Today Surgical Pathology Teaching

Aim of today’s surgical pathology demonstration was to illustrate some aspects of Breast Skin & Soft tissue Macros Specimens and where possible link in to clinical assessment

Example shown or discussed

Breast Pathology

  • Fibrocystic disease
  • Fibroadenosis  including Sclerosisng Adenosis
  • Breast cysts – If bloody aspirate send to cytology
  • Nipple discharge           if bloody Duct papilloma v Intraduct Carcinoma
  • Nipple  Eczema v Paget’s disease
  • rarity Malignant melanoma of the nipple but in diff diagnosis
  • Peau d’orange
    • Tumour infiltrating dermal lymphatics causing oedema

Carcinoma (invasive)

  • Presenting as a primary
    • Invasive Ductal Carcinoma ( Carcinoma NST) 80%+
      • Subtype Tubular Carcinoma
    • Invasive Lobular Carcinoma    10%
      • typical “Indian File pattern” histology
    • rare types eg
      • Medullary 
      • Adenoid Cystic
    • Not discussed  DCIS LCIS
    •  Use of Indian ink for staining margins
    • The shellac binder links to formalin or actetic acid which binds to tissue and can be seen after processing,
  • Presenting as secondary – Less common
    • Axillary Node
    • As Liver or Brain mets
    • As GI tract lesion

Fibroadenoma of the breast

  •  Including Giant Fibroadenoma versus Phylloides Tumour


Gynaecomastia in male breast

  • History should include Drug History eg Cardiac Drugs, steriod,  cannabis
  • Histology fibrosis and proliferation of ducts

Breast implants

  • Pseudocapsular reaction
  • Synovial metaplasia  calcification, inflammation
  • Silicone Granuloma in surrounding breast tissue and lymph nodes
  • Rare lymphoma associated with implants Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

Skin disease  Malignancy

  • BCC
  • SCC            v  Keratoacanthoma – length of history essential
  • Melanoma
    • Clarke staging versus Depth
  • Melanoma at other sites
    •  Uveal 
    • Anal
    •  Oesophagus 
  • Melanoma of Soft Parts

Not discussed

  • Primary skin Lymphoma
  • Dermatofibrosarcoma Protuberans
  • Merkel Cell Carcinoma

Other skin lesions shown

Seborrhoic Keratosis / Basal cell papilloma

Epidermal Cyst

Pilar Cyst

Dermoid Cyst

Soft tissue tumours

Benign           Lipoma

Myositis ossificans

Abdominal Fibromatosis

Malignant       Liposarcoma



Shape of Training Steering Group Report

The UK Shape of Training Steering Group (UKSTSG), chaired by Professor Ian G Finlay,  published its report on August 11th this is in follow up to Professor David Greenaway’s independent Shape of Training review.

Background information can be found at

BMA’s response to the shape of training review can be found at

The UK Shape of Training Steering Group had the following BMA representatives:-

Dr Ian Wilson               Dr Anthea Mowatt   & Dr Jeeves Wijesuriya

 The full report can be found at

Note individual Royal College responses can be found in the appendices

The BMA has a number of policies passed by ARM that are pertinent to read

BMA policies that addresses some points of “shape of training”

That this Meeting deplores the proposal by the Shape of Training Review to give full registration to junior doctors at completion of their medical school studies and before they have worked in a supervised capacity managing patients and believes:-

  1. this may put the public at risk as such qualified doctors will not have the necessary supervised training which allows them to practice safely;
  2. this will risk damaging the well-being and career of these young doctors;
  3. this policy will prejudice the ability of home grown graduates to work in the NHS which has trained them, as they will be competing for posts with doctors from overseas.
  4. the financial risk of possible non-entry to the foundation programme will reduce the socio-economic diversity of applicants to medical school. (ARM 2014)


That this Meeting believes junior doctors should be involved in discussions that affect their future careers from the outset. We therefore call on the BMA to lobby relevant stakeholders:

  1. for a meaningful seat on groups discussing implementation of the Shape of Training Review;
  2. to ensure there is no implementation of any elements of the Shape of Training Review without full and open consultation;
  3. to ensure explicit and robust transition arrangements for current trainees are specified should any part of the Shape of Training Review be implemented. (ARM 2014)


That this Meeting believes generalist & specialist knowledge and skills can & should co-exist in the same doctor, and we:-

  1. believe the solution to the problems of the acute take is not to create a new cadre of generalist-only doctors, but to better equip doctors in specialty training with more generalist training;
  2. call on the Shape of Training review to avoid recommending a separation of generalist & specialist training;
  3. call on the Royal Colleges to consider extending training programmes to allow more generalist experience to be gained in the setting of a regulated, funded training programme rather than outside training. (ARM 2013)


That this Meeting is deeply concerned over the direction being taken by the Shape of Training Review and calls on the BMA to continue to:-

  1. uphold the CCT as the internationally recognised end point of training and a CCT/CESR/CEGPR remaining as the only requirement for a consultant or GP post;
  2. ii) vigorously oppose any move to introduce a CCT-level (or equivalent) sub-consultant grade. (ARN 2013)

That this meeting is opposed to moving the point of full registration of doctors to the point of graduation from medical school and calls upon the GMC to retain the pre-registration year post graduation; (ARM 2015)


The following points and recommendations I have copied from the report and have rearranged them to make it more readable

Regarding supervision

The report advocates a return to a more apprentice style of training based on the attainment of competencies and generic capabilities rather than solely time based.

  • Requiring longer clinical placements and more focused supervision and support.

Recognises that doctors require more support at the transition points during their careers when they are new to carrying a higher level of responsibility Eg with first consultant post

Doctors in training  should be better supported by trainers and supervisors..

