June 2012 - Macquarie University Hospital

June 2012
1
Click here
for a
virtual tour
of our
facility
Happy Second Birthday MUH
Welcome from the CEO, Carol Bryant
Welcome to another edition of our GP
e-newsletter. This month we are
celebrating our second birthday. A lot has
happened in these last two years and we
have been grateful to you all for supporting
us in this venture.
The first half of the year has been spent
talking with our stakeholders and asking
them what they need from us to provide an
exceptional service. We recently sent all
our GPs a hospital survey, asking you what
you thought of us and what you needed
from us. We had an overwhelming
response and I would like to thank you for
taking the time to complete the survey.
If you did not get a chance to fill out the
survey and would like to provide feedback,
please don’t hesitate to email me here.
In the event you would like to find out more
about us, I encourage you to attend one of
our GP educational sessions, or visit our
hospital website and view our virtual tours.
Alternatively, you can contact our Business
Development Director who will visit your
practice with a Macquarie University
Hospital Specialist so you can find out
more about what we can offer you.
I would also be delighted to chat with you
personally should you have any questions.
I can be reached on 9812 3011.
I do hope you enjoy this month’s
newsletter.
Carol Bryant, CEO, MUH.

GP NEWS
2
Congratulations Professor Rowe
Order of Australia
Professor Dominic Rowe, founder and director of
Macquarie Neurology and MND Service at Macquarie
University was named a Member (AM) in the general
division of the Order of Australia for his service to
neurology and for his tireless work on Motor Neuron
Disease.
Motor Neuron Disease (MND) is a rapidly progressive,
terminal neurological disease, with no known cure. An
estimated 1400 people have MND in Australia and
thousands more families and carers live daily with its
effects.
To serve people living with MND, Professor Dominic
Rowe has set up a multi-disciplinary MND service at
Macquarie University. The MND Service at Macquarie
University accepts referrals from all geographical areas,
including rural and remote areas.
"Studies show that coordinated care doubles the
survival of people living with MND," Professor Rowe
explains. "Our patient-centric model helps us, as
clinicians, to provide this care and anticipate problems
before they arise."
Each person living with MND has unique difficulties with
communication, mobility or speech. In a session at the
clinic, they might see a broad range of allied health
professionals – including speech and language
therapists, respiratory physicians, dietitians, nurses,
occupational therapists, physiotherapists, orthotic
specialists, social workers and neurologists.
Bringing these clinicians to the one place means less
time traveling between medical offices, but Professor
Rowe also sees a significant cost benefit in the service.
For more
information
click here or
to make an
appointment
please call
02 9812 3720
"Seeing all these clinicians normally wouldn't give you
much change from $1000, however, because this is a
clinic funded nearly entirely from donations a visit to
see all ten practitioners costs only $100. After
Medicare, the net cost to the patient is just over $30."
Additionally, when living with a disease like MND,
access to expert care is another huge relief, says
Professor Rowe – especially with a disease that is
relatively uncommon.
"All of the staff in the clinic have experience in MND,
whereas most GPs and community allied health
practitioners will have perhaps one person with MND to
manage," he explains. "The MND Service enables a
concentration of experience to help the patient and their
family."
Based on a US model, the clinic was first implemented
in Australia by Professor Rowe at Sydney's Royal North
Shore Hospital in 1998. He recently moved his clinic to
Macquarie University, where he could combine clinical
practice with research as part of the Australian School
of Advanced Medicine (ASAM).
"Excellence in clinical service provision and research
go hand in hand. Our patients with neurological
diseases must have access to the best therapies and
research programs available," says Professor Rowe.
The clinic is funded through tax-deductible gifts, which
can be donated through the Macquarie Foundation and
ASAM. To find out more please click here.

June 2012
3
Musculoskeletal training could help millions
Many Australians are suffering
from pain related to treatable
musculoskeletal conditions that are
difficult for primary care doctors to
diagnose without further
postgraduate training.
