GP NEWSLETTER DECEMBER 2013

Welcome from the CEO

Welcome to another edition of our GP e-newsletter. This publication is designed to keep you informed about what is happening here at the Hospital.

We recently hosted our second Breakfast on the Terrace, a breast cancer fundraiser and awareness event. It was a highly successful morning with over 80 guests in attendance. A number of our GP friends came along. Thank you so much for your support. We managed to raise over $2500.

Our Medical Minds program on 2GB has been running for the past two months. Below are links to podcasts of our specialists on air. If you get the chance, have a listen as they really are terrific interviews.

Should you like to discuss an issue or provide feedback on the Hospital, please do not hesitate to contact me on 9812 3011 or alternatively email me at carol.bryant@muh.org.au.

Kind Regards
Carol Bryant
CEO, Macquarie University Hospital


Love thy Neighbour

Dr Fiona Foo

Fiji conjures up images of a tropical island paradise, white sandy beaches, turquoise blue water and palm trees. However, despite only being a few hours flight away, our health systems are worlds apart. We used to think infectious/communicable diseases were the main problem in the Pacific Islands. However, non-communicable diseases (NCDs) have now become the number one health problem.

According to WHO 2008 estimates, NCDs account for 77% of all deaths in Fiji, with cardiovascular disease (CVD) accounting for 42% of the total. Similarly in Australia, NCDs are estimated to account for 90% of total deaths, 35% due to CVD. There is also a similar prevalence of metabolic risk factors. However, our ‘neighbours’ have a much lower life expectancy, a greater percentage of deaths from NCDs <60year old, a greater percentage of CVD deaths, and more than three times the age-standardised death rate per 100,000 from cardiovascular disease and diabetes compared to Australia – while the amount spent per capita/as a percentage of GDP is significantly lower in Fiji.

Yet the total number of cardiologists in Fiji is zero and, up until recently, they had no cardiac catheter theatre or echo machine.

  Fiji
Males
Fiji
Females
Australian
Males
Australian
Females
Total NCD deaths (000) 2.4 1.8 63.4 63.2
NCD deaths under age 60 (% of all NCD deaths) 45.6 38 13.4 9.2
Age-standardised death rate per 100000 All NCDs 928.4 590.9 364.8 246.3
Age-standardised death rate per 100000 - cardiovascular diseases and diabetes 579.9 328.2 136.3 88.6

WHO estimates 2008

  Fiji Australia
Total Population 875000 23,050,000
Life expectancy at birth m/f (years) 67/72 80/84
Probability of dying between 15-60 years m/f (per 1000 population) 244/153 80/46
Total expenditure on health per capita (Intl $, 2011) 183 3692
Total expenditure on health as % of GDP (2011) 3.8 9.0

WHO statistics for 2009 unless indicated.

Nowadays, it would be unimaginable in large towns and cities across Australia not to have access to a cardiac catheter theatre if you were having a myocardial infarction or intractable angina. Similarly, not having access to an echo machine to look for structural heart disease or left ventricular dysfunction after presenting with heart failure or worsening shortness of breath on exertion, would seem incomprehensible. But this is the reality in countries like Fiji, where cardiology services are needed the most.

I was fortunate to become involved in bringing cardiology services to Fiji. This was through Dr Vijay Kapadia, an interventional cardiologist working on the Gold Coast, originally from Fiji, who has undertaken the provision of cardiology services to Fiji. This project is non-profit with no formal funding arrangement. In Bill Gates’ paraphrased words, Dr Kapadia is a true philanthropist, someone who gives without expecting any personal gain.

Through Dr Kapadia’s vision, dedication and persistence, he managed to acquire a second-hand cardiac catheter theatre, which was finally assembled in 2009. This is in The Colonial War Memorial (CWM) Hospital in Suva. Since then, several teams from New Zealand and Australia, and other countries, have given their time to perform angiograms and angioplasties/stents for the growing list of patients who have coronary artery disease.

I visited Fiji in February 2013. Kumaran Kumar (chief cardiac catheter radiographer at Macquarie University Hospital) also came and provided invaluable teaching and technical support to the local staff.

Left image: Generous equipment donations from Boston Scientific; Right image: The impressive donation of stents and balloons collected by others from past trips.