Appropriate organisations :-

  • Must make sure post-graduate medical education and training enhances its response to changing demographic and patient needs. Recommendation 1
  • Should identify more ways of involving patients in educating and training doctors. Recommendation 2
  • must provide clear advice to potential and current medical students about what they should expect from a medical career. Recommendation 3
  • must introduce a generic capabilities framework for curricula for postgraduate training based on Good medical practice that covers, for example, communication, leadership, quality improvement and safety. Recommendation 6
  • must introduce processes, including assessments, which allow doctors to progress at an appropriate pace through training within the overall timeframe of the training programme. Recommendation 7
  • including employers must introduce longer placements for doctors in training to work in teams and with supervisors including putting in place apprenticeship based arrangements. Recommendation 8
  • working with employers, must review the content of postgraduate curricula, how doctors are assessed and how they progress through training to make sure the postgraduate training structure is fit to deliver broader specialty training that includes generic capabilities, transferable competencies and more patient and employer involvement. Recommendation 11
  • including postgraduate research and funding bodies, must support a flexible approach to clinical academic training Recommendation 14
  • including employers, must structure continuing professional development (CPD) within a professional framework to meet patient and service needs, including mechanisms for all doctors to have access, opportunity and time to carry out the CPD agreed through job planning and appraisal. Recommendation 15
  • including employers, should develop credentialed programmes for some specialty and all subspecialty training, which will be approved, regulated and quality assured by the GMC. Recommendation 16
  • should review barriers faced by doctors outside of training who want to enter a formal training programme or access credentialed programmes. Recommendation 17
  • should put in place broad based specialty training as described. Recommendation 18


Medical schools, along with other appropriate organisations, must make sure medical graduates at the point of registration can work safely in a clinical role suitable to their competence level, and have experience of and insight into patient needs Recommendation 4

Full registration should move to the point of graduation from medical school, subject to the necessary legislation being approved by Parliament and educational, legal and regulatory measures are in place to assure patients and employers that doctors are fit to practice. Recommendation 5

Training should be limited to places that provide high quality training and supervision, and that are approved and quality assured by the GMC Recommendation 9

Postgraduate training must be structured within broad specialty areas based on patient care themes and defined by common clinical objectives. Recommendation 10

All doctors must be able to manage acutely ill patients with multiple co morbidities within their broad specialty areas, and most doctors will continue to maintain these skills in their future careers. Recommendation 12

There should be immediate discussion about setting up a UK-wide Delivery Group to take forward the recommendations in this report and to identify which organizations should lead on specific actions Recommendation 19



BMA News and other items

News as supplied by BMA Comms

Shape of Training report

On Friday, the UK Shape of Training Steering Group, chaired by Professor Ian G Finlay, published its report on the way in which doctors are trained.

BMA junior doctors committee chair Dr Jeeves Wijesuriya welcomed a ‘pragmatic approach’ advised by the report in a statement to the press. He added: “We want to reassure patients and doctors that we continue to oppose any changes which devalue the high standard of medical training in the UK or compromise patient care.”

The story was covered in Pulse, GP Online and National Health Executive.

‘Surplus’ NHS start being sold

continues its coverage of plans for the NHS to sell off surplus land to fund STPs and notes a two-storey Victorian cottage hospital with 1970s purpose-built ward and clinic extensions has been deemed ‘surplus to requirements’ by Torbay and South Devon NHS Trust. The story mentions the BMA’s GP survey which found 40 per cent of general practitioners felt facilities were inadequate for delivering services. 70 percent of doctors surveyed felt premises were too small.

GMC tells doctors to ignore ban

Guidance from the General Medical Council says it is up to GPs to make a professional judgement on whether “local developments” could have an “adverse impact on patient care” reports The Sun. The guidance follows plans across the country to reduce the number of over-the-counter medication prescribed by GPs which  could save £100m. The story mentions the BMA’s stance that GPs could be vulnerable to complaints if they refuse to prescribe treatments that patients need – even if they are available without a prescription.

 A&E waiting times not met

There was further coverage of or response to latest NHS performance figures was reported in Devon Live.

Investment needed in NHS recruitment and services

Another letter from regional chairs condemning the 80,000 NHS posts vacant in England were published in print in The Romford Recorder (Dr Gary Marlowe). A letter from representative body chair Dr Anthea Mowat on maternity care was published in The Wakefield Express.

Other news

The Sun claims to have uncovered plans for a £44k slate-lined bathroom with sensor-activated lights in health secretary Jeremy Hunt’s office in the new Department of Health building in central London despite overseeing £22bn in efficiency savings. A ‘whistleblower’ told the Sun: “People across Britain are waiting on trolleys at hospitals because there are no beds and waiting lists are getting longer by the day. But that’s OK so long as Jeremy doesn’t have to queue for the bathroom.”

Concerns were raised about the quality of healthcare in North Somerset after the CCG was rated ‘inadequate’ with particular worries centring dementia and learning disability services in the region. Devon Live has the story.

According to the Daily Mail, Britons will be encouraged to check their own blood pressure and heart rate in GP surgery waiting rooms as part of an NHS drive to prevent early deaths.


Medical Staff Committee 11th August

The Medical Staff Committee of NMUH took place today with the following items discussed these are my notes and are not official minutes

 Education info

An analysis of how 2016-17 UCL medical students taught at NMH performed at their finals compared with other DGHs is given separately (see near end) . Please note the information I gave at the MSC meeting was inaccurate there was one failed student not no fails as I said.

The Education Centre asks for consultants to find patients for the Mock and Final OSCE. The OSCE format is changing as dictated by UCLMS. Senior Junior Doctors will be able to examine in the finals providing they have examined in MOSCE and had finals OSCE training. The UCL finals date is to be confirmed  The next MOSCE is over 2 days

14th November History stations only  17th November Clinical Stations

23rd January History stations only  26th January  Clinical Stations

Local Negotiating Committee

The Staff side LNC took place Friday 4th August 2017 . Matters discussed included

Junior Doctors matters. The LNC has a new Junior Doctor representative Mat Beresford a FY2 but there is a need for other junior doctor representatives. The Junior Forum has taken place. I deputised for LNC chair at theJune Meeting. Exception Reporting was discussed , It was agreed that consultants should not pressurize or dissuade juniors from submitting exception reports. Rota gaps and how they are being filled was discussed and the notice given of not being filled was noted often as being very short,

The LNC Constitution needs to change to indicate requirement for BMA membership and a recognition that constituents can ask for their representative to step down from the LNC

Other matters

The London Regional council executive meeting took place on  25th July

STPs and in particular North Central London was discussed. See full report  27th July Blog . The lobbying of London MPs is in hand and there is a need for individual BMA members to approach their own MP if they live in London. The LRC is going to have a protest march (? When) . The North Central STP is now officially the North London Partnership with its own web site and twitter feed.