An RACGP survey estimates six
million people across the country
suffer from musculoskeletal
problems, costing the health
system and economy many
millions of dollars every year. Many
of these people have soft tissue
pain sources that are not always
identified, in their joints, muscles
and ligaments.
“Soft tissue pain is a great mimic,”
says Macquarie University’s
Associate Professor Michael
Creswick. “These disorders can
mimic many other health problems
and yet are diagnosable and quite
often very treatable if doctors are
appropriately trained. Appropriate
early intervention can minimise
chronic pain and long term
medication such as antiinflammatories
and opioids.”
Sometimes musculoskeletal pain
can be so severe that the patient
requires urgent or semi-urgent
admission to MUH for pain relief
and for rapid assessment.
Availability of world class facilities
including imaging is very helpful of
course. These can be utilised to
direct appropriate conservative
care, including injection
techniques, or surgical care when
necessary.
He and Associate Professor Rod
Ayscough have helped establish
the country’s only Master of
Medicine Degree in
Musculoskeletal Medicine at
Macquarie University’s Australian
School of Advanced Medicine.
The course specifically trains
qualified GPs to better identify and
treat musculoskeletal disorders.
Such training is growing in the
United States and Europe as more
is understood about
musculoskeletal conditions.
Creswick believes that doctors,
after ruling out serious causes of
pain, often refer patients to
therapists for treatment of soft
tissue pain without a specific
diagnosis. This is because the
source of pain is not always
apparent from the application of a
standard medical approach.
“Our course participants are
trained in recognising pain referral
patterns, performing a detailed
physical examination and applying
advanced physical medicine
treatment skills. These include
gentle manual therapy, the
injection of muscular “trigger
points” if clinically indicated and
specific exercise prescription.
“There has been a worldwide
medical trend towards treating pain
as an entity in itself, and to
diagnose persisting pain as
intractable, due to nerve damage.
However some people who have
been told they have “neuropathic”
pain have been found to have
ongoing unrecognised but
treatable musculoskeletal, soft
tissue disorders, without nerve
damage,” Creswick says.
Ayscough and Creswick train GPs
to look for possible sources of pain
from soft tissues, including
muscles, ligaments, the bony
attachment points of muscles, as
well as associated nerves. “How
these structures interact in relation
to each patient’s posture and
movement is an important part of
diagnosis and treatment.”
“GPs already have an excellent
overview of the whole patient and
knowledge of underlying serious
diseases. We use a medical model
of diagnosis, so we only train
experienced GPs. Often, with
further training at ASAM, known
pain patterns will be evident on
examination, and our graduates
can immediately treat a
musculoskeletal problem.
If the patient responds and stays
pain-free, then they can avoid
expensive and sometimes
unnecessary tests. One of the
great advantages of primary care
is the ability of the doctor to treat
patients and observe progress
over short timeframes, and adjust
management based on those
observations.
If a patient doesn’t respond as
expected, a revised diagnosis may
be apparent, or it may be
appropriate to order radiological
imaging or blood tests to aid
diagnosis,” says Creswick.
“Many patients have muscular and
postural patterns that are leading
to their pain, and that’s what we
train our graduates to identify and
treat.”
A/Prof. Michael Creswick
Musculoskeletal Medicine
Special Interest: Muscular Pain &
Dysfunction Including Cervicogenic
Headache.
To make a referral, please
call 02 9481 9585. For
more information, please
click here

GP NEWS
4
Advances in Breast
Cancer Surgery help
patients cope much
better with treatment
Total skin sparing
mastectomies
As an experienced breast
surgeon, I witness how breast
surgery has evolved dramatically
over the last few years. As the
newer techniques of immediate
breast reconstruction offer superior
cosmetic results, it is now very
uncommon that my patients would
choose delayed breast
reconstruction when deciding to
have a mastectomy. Patients can
choose to either have an
autologous “flap” or tissue
expander / implant for immediate
reconstruction after we completed
the total skin-sparing mastectomy.