One thing that can be gained from an overseas aid trip, is an appreciation of what you have in Australia. Running a cardiac catheter theatre is not easy. Despite not being used everyday, it needs to be activated daily, kept cool (in prevailing warm and humid conditions) and maintained regularly. There are a huge number of consumables needed to perform a single angiogram, not to mention the cost of angioplasty balloons and stents. How can a country that only spends a few hundred dollars per capita on health afford to pay for one coronary stent that can be worth almost $1000? Fortunately, during my trip we had generous support from companies such as Boston Scientific who provided us with much needed angioplasty balloons and stents.

As with any overseas medical trip, there are a number of ‘hurdles’. It started with obtaining consumables and then getting more than 80kg of equipment to Fiji, going through customs and then transporting it to the CWM hospital on the other side of the island. Hurdles continued from day one in the lab with significant delays due to availability of basic haemodynamic monitoring equipment. Gathering the essentials was akin to attending a garage sale in many ways and a baptism of fire regarding the limitations of working in the Pacific Islands – and how compromise is the key. They try not to resterilise much equipment at CWM, since they have been able to obtain significant amounts of sterilised disposables, though they do need to resterilise items that would be strictly single use only in the developed world. We narrowly avoided a major hiccup, in noticing the fluid in a resterilised inflation device was a fluorescent yellow. Even availability of sterile gowns caused delays in starting cases – and we realised that it would be worth taking disposable gowns next time (as much as they contribute to landfill).

Compromise: portable BP monitor and a separate defibrillator for the ECG monitoring

Left image: Shoe covers fashioned from theatre caps; Right image: Action in the cath lab

Kumaran Kumar lending a hand in the cath lab. Dr Nusair is in the blue.

The cardiac pathology I saw in Fiji was quite severe. Going through patients’ files, many patients had repeat myocardial infarcts, often within a year of their first one, as well as repeated presentations in heart failure. Even after meeting the first few patients, it became clear I would have to start considering everyone to be biologically 20 years older than their actual age. I was seeing coronary disease in much younger Fijians, and in older Fijians the disease was far more severe compared with similarly aged Australians. Diabetes was common, and if they were diabetic and Indian Fijian, they were almost definitely going to have coronary artery disease.

We had three patients develop contrast-induced acute pulmonary oedema during or just after their procedures, indicative of the severity of their coronary artery disease and left ventricular dysfunction. One outpatient, after five minutes of lying flat on the cath lab table, started coughing – the first sign that she had developed acute severe pulmonary oedema. I tried to do as many procedures via the radial approach as I could. However, I also encountered quite severe radial artery spasm.

Left image: Severe OM1 stenosis 55 year old male; Right image: Successful stenting of OM1

Left image: Occluded Circumflex, in a 38 year old male with a recent lateral nstemi. Patient also had an occluded RCA and had an inferior STEMI 1 year ago.e; Right image: Successful stent to occluded Circumflex.

Unfortunately, coronary artery bypass surgery is not available in Fiji. Indicative of many cases in Fiji, one young male with critical left main stenosis of 99%, who ultimately needed CABGs, which had to be left on a heparin infusion until we decided where he could go for surgery. Although this year a cardiothoracic team from India did make one visit, patients are otherwise sent to India for their surgery, or New Zealand if they are insured. The Fijian health department often helps those with financial difficulty to get their surgery. One problem with long international flights is the potential compromise of the patient’s condition.

It is amazing how much the Fijians with CVD put up with in their day-to-day life. People significantly limit how far they walk because of chest pain or shortness of breath. One patient I saw was having so much chest pain, they used up a bottle of GTN spray a week. The Fijian patients we treated were all so appreciative and grateful.

The staff there were also fantastic and warmly welcomed me from the first day. Apart from doing procedures, the other purpose of these visits is capacity building with local personnel, so that they are able to perform investigations and procedures themselves. Dr Shahin Nusair is training in cardiology there and was extremely dedicated, as were the other technical staff, ultrasonographers and nurses who were all eager to learn, and so being very ‘teachable’. We also had a lovely porter who brought a trolley of food for morning tea/lunch/afternoon tea/dinner – much more food than we could eat. I can understand how easy it is put on weight over there.

The Cardiac Cath lab team at CWM hospital - always fun, always smiling

I was eating too well...

Apart from the cardiac catheter theatre, CWM hospital does have a few much needed echo machines. The population is plagued by rheumatic heart disease. Whilst there, a young female presented with a massive stroke, and echo confirmed severe mitral stenosis with a severely dilated left atrium and clot swirling around the atrium.

With the help of some overseas visitors and tutorials from Queensland, several ultrasonographers have been trained. Of course, an echo machine is not cheap and they all have an ‘expiry’ date. You really take for granted the quality of images you get with up-to-date machines in Australia. I would like to acknowledge the generous support of Phillips, and also of Sydney Cardiology Group who will be providing another much needed echo machine, to replace a machine that has breathed its last.