The closing date for nominations for the six London Regional Council Assembly member places on the LRC executive closes at 5pm on the 5th September 2017. You need to register to attend the ABM 12th September at 7pm. Anyone interested in standing,  speak to me to arrange that the nomination form is sent to Andrew Barton

No firm offer is on the table regarding the new consultants contract. The Next UK-CC meeting is in October which I will attend.

Rosemary Stanley McKenzie BMA IRO will be in the NMH Restaurant on Tuesday 15th 12 – 2 pm to discuss any BMA or related matters on a 1:1 basis

The Royal Medical Benevolent Fund is highlighting the pressures faced by doctors at work as part of its campaign to spread the word about available support. Share your thoughts on working conditions in the short survey (12 questions only)

Matters arising form the minutes of the previous meeting discussed comments about the cladding of the PFI  building. There is no immediate need for replacement but many panels are being retested. Full communication is taking place. NHSImprovement is also informed.

Junior Doctors Morale

There was a presentation based on one given earlier in the day by the Post Graduate Director of Medical Education to the Executive board. A report has been produced by Health Education England on the back of two very challenging years for Junior Doctors.

Junior Doctors Morale – Understanding best practice working environments

The Junior Doctors strike was challenging and 2016 GMC survey showed unprecedented dissatisfaction. Increased number of trainees not taking up core training 50% of trainees have not gone into core medical training. According to a RCP survey:80% of trainees felt excessive stress because of job. Of the 40 trainees at NMH 2 have left the profession.

The role is to identify and address contributory factors and to share best practice which requires a muli agency approach

Factors affecting low morale were distilled into four themes including

  • Excessive workforce pressure
  • Poorly managed working environments
  • Lack of interest in wellbeing of staff with the JDr perception there just to provide service
  • Restricted access to training opportunities.

The NHS Constitution 3rd principal states

Respect, dignity, compassion and care should be at the core of how patients and staff are treated – not only because that is the right thing to do, but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported.

Good practice includes the following

  • Supervision:               = Good education supervision
  • Rota Management     = Good rota management
  • Valued by employer   = Explain to the trainee how they are valued
  • Protected Time           = Teaching and Study
  • Team Working           = the spirit of “firm working”
  • Support Systems        = Knowing how to support

Existing and Suggested Work for all NHS Organisations includes the following

  • Commit to learning from good practice
  • Increased Junior doctor representation at all levels of decision making
  • Accountable officer for the morale of junior doctors
    • Someone who is for pastoral care not the PGDME or GoSW
  • Educational representation at board level
    • This is in the hands of the Medical Director

Examples of good practice are

  • Chief Executive/ Junior Doctor Forum
    • There is a need for more Junior Doctors to be involved
    • Formal and Informal Forum are taking place alternately
    • There is a need for better engagement with Junior Doctors
      • Not only doing the right stuff but communicating
    • Paired Learning
    • Pastoral Lead
    • Electronic On-boarding and Induction
      • This is being reviewed by the HR Director

All the above is relevant not only to medical staff but all staff groups. The executive board has an action plan of what to do and is aware of where there are the gaps. There is a need to tell the Juniors what we are doing. Educational supervisors have a key role and should be seeing their trainees once a week. Rota gaps need to be addressed. Maternity leave should be adequately covered.

The following is another useful link


IT strategy at North Middlesex and the Fast Follower program

There was an in depth review of the evolution of the current IT system at North Middlesex with its apparently fragemented appearances with less communication

He discussed the Global Digital Exemplar – Fast Follower Programme


Most clinical processes (>95%) could be paper free. There is a need to build on existing systems rather than replacing them. Although NMUH is linked to RFH there will not be a replacement by RFH systems . There should be a seamless interfaces between systems.

There has to be electronic forms with decision support  to aid mobile working and nurse documentation. Electronic prescribing will be suitably monitored. Clinical informatics to support CPGs with Information exchange with primary care & population health

All this must have better usability/ user friendly

We need to enter information only once not repeatedly. The current fragmented state of the NMUH was reviewed with a evolution presented of the current system.

There is a need to get away from the 150 or so forms used in the Trust. There needs to be Consultant and other staff feed back on what needs to be on the electronic request forms. Some of the systems such as the Primary Care interface and Patient Portal need an STP wide solution.

There are a number of mobile apps working on iOS smart phones marketed by System C. These iphones/ipads will replace pagers and enhance nurse documentation and teamwork. These need to be integrated with Medway, clinical noting, edms and viewing results.

The evolution of e-prescribing will enhance documentation of what patients have been prescribed and what they have received, help  monitoring of drug interactions and aid in the administration and supply of drugs. Overall the success will be in the realisation of multiple benefits.

There is already  an agreement with Royal Free GDE and  an Application to NHS Digital has been made which has been approved in principle by NHS Digital

The next step in the GDE Fast Followers Programme is a Full business case to Executive Board to include Financial details and the Benefits realisation plan. If passed this will go through the Finance & Investment Committee after which a Contract with NHS Digital is followed by recruitment of specialist (mainly IT staff) This is a 3 Year Programme which require £5million investment by NMUH to gain £5 million GDE money.

Asked whether in spending £5 million of NMUH money any of the £5 million goes to RFH group management says this would not be not the case.

Management report

There was a discussion of Quality and Performance. It was recognosed that the spotlight has been on ED with most queried on performance being ED. There needs to ba a change in process. UCC currently sees 500 patients per day. All those who work in the hospital have a shared responsibility. Clinicians should know how long it takes to see patient in ED. This is significant in some specialities. There is a need to develop more staff engagement.

The CQC was the end of last year. A repeat inspection before the end of the year is expected. Whilst this is being prepared with all the that the CQC has asked for it is worth all clinicians re-reading the report. Look at the grid. In particular ensure all the “tiles” for Safe and Cared for are in the green

The meeting ended at 2 pm Next MSC September 11th

REPORT ON UCL MEDICAL STUDENTS          2016-2017  by Dr John Firth

Of the final year medical students  attending NMUH there was one fail. The person who failed was identified as an under performer in the Mock OSCE with 5 borderline stations and one fail. The whole year however  had  a noticeable 19 fails compared with the previous years 4 fails. UCL has only supplied me with distinction merit pass and fails but with no position table.  Below compares the percentage of students attaining top 10% and Top 20% in the final exams.