The patient wakes up with a
reconstructed breast with minimal
scarring in the recovery ward.
My patients say they are so amazed
that by being able to minimise
scarring and to save all their breast
skin including their nipple, the
psychological impact of a
mastectomy is much reduced. It
allowed them to cope much better
with their overall oncological
treatment.
Many studies have shown that
immediate breast reconstruction in
well-selected patients is safe and
does not affect survival.
As a mastectomy operation
generally causes denervation of the
chest wall, most patients have
relatively minimal pain. Patients
typically are discharged within 2-3
days after their operation. They are
fully ambulant and are doing most
daily activities within 2-3 weeks.
Therapeutic
Mammaplasties
For patients with breast cancers
in tricky areas, and patients with
large breasts, we individualise
our technique to resize and
reshape the breast after removal
of the tumour and lymph nodes
staging.
Particularly for patients with very
large breasts, radiotherapy may
cause severe and permanent
fibrosis. They will be left with a
Dr Deborah Cheung
Breast Surgeon
Clinical Care Centre,
Suite 302
Macquarie University Clinic
To make a referral please
call 02 9887 8899.
hard and fibrosed breast for the
rest of their lives. The results of
breast reduction surgery after
radiotherapy are unpredictable
and have a much higher
complication rate. Hence, it is
logical to reduce both breasts
before radiotherapy than
afterwards.
This procedure is medicare and
health fund rebatable and is
performed at the same time as
breast cancer surgery. Patients
have a high satisfaction rate.
Most patients tell me how much
better they feel and how little
discomfort they have after the
operation.

Short Scar Breast Reduction
By Dr Steve Merten
In the last 15 years there have been
significant advances in breast reduction
techniques, with major advantages to our
patients. The “traditional” breast
reduction technique, popular since the
1960s, was an effective and safe
operation, however had drawbacks of
frequent healing problems, due to tight
skin closure, in the short term and, being
bottom-heavy with potential for
“bottoming out” in the long term.
Fundamental shifts in the design
concepts of breast reductions have led to
major changes, with the development of
the “short scar” breast reduction, also
termed “vertical” breast reduction or
“lollipop” breast reduction, as the final
scar pattern is around the circular
areolar, then vertically down to the fold
beneath the breast.
This is in contrast to the traditional
“anchor” shaped scar, which has, in
addition, a long scar in the fold beneath
the breast. Short scar breast reduction
differs from the traditional technique in
that the internal blood supply to the
Dr. Rami Sorial (Orthopaedic Surgery),
A/Prof Des. Bokor ( Orthopaedic
Surgery), A/Prof Glen Croxson,(OHNS)
Retiring senior Examiner, A/Prof Ray
Sacks, (OHNS) Senior Examiner, A/Prof.
Graham Gumley (Orthopaedic Surgery)
Senior Examiner.
5
nipple is based high in the breast and the
heavy tissue from the lower breast is
completely removed. The breast is then
reduced and reconfigured in a conical
shape, then sewn so that its new
construction, and not the skin
envelope, maintains the shape of the
breast.
This allows less skin to be removed
and elimination of the scar beneath the
breast. As well as less scars, however,
the even greater benefits are a
shapelier breast and better long-term
maintenance of the result.
RACS PART 2
Surgical fellowship examination
At the recent RACS Part 2
Surgical Fellowship examination in
Brisbane, it was clear that
Macquarie University had a strong
representation on the Court of
Examiners. The Examiners are
responsible for the development,
setting and evaluation at the end
of training examinations in their
fields. Examiners serve for 8 years
on the Court and take up to 10
days of unpaid time to serve the
profession and community in this
way, upholding the professional
standards of surgery.
The short scar breast reduction is best
suited for moderate sized breast
reductions, however by combining the
internal reconstructive concepts with a
scar beneath the breast, even the largest
breasts can be successfully reduced with
the shape advantages of this technique.
Dr Merten was one of the first surgeons
in Australia to be trained and
experienced in the short scar breast
reduction, during his additional training in
Canada in 2002, and has been
exclusively using these techniques since
that time.