I have seen how coronary heart disease causes significant morbidity and mortality in Fijians. The ability to perform early diagnostic coronary angiograms to guide subsequent intervention such as angioplasty/surgery will help prevent repeat myocardial infarctions, the development of heart failure, and thus improve quality of life and life expectancy, as well as DALYs (disability adjusted life year outcomes). However, having a cardiac catheter theatre is only one element of the fight against cardiac disease. Increasing public awareness of cardiac disease, primary prevention including risk factor management, pharmacotherapy, and ongoing management of patients with heart disease are all important.

I am returning again to Fiji in February 2014, and will continue to do so every year. On such trips, I find I meet wonderful people, encounter extremely grateful patients, become a better clinician, learn to compromise, and appreciate the medical services and the lifestyle we have in Australia. As much as I embrace all the technological advances that I work with, particularly in the cardiac cath lab and with echo machines, trips like these keep my feet firmly planted.

A broader question that arises is why we may feel that such an inequality of healthcare which exists between ourselves and our neighbours is worth addressing by any individual (or government). Could it be for ethics, morals, perhaps religious reasons, altruism or even self-interest? Volumes have been written about such concepts.

For me, one of the main reasons I involve myself in such activity is simply that it doesn’t add up – this degree of inequality existing, at all, let alone between neighbours.

There is something fundamental about the human quality of compassion. There is something good, about loving thy neighbour.


Dr Fiona Foo,
General and Interventional Cardiologist
MBBS (Hons), FRACP
Sydney Cardiology Group and the Heart Care Centre; Tel: 02 9422 6070


Hospital Acquires Latest 3T MRI for Prostate Cancer Diagnosis and Laser Treatment

Jeff McIntosh, MMI

Macquarie University Hospital recently invested in state-of-the-art dedicated prostate imaging equipment that uses the latest 3-tesla (3T) MRI technology to accurately guide biopsies and treatment. The MRI can characterise structures as small as 5mm within the prostate and is particularly valuable in the early detection of cancer.

The new 3T MRI overcomes some of the current shortcomings of prostate cancer diagnosis, currently reliant on PSA testing and non-targeted, ultrasound-guided biopsy.

Dr Yang-Yi Ong, radiologist with Macquarie Medical Imaging (MMI), where the new equipment will be housed, said that accurate diagnosis using existing approaches can be confounded for a number of reasons.

“PSA levels can become falsely elevated, including as a result of benign prostatic enlargement, which is a common condition in older men” said Dr Ong. “Similarly, the current random core biopsy samples can lead to the real tumour areas being missed completely, or can underestimate the extent and malignancy of a tumour.

“Early detection of aggressive tumours is the key. However, with less-than-certain results, patients can be left in limbo for months or years under a ‘watch and wait’ approach.”

The new 3T MRI at Macquarie University Hospital uses MRI-guided biopsy, and is revolutionary in being able to pinpoint areas of tumour and so produce significantly more accurate biopsies.

In addition, the new equipment will be used in MRI-guided focal LASER treatment of prostate tumours.

Associate Professor Celi Varol, Robotic and Minimally Invasive Cancer Surgeon at Macquarie University Hospital, said that the new approach is a ‘game-changer’ in the way in which surgeons can now diagnose and treat prostate cancer patients.

“The prostate cancer lesion can be targeted under MRI control using highly accurate laser therapy, without the need for removing the prostate through either robotic or open surgery,” said Professor Varol, who is also Head of the hospital’s Department of Urology.

“It gives both the patient and the surgeon far greater confidence and certainty that we are going after the right area and doing the right thing as early as possible. It is part of a University based research trial that should begin by the end of the year for prostate cancer patients.”

Already in use in North America, the new LASER imaging equipment is the first in Australia and is part of the comprehensive urology services offered by Macquarie University Hospital.

The service forms part of the hospital’s coordinated and integrated management services for prostate cancer patients. From early diagnosis through to focal LASER Prostate Cancer therapy or surgery and ongoing surveillance, the hospital’s team of expert radiologists, physicians and surgeons offers a multidisciplinary approach that brings patients the best available care.

About MMI

Macquarie Medical Imaging was established as the state-of-art facility and is the most integrated medical imaging department in Australia. MMI performs the broad range of scans such as high definition low dose CT, 3T MRI, contrast enhance Mammography, high definition Cone Beam CT, Nuclear Medicine scanning and Pet scanning, which are offered within one practice. MMI uses cutting-edge technology, and has been the only imaging department in NSW that fuses PET, CT and MRI together to produce the highest quality imaging.