 Hospital Numbers Top 10% Top 20% Fails
Barnet Hospital  46 11.11% 20.00%  8.7%
Basildon  80 10.00% 20.00%  6.3%
Lister Hospital 36 11.11% 11.11% 0%
Luton Hospital 93 10.75% 24.70% 5.4%
North Middlesex  52 5.70% 15.38%  1.9%
Watford General Hospital 29 13.70% 24.13%  13.8%



Hospital Numbers Top 10% Top 20% Fails
Barnet Hospital 43 7% 16.30% 6.97%
Basildon 75 9.30% 25.3% 0%
Lister Hospital 32 9.40% 25.% 0%
Luton Hospital 97 12.40% 18.60% 1.03%
North Middlesex 55 9.10% 14.60% 0%
Watford General 29 10.30% 24.10% 0%



There has been a drop in those NMUH trained students attaining Top 10% and Top 20% positions.  NMUH had the lowest percentage of students in the top 20%. but the percentage fail is second lowest compared with all 6 DGHs


Other News supplied by BMA Comms

Expanding medical school places

There was further coverage of our response to news the Department of Health plans to expand the number of medical school places by 1,500 by 2020. iNews and The Daily Telegraph saw the announcement as stepping back from a pledge to force newly graduated doctors to work for a mandatory four years in the NHS. The Telegraph goes on to say, “The British Medical Association argued that ‘taxpayers get a significant return on their investment from the dedicated service provided by all doctors over the course of their career’.

The story was also covered in  Mail OnlineGP OnlineBury Times and  National Health Executive. It was also mentioned on 5 News at 5.

Harrison Carter was also interviewed live on Bradford community radio station BCB 106.6FM and BBC Radio Berkshire.
GP premises – rent increases

The Times reports the NHS is in talks with private GP landlords over increasing rents in an effort to generate £3.3billion to renovate surgeries in poor condition. The story first appeared in yesterday’s print edition.  

Dr Gavin Ralston, BMA GPC executive member, told The Times that many GP buildings were too cramped to provide first-class care but that ensuring money promised in the past by the government was properly spent would be a better bet.

He said: “Urgent investment is undoubtedly required, but we should treat these proposals with a high degree of caution,” he said. “A considerable question mark exists over whether PFI-type deals deliver good value for money to the taxpayer.”

Maternity services need more investment

A letter from BMA representative body chair Dr Anthea Mowat was published in today’s Yorkshire Post reflecting on research from Labour which revealed the shocking extent of which hospitals have had to temporarily close maternity wards to new admissions.

Dr Mowat wrote: “Lack of investment in maternity care from consecutive governments has left hospitals in the difficult position where they have had to turn pregnant women away as a lack of bed capacity, increasing demands and staff shortages have pushed services to breaking point.”

Naylor-inspired sell off criticised as ‘secret fire sale’

A secret “fire sale” of hospital land – including dozens of properties still being used for medical care – is planned to bail out the cash-strapped NHS, new documents show, The Independent reports.

According to the splash, The Department of Health has quietly doubled the amount of land it intends to dispose of, triggering accusations of desperate measures to plug a big hole in NHS finances. Details of more than half of the 1,300 hectares now up for sale have been kept under wraps because of “sensitivity” – raising suspicions that many other sites also have clinical uses.

Dr Kailash Chand, honorary vice president and former BMA deputy chair, described the Naylor report when published as “an outline to sell off the NHS.”

Other news

Labour has accused the government of selling off valuable hospital assets to help plug a hole in NHS financesBBC News Online reports.

BBC News in Hereford and Worcester found tens of thousands of hospital appointment follow up letters have not been sent to GPs due to a computer system error.

The Daily Telegraph writes care home residents are being dressed in other people’s clothes and left languishing without exercise for weeks at a times according to a new Healthwatch investigation.

A hospital trust in Brighton will remain in special measures despite making “significant improvements”. The Brighton Argus has the news.



Core Medical Trainee Mock OSCE stations

Yesterdays mock OSCE exam for Core Medical Trainees took place in the PM Room aimed mainly at pathology learning.

As promised I have listed the stations with answers. Due to copyright and legal reason no photographs or specimen photographs included. The Photographs can be viewed in the Ferriman Library for a short period of time. (Ask the  reception)

Station 1

Robert Hooke first coined the term cell in his book Micrographia (1665) as the microscopy of cork resembled a monks cell.

Eos is the Titan goddess of the dawn who with her pink fingers opens the skies for the sun god to traverse the world!  Eosin is the pink stain that give cytoplasm eosinophilic (acidophilic) staining properties.

Station 2

photos and radiology (donut sign)  of Intussuception with a macro specimen of ileo caecal intussusception.

Station 3a

Gastric polyp endoscopy. A pot showing similar features

Typical appearance of a GIST (Gastrointestinal Stromal Tumour (usually CK117 and DOG1 positive immuno). Origin from the Interstitial Cell of Cajal.

Station 3b

This is a CT abdo of a patient with  2 week history of abdominal pain getting progressively worse

Macros specimen is a gastric abscess

Diagnosis Fishbone perforation of the stomach (Fish & Chips 2 weeks before)

NB AXR will only pick up 50%  CT Scan > 90%

Station 3C

Biopsy of stomach H&E and Toludine blue stains

What is this histology showing.  Little toludine blue positive organisms on the surface. High power would be like little seagull shaped or spiral

Diagnosis Helicobacter like organisms (usually H pylori)

Station 4a

Histological picture and macroscopy of Pseudomembranous Colitis (C Diff)

Station 4b

This is the high power histology of a patient with diarrhoea who had spent the previous 3 months in a London psychiatric hospital. You are seeing the surface slough. What is the diagnosis

Diagnosis          Amoebic Colitis

Station 4 C


Histology of 4 polyps  Tubular adenoma,  Hyerplastic Polyp,  Villous Adenoma,  Peutz Jegher Polyp

Station 4D

This is a patient with malabsorption. A duodenal biopsy was performed

Give the pathological diagnosis.     Coeliac Disease

First described by Aretaeus of Cappadocia (2ndC BCE).                                                     Named Coeliac Disease by Samuel Gee in 1887

Give the three classical diagnostic features

  • Marsh stage 0: normal mucosa
  • Marsh stage 1: increased number of IELs, usually exceeding 20 per 100 enterocytes
  • Marsh stage 2: proliferation of the crypts of Lieberkühn
  • Marsh stage 3: partial or complete villous atrophy and crypt hypertrophy

Another patient has abdominal symptoms and anaemia, The duodenal biopsy is shown

What is the diagnosis ?      Giardia on the surface of the duodenum

High power should see sickle shape (on side) or nuclei and flagella,face on

What is the treatment       Metronidazole

Station  5A

Compare and contrast macro specimens of Crohns Disease and Ulcerative Colitis

Station 5B

Photograph of cobblestone mucosa of Crohn’s Disease.

