using criteria based on the
patient’s history and symptoms,
according to the current gold
standard of the Rome III criteria*.
There is no clinical evidence to
recommend the use of biomarkers
in blood to diagnose IBS. Various
mechanisms and theories have been
proposed about its aetiology, but the
biopsychosocial model is the most
accepted.
17
There is no single definitive treatment
for IBS, so traditional management
has been symptom based. There have,
however, been recent developments
in the understanding of the complex
interaction between the gut, immune
system and nervous system, leading
to an expanded range of therapeutic
options for relief of both bowel
movement related symptoms and
pain. As ever though, a strong doctorpatient relationship remains the
key for the management of realistic
expectations and effective treatment
of patients.
Recent guidelines from AGA
(American Gastroenterological
Association) emphasise that IBS is
no longer a diagnosis of exclusion.
Instead clinicians are encouraged to
make a positive diagnosis using the
Rome III Criteria alone. To this end the
definition of IBS has been simplified
to that of the typical manifestations
MEDIscene - ISSUE 12
SYNDROME
being discomfort or abdominal pain
relieved by defecation, associated
with a change in stool form.
Patients with IBS can present
with a variety of symptoms which
include both GI and extraintestinal
complaints. Factors such as emotional
stress and eating may exacerbate
pain. In contrast, defecation usually
provides some relief. Patients with
IBS complain of altered bowel habits,
ranging from diarrhoea (IBS-D),
constipation (IBS-C), or alternating
diarrhoea and constipation (IBS-M).
The
prevalence
is worldwide,
and it may affect up
to one in five people
at some point in
their lives.
Other red flags noted during the
history must not be neglected. Large
volume or nocturnal diarrhoea, bloody
stools, anaemia or weight loss are
not associated with IBS and suggest
organic disease requiring further,
often urgent investigation.
Patients with IBS-C may experience a
sensation of incomplete evacuation,
and periods of constipation may last
from days to months, alternating with
diarrhoea or normal bowel function.
Abdominal bloating or the feeling
of abdominal distension are very
frequent complaints in IBS and are not
represented in the Rome III criteria.
They were however highlighted in
the 1978 Manning criteria** which
preceded the development of the
Rome definitions.
Other digestive symptoms such as
dysphagia, intermittent dyspepsia,
nausea and non-cardiac chest pain
are also often associated with IBS.
Moreover, extraintestinal symptoms
such as psychiatric disorders,
especially depression, anxiety
and somatoform disorders occur
frequently in IBS.
The non GI, non psychiatric disorders
with the best documented association
with IBS are fibromyalgia, chronic
fatigue syndrome, temporal
mandibular joint disorder, chronic
pelvic pain and headaches. These
comorbidities are correlated with
enhanced medical seeking behaviours,
worse prognosis, and higher rates of
anxiety and depression, which all
result in a reduced quality of life.
The prompt identification of these
clinical problems may improve the
therapeutic options and prevention
strategies in many patients.
The basic diagnosis should include
a careful and thorough medical
history. Having identified a symptom
complex compatible with IBS based
upon Rome III criteria, patients with
no alarm symptoms or family history
of IBD (inflammatory bowel disease)
or colorectal cancer may only require
a limited number of diagnostic
studies to exclude organic disease. A
considerable number of patients will
not require any tests at all. This limited
diagnostic approach excludes organic
disease in more than 95% of patients,
and it is rare to use abdominal imaging
tests for patients with suspected IBS
and no alarm features.
monosaccharides, and polyols) diet
is now accepted as an effective
potential strategy for managing the
symptoms of IBS, but limitations still
exist due to the fundamental difficulty
of placebo control in dietary trials,
and the difficulty of maintaining such
a diet in a chronic condition.
In general, IBS patients should avoid
foods that trigger an onset of their
symptoms, consume a minimum of
high fat foods and take part in regular
physical activity. Regarding other
treatment options, Bifidobacteria,
Saccharomyces boulardii and
other combinations of probiotics
demonstrate some efficacy in IBS,
and antispasmodics remain a firstline
therapy for managing abdominal pain.
Antidepressants have analgesic
properties, and Tri Cyclic
Antidepressants and Selective
Serotonin Reuptake Inhibitors appear
to be more effective than placebo in
the overall reduction of symptoms
associated with IBS. Dietary
modifications and lifestyle should
be the initial tools for the treatment
of patients with constipation
predominant IBS and mild to
moderate symptoms.