MMI provides these services to outpatients.

GPs can refer patients by calling (02) 9430 1100 or by contacting.

Dr Yang-Yi Ong, Radiologist, Macquarie University Hospital
Tel: 0408 522 583, Email: yanyi.ong@gmail.com

A/Prof Celi Varol, Urology Surgeon, Macquarie University Hospital
Tel: 4721 8383, Fax: 4721 2575, Mobile: 0412 262624, Email: celi.varol@mq.edu.au


Saving the Young Hip - Hip Arthroscopy

Dr Peter WalkerDr Peter Walker

Hip arthroscopy is one of the fastest growing orthopaedic procedures. This is due to improved techniques, training and understanding of hip disorders. In the past, a lot of hip pain has been labelled as groin strains and gone untreated.

The most common reason for hip arthroscopy is labral tears and articular cartilage damage secondary to what is known as femoral acetabular impingement (FAI). Impingement basically means the femoral neck abuts or impinges on the labrum which runs around the edge of the acetabulum. If there is too much bone on the femur it is known as cam impingement while too much bone on the acetabular edge is known as pincer impingement.

FAI leads to limited hip range of motion (ROM), labral tears and articular cartilage damage1.

The symptoms are usually pain in the groin or lateral side of the hip. Mechanical catching or clicking is also common. It is common in all ages and can start from teenage years. As you get older, arthritis becomes a greater possibility.

It is very important to diagnose and treat impingement as early as possible as it is a common cause of early onset arthritis.

Patients with labral tears commonly go undiagnosed during an extended period of time and patients are often seen by multiple health care providers before obtaining a definitive diagnosis2. Studies have shown that there is on average greater than 2 years before diagnosis is achieved3.

When hip pathology is suspected, the examination involves palpation around the area of tenderness. Generally the pain is deep and not tender to touch. The most pathognomonic test is pain and restriction of motion with flexion and internal rotation of the hip the so called impingement test.

Differential diagnosis includes things such as trochanteric bursitis, adductor tendonitis, pubic symphysitis or hernias. These are usually tender to touch in the anatomical area.

Imaging is of vital importance. This includes a good quality x-ray which must include an AP of the pelvis to compare the other hip. The x-ray shows arthritis as well as the shape of the hip, including dysplasia or impingement. To see in more detail, a 3D CT is helpful.

A good quality MRI performed by a radiologist with expertise in musculoskeletal disorders is also important. The MRI is looking for soft tissue problems such as labral tears, tendon inflammation or articular cartilage pathology.

Initially, a trial of conservative management, including relative rest, anti-inflammatory medications, and pain medications as necessary, combined with a focused physiotherapy protocol for 10–12 weeks is recommended.

When conservative measures do not control the patient’s symptoms or when functional limitations remain unsatisfactory, a surgical referral is appropriate.

If hip arthroscopy is advised, it is important to be operated on at an institution that specialises in hip arthroscopy as it is quite a specialised procedure.

It generally involves an overnight stay in hospital. Crutches are used for comfort for a week or two. Usually patients can return to office work and drive at one week. Physical work and sports may vary from between 6 and 12 weeks depending on what is done.

Surgery is all performed through keyhole incisions and involves debridement or repair of the labrum and often removal of the bone from the femur or acetabulum reducing ongoing impingement.

Results are generally good in the order of 90%, but it is very dependent on the degree of articular cartilage damage at the time of surgery. This is not always picked up on MRI. McCarthy and colleagues found 63% of hips scoped for labral tears were found to have articular cartilage abnormalities4.

Farjo et al.5 reported associated arthritic changes as a poor prognostic indicator to arthroscopic repair of labral tears.