Station 6A

This is a Rectal Carcinoma

Histology was of a moderately differentiated adenocarcinoma invading into the muscularis propria and  present in 4 out of 20 nodes including the apical node with a confirmed metastasis in the liver

What is the Dukes’ Stage           C2

What is TNM Stage                    PT2 N2 M1

Station 6B

Photos of          Alfred the Great and President Eisenhower – both had Crohns Disease

Burrill Crohns     (disease named after)

Antoni Lesniowski (described it in 1904 in Poland where it called Lesniowski-Crohns Disease)

Stations 7 – 11 are examples photographs of hands and fingers showing clinical signs related to a variety of pathological conditions and causes

Stations 7a     Hands

  • Gross irregularity of shape and size
    • rheumatoid arthritis, Paget’s disease of bone,  neurofibromatosis.
  • Unilateral enlargement of a hand
    • manual labour ,  arteriovenous aneurysm ,
  • Square dry hands
    • Myoedema
  • Fasciculation
    • Motor neurone disease

Station 7b Blunt Fingers

  • Large             Acromegaly
  • Small             Renal failure with secondary hyperparathyroidism


Stations 8A Mees Lines

  • Any acute illness
  • Heavy metal toxicity (eg arsenic, Thallium)

Station 8B Terry’s Half and Half

Proximal portion is white (oedema and anaemia), the distal portion is dark.Implies either liver or (if + brown band) renal disease

 Station 9A Beau’s Lines    named after Joseph Honoré Simon Beau 1806-1865

  • Severe infection
  • Myocardial infarction
  • Hypotension, shock
  • Hypocalcemia
  • Surgery
  • Intermittent doses of immunosuppressive or chemotherapy
  • Severe zinc deficiency

 Station 9B Longitudinal Brown Lines

  • Addison’s disease
  • Naevus at the nail base
  • Melanoma
  • Trauma


Station 10a

Clinical erythematous patch on the neck. Histology of full thickness high grade dysplasia of squamous epithelium. Diagnosis Bowen’s Disease = Squamous Cell Carcinoma in Situ

Named after   John Templeton Bowen (1857–1940) was an American dermatologist

Station 10B

Dupytren’s Contracture. Named after Guillaume Dupuytren (treated Bonaparte’s piles who made him a Baron) . Histology is Palmar Fibromatosis – Histology shown

Station 11a

Thomas Willis book Cerebri Anatome was published in 1664 with drawings by Christopher Wren. The circle of Willis photograph shows a Berry Aneurysm.

Station 11B

Slice of brain with haemmorhagic infarcted Mammillary Bodies associated with Wernicke Korsakoff Syndrome

Station 12

Macro photo and histology. Histology is of a Lobular Capillary Haemagioma (a better name) but better known as Pyogenic Granuloma. This can occur in the mouth in pregnancy (rare = Pyogenic Gravidarum)

Station 13

Keratoacanthoma versus Squamous Cell carcinoma of the skin =. Can look the same histologically. Difference is the length of history (KA short = weeks SCC long = months)

Station 14

Clinical Picture of the head with a prominent (tender) temporal artery. Histology is of an artery with prominent lymphocytic and giant cell inflammation. Diagnosis Temporal Arteritis.

Station 15

Low power view of a lymph node with prominent follicle (high power you would see loss of polarity of the germinal centres) = Follicular Lymphoma

Low power view of a diffuse lymphoid process with “star sky” appearance” due to prominent macrophages  . Typical of Burkitts Lymphoma (B cell lymphoma associated with EBV)


Professor Epstein was my professor of Pathology who gave me my first pathology job!

Station 16 Station

Photograph of a Liver with multiple nodules of adenocarcinoma. Clinically it is Carcinoma of Unknown Primary. What immunochemistry can the Pathologist do to help in identifying a primary ?

The following immuno chemistry are a useful panel  depending on the clinical background

  • CD20  CDX2 (Large bowel)
  • CK7   (Stomach Breast Pancreas Biliary Ovary)
  • ER/PR (Breast  Ovary)
  • TTF1 (Lung)
  • CK5/6   (Squamous)
  • Chromogranin CD56 Synaptophysin   (Neuroendocrine)
  • PSA (Prostate)
  • AFP   (HCC)

Station 17a

“Anchovy Sauce” Abscess – Amoebic Liver Abscess

Station 17 B

Alcoholic Hepatitis histology. Mallory-Denke Bodies are CAM5.2 (cytokeratin marker) positive

Station 18

Some examples of Cause of Death statements

Q1.    Ia       septicaemia              b –           c –

II      –

Incorrect; septicaemia is a mode of dying. It stated alone, the death will be treated as a death due to unknown cause by the Registrar of Births and Deaths and will automatically be reported to the Coroner. The term is acceptable if it is accompanied by an Underlying Cause of Death, for example, septicaemia due to recurrent infected pressure sores due to multiple sclerosis.

Q2.    Ia bronchopneumonia    b –           c –          II      –

Could be correct, but usually there is an Underlying Cause of Death precipitating the bronchopneumonia, and if this is the case it should be stated.


Q3.    Ia bronchopenumonia          b  carcinoma of bronchus     c   –      II       –

Correct; but give further site and histopathological details if known.

Q4.    Ia       carcinoma of Rt Tonsil     b       metastases      c   –      II       –

Incorrect; sequence should be reversed. Abbreviations should not be used, and further histopathological detail of the carcinoma should be given if known.

Q5.  Ia cardiopulmonary failure         b       bronchopneumonia    c –

II        lung cancer

Incorrect; seems likely that lung cancer is part of the sequence of events leading to death and should not therefore appear in Part II but in Part I as the Underlying Cause of Death. This is however ultimately a matter for your clinical judgement. More detail on site and Histopathology should be given if known.