Because of the abnormalities in
bowel habits associated with each
IBS subtype, it is not likely that one
agent would successfully treat all
three subtypes. Some of the newer
agents for IBS-C are Lubiprostone
(which enhances chloride chloriderich intestinal fluid secretion),
Linaclotide (which stimulates
intestinal fluid secretion and transit),
and Prucalopride (which has been
reported to reduce general IBS
symptoms, but is only approved for
female patients).
to understand the particular
concerns and fears of patients
and allay these with confidence
and reassurance. Knowledge
of and consideration of all
available treatment options
is key once a solid patientphysician relationship has been
established.
*The Rome III criteria for irritable
bowel syndrome (IBS) is as follows:
Symptoms of recurrent abdominal
pain or discomfort and a marked
change in bowel habit for at least six
months, with symptoms experienced
on at least three days of at least three
months. Two or more of the following
must apply:
• Pain is relieved by a bowel movement
• Onset of pain is related to a change in
frequency of stool
• Onset of pain is related to a change
in the appearance of stool
**The Manning criteria is a
diagnostic algorithm used in the
diagnosis of IBS. The criteria
are:
Onset of pain linked to more
frequent bowel movements
1.Looser stools associated
with onset of pain
2.Pain relieved by passage
of stool
3.Noticeable abdominal
bloating
4.Sensation of incomplete
evacuation more than
25% of the time
5.Diarrhoea with mucus
more than 25% of the
time
Whatever new medications are
in the pipeline for IBS, we need
Treatments
IBS has no definitive treatment, but
may be controlled by eliminating
exacerbating factors such as stress,
dietary habits or use of certain drugs.
The traditional management of IBS is
symptom based, and the fundamental
aspect of doctor/patient interaction
remains the cornerstone of therapy.
The treatment goal is to try to
eliminate or decrease the patient’s
primary symptoms, which should be
addressed on the first consultation.
The intake of foods does not cause
IBS, but many IBS patients have nonspecific intolerance to foods.
The low FODMAP (fermentable
oligosaccharides, disaccharides,
Dr Lisa Das MBBS Board Certified
in Gastroenterology (ABIM) is a
Consultant Gastroenterologist at
Bart’s and the London NHS Trust
Bupa Cromwell Hospital.
To make an appointment please
call 0800 783 9229
cromwell direct 0800 783 9229
18
Cromwell Direct
A dedicated service for all your appointments
and admissions.
t. 0800 783 9229
f. 020 7835 2450
e. [email protected]
Allergy
Health screening and assessments
Paediatric general medicine
Angiography
Hearing centre
Paediatric occupational therapy
Audiology
Hepato-pancreato-biliary surgery
Paediatric orthopaedic surgery
Bariatric surgery
Intensive care - adult and paediatric
Paediatric out-patients
Breast care service
Liver and gastro-intestinal surgery
Paediatric physiotherapy
Breast surgery
Lymphoedema
Paediatric plastic surgery
Paediatric speech language
Cardiology
MRI scans
Cardiothoracic surgery
Musculo-skeletal services
Chemotherapy day unit
Neurology
Paediatric spinal surgery
Colorectal surgery
Neurophysiology
Paediatric urology
PET/CT scans
Craniofacial surgery
Neurosurgery
CT scans
Nuclear medicine
Pharmacy
Dermatology
Nutrition and dietetics
Physiotherapy
Occupational therapy
Plastic surgery
Dialysis
Oncology - clinical (radiation)
Ponseti method clubfoot clinic
Ear, nose and throat surgery
Oncology - medical
Pulmonary rehabilitation (COPD)
Endocrine surgery
Ophthalmic plastic surgery
Radiology
Endocrinology and diabetes
Ophthalmology
Radiotherapy
Oral and maxillofacial surgery
Orthopaedic and trauma surgery
Rheumatology
Orthopaedic medicine
Sleep clinic
Speech and language therapy
Diagnostic services
Endoscopy
Gamma Knife surgery
Gastroenterology
Respiratory medicine
General medicine
Paediatric allergy
General practice
Paediatric audiological medicine
Thoracic surgery
General surgery
Paediatric dentistry
Transplant surgery - pancreatic
Genito-urinary medicine
Paediatric dermatology
Transplant surgery - renal
Gynaecology
Paediatric ear, nose and throat surgery
Urology
Haematology
Paediatric endocrinology and diabetes
Vascular surgery
Haemato-oncology
Paediatric general surgery
Weight management
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therapy
Editor
Gaskell
MEDIscene - ISSUE 12
19 Alex
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Alison Taylor-Smith
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