Dr Merten has been training the next
generation of plastic surgeons these
techniques for the last 10 years.
Click here to see before and
after photos
To make a referral to Dr Steve
Merten, please call 02 9812
3890 or click here for more
information.
RACS Annual Scientific Congress
On 6 - 10 May this year, the RACS
Annual Scientific Congress was held in
Kuala Lumpur. A number of MUH
specialists were chairing and presenting
seminars at this activity including;
Professor Marcus Stoodley
Professor John Cartmill
Dr Michael Vallely
Dr Paul Bannon
Dr Michael Wilson
Dr Jonathan Clark
A/Prof Reginald Lord
A/Prof Greg Falk
Dr Matthew Rickard
Dr Carsten Palme
Dr Michael Stephen
Dr John McGuinness

June 2012
6
Breast Program
Our Breast Cancer Program is well
underway with multi-disciplinary team
meetings occurring every fortnight. In
the first two meetings in June, the
team has discussed 15 new cases,
exploring the best available treatment
options for each patient, as well as
developing a planned approach to
their care. Doctors in attendance
included surgeons Dr Deborah
Cheung, Dr Elisabeth Elder, Dr
Jeremy Hsu, with input from radiation
oncologists Professor John Boyages,
Associate Professor Susan
Pendlebury, Dr Annie Ho and medical
oncologist Dr Pirooz Poursoltan and
plastic surgeon Dr Thomas Lam.
Pathologist, Dr Jessamine Reddy
from Douglass Hanly Moir and a
consultant from Macquarie Medical
Imaging are also in attendance,
ensuring all the necessary experts
are available in one room, to offer a
truly coordinated approach to cancer
treatment.
Professor John Boyages, Director of
the Macquarie University Cancer
Institute (MCI) and Professor of
Breast Oncology at the Australian
School of Advanced Medicine
(ASAM) is delighted with what has
been achieved over the last few
months. “It’s a very exciting time for
us, as the breast cancer program
grows from strength to strength.”
Breast Assessment Clinic
A daily breast assessment clinic is
opening in Suite 302 at the
Macquarie University Clinic.
Appointments to this service can be
made on 9887 8887.
For all appointments and
enquiries, please
telephone 02 9887 8899
Professor John Boyages, Megan Southwell
Lymphoedema Treatments
at MCI
A suite of lymphoedema treatments
are now available through the
Macquarie University Cancer Institute
(MCI), from early detection and
intervention methods to new surgical
options, including liposuction.
Last month, high school teacher,
Megan Southwell was the first patient
at MUH to be treated for
lymphoedema with liposuction.
The operation was a resounding
success and was covered by channel
10 news. To view the program click
here.
Clinical Psychologist
joins MCI
Dr Jemma Gilchrist, a leading
Clinical Psychologist has joined the
team at the Macquarie University
Cancer Institute. She is a key
addition to our multi-disciplinary
team of experts, as we recognise
the importance of psycho-social
and supportive care in providing
comprehensive cancer
management.
Dr Gilchrist has particular expertise
in oncology. Common concerns
Macquarie
University Cancer
Institute
Hotline
02 9887 8887
The team of cancer experts involved
in her treatment including:
Dr Thomas Lam
Cosmetic & Plastic Surgery
Dr Quan Ngo
Cosmetic & Plastic Surgery
Dr Helen Mackie
Rehabilitation Medicine
Louise Koelmeyer
Occupational Therapy
Asha Heydon-White
Physiotherapist
For further information about these
options in lymphoedema treatment,
please contact the MCI Cancer
Hotline (during business hours) on
9887 8887.
that she assists with are:
adjustment to diagnosis, treatment,
chronic disease or disability;
managing stress and anxiety;
sadness and depression; sleep
difficulty; body image and sexuality;
communication and decisionmaking;
grief and loss; relationships
and living with uncertainty.