Q6.    Q6.    Ia left-sided heart failure   b       ischaemic heart failure   c –          II     –

Incorrect. “failure” is a mode of death an not used as an underlying cause


Q7. Ia old age             b  –              c    –                 II       –

Correct; however, this term should only be used if a more specific cause of death cannot be given and if the deceased is over 80

Station 19

CONSENT 1. It is always a legal requirement to obtain a signed consent form prior to any surgical procedure.        False
Although completion of a consent form in most cases is not a legal requirement, the use of such forms is good practice where intervention such as minor surgery is to be undertaken. Exceptions include abortion and certain treatments under the Mental Health Act.

  1. Consent must be taken by the doctor doing the procedure.
    If you are the doctor providing treatment or undertaking an investigation, it is your responsibility to discuss it with the patient and obtain consent as you will have a comprehensive understanding of the procedure or treatment, how it is carried out and the risks attached to it. Where this is not practicable, you may delegate these tasks to someone who is suitably trained and qualified, and has sufficient knowledge of the procedure and understands the risks.

  2. If information about the procedure will make the patient anxious, you should not mention it.

Doctors may withhold details of treatment and attendant risks if disclosure would be likely to cause serious harm to the mental or physical health of a patient. However, this is not licence for paternalistic medicine. The emphasis is on the likelihood of disclosure causing serious harm.

  1. If information leaflets set out all that the patient needs to know about the procedure, there is no need for the doctor to explain the procedure as well.
    Information leaflets are a valuable adjunct to counselling prior to treatment. Numerous studies have demonstrated how little information may be retained by patients following a consultation, particularly when they are anxious, or have just received bad news. Using illustrations during the counselling process and providing written information to patients is therefore valuable, but must never be seen as a replacement for adequate discussion between doctor and patient.

  2. When discussing treatments you should describe any serious or frequently occurring risks.

The information which patients want or ought to know before deciding whether to consent to treatment or an investigation may include:

  • Explanations of the likely benefits
  • The probabilities of success
  • Discussion of any serious or frequently occurring risks, and of any lifestyle changes which may be caused by, or necessitated by the treatment
  • Alternatives.

  1. Competent patients have a right to refuse treatment even if they may die as a result.

If the process of seeking consent is to be a meaningful one, refusal must be one of the patient’s options. A competent adult is entitled to refuse any treatment except in circumstances governed by the Mental Health Act 1983. However, the situation for children is more complex. If, after discussion of all treatment options, a patient refuses all treatment, this fact should be clearly documented in the notes.

  1. A competent patient has the option of nominating a person to make certain decisions for them. True
    A competent person can nominate a person to make decisions for them, for example, when setting up an Lasting Power of Attorney in accordance with the Mental Capacity Act (2005). It would be rare for a competent person to nominate another person to make decisions at a time when they had capacity.
  2. In an emergency, when you cannot obtain consent, you can provide urgent, necessary treatment.

In an emergency, where consent cannot be obtained, you may provide medical treatment to anyone who needs it, provided the treatment is limited to what is immediately necessary to save life or avoid significant deterioration in the patient’s health.

  1. Intimate examinations require express consent. True
    It is important to remember that consent is a process and that consent is required for absolutely every physical examination, referral etc.
  • Explain what needs to be done and why
  • Explain what the examination will entail
  • Obtain the patient’s permission
  • Offer a chaperone, or the patient’s companion of choice, and document this.

  1. Children under 16 years cannot consent to medical treatment.
    “Provided that the patient, whether a boy or girl, is capable of understanding what is proposed, and of expressing his or her own wishes, I see no good reason for holding that he or she lacks the capacity to express them validly and effectively and to authorise the medical man [sic] to make the examination or give the treatment which he advises.” Extract from Gillick v Wisbech Area Health Authority 1986.

  2. Advance directives or living wills – statements made by patients when competent about treatment they would not wish to receive if subsequently incompetent – are binding on treating doctors.
    You must respect any refusal of treatment given when the patient was competent, provided the decision in the advance statement is clearly applicable to the present circumstances, and there is no reason to believe that the patient has changed his/her mind.

  3. A patient can refuse to be tested for HIV.
    You must respect a patient’s decision to refuse an investigation, or treatment, even if you think their decision is wrong. Explore your concerns and the positive consequences to the patient, but do not pressurise them

 Station 20

1) The photo shows a vegetation on one of the mitral valve leaflets. The signs of sub-acute bacterial endocarditis include:

  • in the hands: clubbing and splinter haemorrhages
  • in the abdomen: splenomegaly and microscopic haematuria
  • in the heart- variable murmurs
  • Osler’s nodes
  • Roth spots
  • Janeway lesions

2) X-ray shows mottled shadows in both mid and lower zones, loss of costo-phrenic angles and prominence of vessels to upper lobes. Suggest Pulmonary Oedema

The physical signs include:

  • Acutely unwell- looks ill, cold, clammy peripheries, frothy sputum, sometimes blood stained
  • Short of breath at rest with use of accessory muscles
  • Tachycardia or atrial fibrillation
  • Signs of valvular heart disease eg mitral regurgitation
  • Additional heart sounds eg HS3 or HS4
  • Fine basal crackles

3) Left ventricular aneurysm. Persistent ST elevation- concave upwards (“saddle appearance”).

Signs include:

  • cardiomegaly (displaced apex, sometimes with a double pulsation- “paradoxical apex”),
  • third heart sound,
  • signs of mitral regurgitation.



NHSP Quality Conference Info

The NHS Providers annual Quality Conference took place in June 2017. The conference discussed how NHS quality culture can be embedded, adaptable and resilient. It also discussed supporting greater collaboration and innovation to improve care.

All the following is taken from

The programme featured:

  • A keynote presentation that explored the opportunities and challenges that a triple-value framework provides greater personalisation and more sustainable population healthcare.
  • Board leadership behaviour changes to improve quality and safety.
  • Breakout sessions exploring
    •  organisational determinants and context for quality,
      • including human factors, supporting staff to raise concerns, and using data more intelligently for transformation and improvement.
    • innovation in quality culture and patient safety within key service areas,
      • including end of life care, maternity services and mental health, learning disabilities and community services.