Left image: MRI cyst evidence of impingement; Right image: Labral tear at arthroscopy

Left image: Bony prominence femur; Right image: Normal hip

Left image: types of impingement; Right image: bony prominence femur


  1. Philippon MJ, Stubbs AJ, Schenker ML, Maxwell RB, Ganz R, Leunig M. Arthroscopic management of FAI: osteoplasty technique and literature review. Am J Sports Med. 2007;35(9):1571–1580.
  2. Burnett S, Della Rocca G, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006;88(7):1448–1457
  3. Fitzgerald RH. Acetabular labrum tears: diagnosis and treatment. Clin Orthop. 1995;311:60–68.
  4. McCarthy J, Nable P, Alusio FV, et al. Anatomy, pathologic features and treatment of acetabular labral tears. Clin Orthop Relat Res. 2003;406:38–47
  5. Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy. 1999;15:132–137

Dr Peter Walker, Hip & Knee Surgeon, M.B., B.S., F.R.AC.S.Orth

A: Macquarie University Clinic, Suite 303, Level 3, 2 Technology Place, Macquarie University, NSW 2109;
Tel: 02 9735 3637

A: Retail 4 / 8 Australia Ave, Sydney Olympic Park, NSW 2127; Tel: 02 9735 3637; Fax: 02 9735 3635


Heart Care Centre comes to Macquarie University Hospital

Macquarie University Hospital has opened a new Heart Care Centre that will strengthen the hospitals capacity in coordinated state-of-the-art treatment for residents of New South Wales.

The unique model for heart care is based on a coordinated patient-centred approach that brings together an outstanding group of cardiothoracic surgeons, cardiologists and physicians.

Ms Carol Bryant, Chief Executive Officer of Macquarie University Hospital, says that the multidisciplinary team approach is a key aspect of all specialist areas set up at the hospital. The concept ensures patients are treated in a coordinated way, with all areas of need addressed by health professionals working together to ensure the best possible patient outcomes.

“The new Heart Care Centre really is a first in that we are setting up a group of experts in one single location to run a comprehensive heart service in a private hospital,” said Ms Bryant. “Whether a patient has high blood pressure, chest pain, an irregular heartbeat or a problem with one of their major vessels, they can come to the centre and have experts in all relevant fields available to them. It is a truly comprehensive approach.”

Patients need to be referred to the centre by their GP. On arrival, they are assessed promptly and sent to the most appropriate expert. Follow-up treatment and care is coordinated, whether this involves seeing another physician, undergoing surgery or embarking on rehabilitation after surgery.

“There is a complete continuum of care,” Ms Bryant says. “Each patient’s treatment is, of course, individualised but also coordinated in a seamless way. The idea is to reduce the difficulty and the stress of being treated in multiple locations – it’s a one-stop shop.”

She says that because some of the top specialists and surgeons will work from the centre, patients will have access to the best care, supported by the hospital’s nursing and allied health staff.

Specialists working at the Heart Care Centre will use state-of-the-art technology already at MUH to undertake the very latest procedures, for which the hospital is becoming increasingly known. For example, the hospital is able to offer patients cardiothoracic surgery using the da Vinci Surgical System for robotic valve replacement – a novel procedure in Australia. The robotic angiography device is housed in the hospital’s unique hybrid theatre, itself the first of its kind in Australia.

The robotic procedure is used for very ill or elderly patients who cannot withstand open-heart surgery, with its minimally invasive approach resulting in significantly less bleeding and shorter recovery times.

MUH is also undertaking transaortic valve implants – or TAVI – another new procedure.

“While these procedures are happening overseas and in some of our major public hospitals, like Royal Prince Alfred, they are relatively new in Australian private hospitals,” says Ms Bryant.

“Macquarie University Hospital is at the leading edge of these technologies with diverse expertise working together. The cardiothoracic surgeons and supportive specialists who will be conducting these highly technical procedures have worked together for a number of years in New South Wales and are already a cohesive unit.

“Macquarie University Hospital enables them to work under a new structure, supported by our state-of-the-art technology,” Ms Bryant explains. “The Heart Care Centre aims to become a real centre of excellence in clinical practice and academic medicine.”

The centre will also offer more standard types of treatments, including bypass surgery, stents, pacemakers, coronary artery graphs and aortic surgery, as well as interventional cardiology work.

Research will be a key focus, with all specialists gathering longitudinal data around patient outcomes in order to improve on patient treatment and management.


Macquarie University Hospital Medical Minds

For the past two months our Macquarie University Hospital specialists have been going into the 2GB studios to co–host Dr Graham Malouf’s medical program on Sunday nights. To find out what our Specialists had to say, visit our Medical Minds website at www.muh.org.au/medicalminds and click on the podcast button to hear previous shows.


Second Breakfast on the Terrace

Breakfast on the Terrace

Dr Jeremy Hsu, Ms Amanda Maltabarow OAM, Professor John Boyages, Dr Deborah Cheung.

On Wednesday 30 October Macquarie University Cancer Institute hosted its second Breakfast on the Terrace. This annual event is held as a Breast Cancer Awareness and Fundraiser. It was a fabulous day with just over $2500 raised.