Dr. Gilchrist holds fortnightly clinics
on Wednesday at the Clinical Care
Centre. Patients may be eligible for
a rebate from Medicare if referred
by their GP.

7
Ear Drum Surgery
Clinical Associate Professor
Nirmal Patel
Macquarie University
Definition & Natural History
Tympanic membrane perforations
are holes in the ear drum that most
commonly occur as a consequence
of either ear infections or trauma to
the ear.
Tympanic Membrane Anatomy
The pars flaccida region of the
tympanic membrane is that region
above the short process of the
malleus (Figure 1). Typically this
area is called the attic region and is
clean and smooth with a few blood
vessels noted.
If this region is not smooth and free
of wax/ debris and in particular if a
perforation can be seen in the attic,
then a cholesteatoma may be
suspected. The annulus of the ear
drum delineates the margin. A
marginal perforation is a sign of an
unsafe ear.
Box Out – Marginal and Attic
Perforations (The Unsafe Ear)
When either a marginal or attic
perforation is seen, this is an unsafe
situation. A marginal perforation is
one where the hole reaches the
annulus of the ear drum (Figures
2&3). An attic perforation is a hole
above the short process of the
malleus.
Both of these situations can disturb
the normal flow of epithelium from
the tympanic membrane out of the
external auditory canal and may be a
sign of cholesteatoma (epithelial
inclusion cyst of the temporal bone -
see previous therapy update article),
which often requires surgical
intervention.
Red flags in the Diagnosis of
Tympanic Membrane
Perforations
• Marginal perforations
• Attic perforations
• Chronically discharging or bleeding
ear.
• Perforation with significant clinical
hearing loss
For more information on
Clinical Associate Professor
Nirmal Patel click here or to
make an appointment please
call
Management
Most acute perforations from
infection will spontaneously heal with
culture directed antibiotic treatment
of the ear infection. The majority of
acute traumatic perforations will also
heal spontaneously. If the middle ear
is soiled then antibiotics (such as
amoxicillin) are used for a week.
The patient should maintain strict
water precautions and be regularly
checked until the hole heals,
usually in a few weeks.
Occasionally the acute perforations
will not heal and then they are
defined as chronic.
If a patient is asymptomatic then
most dry safe central perforations
are left alone.
Dry safe chronic perforations are
managed surgically if the patient is
symptomatic, in the form of either
discharge from the ear or hearing
loss.
Ear Drum Surgery requires a
tympanoplasty (repair of the ear
drum and/ or ear bones). Two
newer techniques that we employ
are the onlay technique and
cartilage tympanoplasty. Onlay
Tympanoplasty is a technique we
employ for large holes or anterior
ear drum holes
(Figure 4).
Cartilage tympanoplasty is used
when the middle ear pressure is high
causing retraction of the residual ear
drum. At Macquarie University
Hospital we also use the latest
techniques of employing High
Definition (HD) camera endoscopy
to perform minimally invasive ear
surgery to try and reduce surgical
trauma and pain as well as
improve healing times.
Acknowledgements:
Dr John Kelly for two of the
otoscopic pictures.
For more surgical videos of ear drum
hole repair, visit Youtube and search
“Dr Nirmal Patel” or
scan the following QR
code into your
smartphone.
Figure 1 Otoscopic view of a normal
left ear – the oblique line illustrates the
demarcation between pars flaccida
(superior) and pars tensa (below). The
solid white arrow begins on the short
process of the malleus and extends up
to show a normal non-diseased attic
region.
Figure 1 Otoscopic view of a normal left
ear – the oblique line illustrates the
Figure 2 Otoscopic view of a left ear
with a margin (unsafe) perforation –
note the perforation extending to the
annulus of the tympanic membrane and
also inferiorly, the white squamous
epithelium migrating into the middle ear.
Figure 3 Otoscopic view of a left ear
with a marginal unsafe perforation –
if untreated this ear may develop into
cholesteatoma.
Figure 4 Otoscopic View of a Left Ear
with a Central Perforation – the ear is
inflamed and moist.