The following are hyperlinks to the various presentations and notes

Quality in the current NHS Stategic Context

The future of healthcare: population based for higher value presentation

The future of healthcare: population based for higher value notes

Collaborative approaches to quality for better population health: panel session I

Collaborative approaches to quality for better population health: panel session II

Well-led for quality presentation

Well-led for quality Notes

Safety culture: why human factors matters more than ever to better patient safety presentation

Safety culture: why human factors matters more than ever to better patient safety notesf

Just culture: how well are we responding to the Francis recommendations presentation

Just culture: how well are we responding to the Francis recommendations notes

Knowledge culture: information for improvement presentation

Knowledge culture: information for improvement notes

Learning Culture – Learning from deaths in mental health, learning disabilities and community servicesf

Compassionate culture: hearing and heeding patient and family voices in end of life care presentation

Compassionate culture: hearing and heeding patient and family voices in end of life care notes

Safety culture: innovations for safer maternity services


London MPs on Twitter

The Sustainability and Transformation Plans/Partnerships and Capped Expenditure Process will affect the way Health and Social care is provided to Londoners. For those who are on Twitter the following London MPs have Twitter accounts. I have included the STP area that their constituents are in.

Consituency MP Twitter STP
Barking Rt Hon Dame Margaret Hodge MP @margarethodge E
Dagenham and Rainham Jon Cruddas MP @joncruddas_1 E
Hackney North and Stoke Newington Rt Hon Diane Abbott MP @hackneyabbott E
Hackney South and Shoreditch Meg Hillier MP @meg_hilliermp E
Hornchurch and Upminster Julia Dockerill MP @juliadockerill E
Romford Andrew Rosindell MP @andrewrosindell E
East Ham Rt Hon Stephen Timms MP @stephenctimms E
West Ham Lyn Brown MP @lynbrownmp E
Ilford North Wes Streeting MP @wesstreeting E
Ilford South Mike Gapes MP @mikegapes E
Chingford and Woodford Green Rt Hon Iain Duncan Smith MP E
Leyton and Wanstead John Cryer MP E
Bethnal Green and Bow Rushanara Ali MP @rushanaraali E
Poplar and Limehouse Jim Fitzpatrick MP @fitzmp E
Walthamstow Stella Creasy MP @stellacreasy E
Chipping Barnet Rt Hon Theresa Villiers MP NCL
Finchley and Golders Green Mike Freer MP @mikefreermp NCL
Hendon Dr Matthew Offord MP @offord4hendon NCL
Holborn and St Pancras Keir Starmer MP @keir_starmer NCL
Hornsey and Wood Green Catherine West MP @catherinewest1 NCL
Tottenham Rt Hon David Lammy MP @davidlammy NCL
Islington North Rt Hon Jeremy Corbyn MP @jeremycorbyn NCL
Islington South and Finsbury Rt Hon Emily Thornberry MP @emilythornberry NCL
Edmonton Kate Osamor MP @kateosamor NCL
Enfield North Rt Hon Joan Ryan MP @joanryanenfield NCL
Enfield, Southgate Bambos Charalambous MP @bambosmp NCL
Hampstead and Kilburn Tulip Siddiq MP @tulipsiddiq NCL/ NW
Brent Central Dawn Butler MP @dawnbutlerbrent NW
Brent North Barry Gardiner MP @barrygardiner NW
Cities of London and Westminster Rt Hon Mark Field MP @markfieldmp NW
Ealing Central and Acton Dr Rupa Huq MP @rupahuq NW
Ealing North Stephen Pound MP NW
Ealing, Southall Mr Virendra Sharma MP @virendrasharma NW
Hammersmith Andy Slaughter MP @hammersmithandy NW
Chelsea and Fulham Rt Hon Greg Hands MP @greghands NW
Harrow East Bob Blackman MP @bobblackmanmp NW
Harrow West Gareth Thomas MP @gareththomasmp NW
Ruislip, Northwood and Pinner Mr Nick Hurd MP @nickhurdmp NW
Hayes and Harlington Rt Hon John McDonnell MP @johnmcdonnellmp NW
Uxbridge and South Ruislip Rt Hon Boris Johnson MP @borisjohnson NW
Brentford and Isleworth Ruth Cadbury MP @ruthcadbury NW
Feltham and Heston Seema Malhotra MP @seemamalhotra1 NW
Kensington Emma Dent Coad MP @emmadentcoad NW
Westminster North Ms Karen Buck MP @karenpbuckmp NW
Bexleyheath and Crayford Rt Hon David Evennett MP @davidevennett SE
Old Bexley and Sidcup Rt Hon James Brokenshire MP @jbrokenshire SE
Erith and Thamesmead Teresa Pearce MP @tpearce003 SE
Beckenham Bob Stewart MP SE
Bromley and Chislehurst Robert Neill MP @neill_bob SE
Orpington Joseph Johnson MP @jojohnsonmp SE
Lewisham West and Penge Ellie Reeves MP @elliereeves SE
Eltham Clive Efford MP @cliveefford SE
Greenwich and Woolwich Matthew Pennycook MP @mtpennycook SE
Streatham Mr Chuka Umunna MP @chukaumunna SE
Vauxhall Kate Hoey MP SE
Dulwich and West Norwood Helen Hayes MP @helenhayes_ SE
Lewisham East Heidi Alexander MP @heidi_mp SE
Lewisham, Deptford Vicky Foxcroft MP @vickyfoxcroft SE
Bermondsey and Old Southwark Neil Coyle MP @coyleneil SE
Camberwell and Peckham Rt Hon Harriet Harman QC MP @harrietharman SE
Croydon Central Sarah Jones MP @laboursj SW
Croydon North Mr Steve Reed MP @stevereedmp SW
Croydon South Chris Philp MP @chrisphilp_mp SW
Kingston and Surbiton Rt Hon Sir Edward Davey MP   SW
Richmond Park Zac Goldsmith MP @zacgoldsmith SW
Mitcham and Morden Siobhain McDonagh MP @siobhain_mp SW
Wimbledon Mr Stephen Hammond @s_hammond SW
Twickenham Rt Hon Sir Vince Cable MP @vincecable SW
Carshalton and Wallington Rt Hon Tom Brake MP @thomasbrake SW
Sutton and Cheam Paul Scully MP @scullyp SW
Battersea Marsha De Cordova MP @marshadecordova SW
Putney Rt Hon Justine Greening MP @justinegreening SW
Tooting Dr Rosena Allin-Khan MP @drrosena SW

London Regional Council 25th July 2017


The July meeting of the BMA London Regional Council took place at BMA House on Tuesday 25th July 7pm – 9.15 pm.

In attendance was the chair Dr Gary Marlowe and secretary Dr Jackie Applebee with the South East Regional BMA Coordinator, Dr Andrew Barton and a total of 20  representatives from all branches of practice (with the exception of a medical student rep). I attended as representative for NE&NW London Regional Consultants Committee.

I have previously blogged about the role of the London Regional Council and the last meeting of the committee in April (see blog 25th April and others) .  The following are my personal notes on the proceedings with added information gleaned from many sources.

Following welcome and introductions the following matters where noted and discussed. Minutes of the last meeting and matters arising were incorporated in the discussions.

Annual Representatives Meeting (ARM report)

A report from ARM was given by Chair with contributions from those who attended. It was agreed that the enormity of changes to health and social care is just seeping in.

It was noted in particular the following ARM motions are now incorporated as BMA policies

  • condemns the woeful manner in which STPs have been progressed, turning them into vehicles to try to legitimise further cuts to vital NHS services, and proposes STPs are abandoned.
  • believes that all consultants, members on the specialist register and junior doctors of ST3 and above should be balloted on the new consultant contract proposals.
  • calls for social care to be available free at the time of need, financed out of general taxation and provided as part of the comprehensive health service.

Note BMA news item 27th July. including information related to North London

NHS leaders refuse to publish details of millions of pounds more cuts

Updates from Branch of Practices were given by the following

  • General Practice
    • There was a discussion of the e-mail sent out to all GP practices which is polling the willingness to consider a collective closure of  GP lists because of safety issues
  • Consultants
    • Contract is still being negotiated
    • The proposed new contract may cause a division of views
    • There is no new money
    • There is is only slow progress
    • “acting down” should not be used as a document title
  • Junior Doctors
    • All juniors will be on the new contract
    • There is concern on the impact on less than full time trainees.
    • The Juniors are still in dispute over the imposed contract
    • 42% are not going into CT1
    • There is an online tool for rota gaps
    • There is a rota gaps project
    • The GMC includes the impact of rota gaps on education
    • Rota gaps are being correlated by the guardian of safe working but there is no central collation of rota gaps though the information is supposed to be presented at Junior Dr forum and then the Local Negotiating Committees
    • There was a discussion about the variation in the definition of Junior Doctor rota gaps.
    • There is an online checker tool for the new contract but no pay checker tool as yet.
    • There is an ongoing review by HEE of the ARCP
    • There is a change in provider of the e-portfolio there is problem in that the old portfolio may not be archived or retreavable and all juniors should down load and save their portfolio
    • HEE is spending £10m of getting trainees back to training
    • Code of practice from HEE indicates informing by 12 weeks and rotas out by six weeks
  • Public Health


LRC Annual Business Meeting

The Annual Business Meeting of London Regional Council is set for 12th September 2017. Speakers are being invited but are not yet formalised. The Assembly of the Regional Council consists of all BMA members with a registered address in the geographical area of the Regional Council. The rules also provide for the election of six members to the Executive of the Regional Council. Those wishing to attend must register their intention by booking a place by the 22nd August 2017 using this booking link:–AN9DAJ

If you wish to stand for election. Contact

See BMA News article 29th July Make your voice heard

Capped Expenditure Process

A member of the BMA policy unit gave a short presentation of the Capped Expenditure Process which has been brought into effect in 13 of the 44 STP footprints. In London this involves North Central, North west and South east. The STP has been reframed as a partnership of health & care organisations eg North London Partners in Health & Care.

There are significant pressures on budgets particularly in 2017/18. Any proposals from the Capped Expenditure Process will need

    • to be consistent with constitutional rights for waiting times and patient choice
    • to ensure that patient safety and quality is safeguarded
    • to be subject to full public consultation in line with their legal duties if there is significant service configuration.

Although their stated  aim is to deliver the best possible clinical outcomes for local people within the funding available  the required savings involved are large  Eg North Central   £183.1  million NW London £51 million

The BMA has produced a detailed analysis which includes  link to the full document

BMA The capped expenditure process

Following a FOI request by BMA news the NC London STP have expressed their concerns over being told to find a further £61 million savings by March 2018. The STP has drawn up radical plans that would be needed to support the savings but have told the BMA they do not support the plans and felt frustrated over this latest process.

The capped expenditure process is explained by Kings Fund in this document

A recent Sunday Express article

The 24th July NLSTP newsletter

There was a discussion about London Ambulance Service which has come out of special measures But LAS is under one commission (NWLondon) which is expected to make more savings.

Patients receiving ‘outstanding care’ from London Ambulance Service

It was noted that efficiency savings can only apply to in house as outsourced contracts such as CAREUK are for 3 years.

It was suggested that there has been a lack of occupational health for healthcare workers

There was a discussion about union role of the BMA and the BMA as a professional body. A discussion took place of the LRC’s involvement in opposing health and social care cuts due to the risk to patient safety.

Areas discussed included

  • Campaigning with other unions etc
  • The strength of feeling of local population and patients
  • Talking to local groups and getting them involved
  • Funding
  • Lobbying MPs, counsellors, health and scrutiny committees and the London Mayor
  • Organising a London march

NHS Structures and medical students

Explaining BMA and NHS structures to medical students is an area some members of the LRC are already doing. There was a discussion of greater involvement of members of the LRC in their locality.


  1. There was discussion of the current industrial action in Bart’s Health Unite/Serco dispute with LRC giving support to the employees

Barts health staff strike in dispute over 30p an hour pay rise dispute

2. Discussion of the LRC organised free CPD events @BMA House or webcast

Infection matters – 6.30pm, 1 August 2017

  • overview and case studies relating to HIV Infection
  • update on meningococcal diseases
  • case studies of infectious diseases and immunology in children.


Men’s health matters – 6.30pm, 16 August 2017

  • management and treatment of prostate conditions
  • update on testosterone
  • managing sexual dysfunction in men.

Child health matters – 6.30pm, 5 September 2017

  • sleep disorders in children
  • case studies of paediatric emergency & intensive care
  • immunisations update

BMA CPD further info


Additional notes for information

STP dashboard and North London rating

On Friday 21 July NHSE and NHSI publicly released what a rating on STP performance.

 NHSE STP Dashboard

The STP dashboard four level rating system is;

  1. outstanding
  2. advanced
  3. making progress
  4. needs most improvement

North London Partners in health and care (NCL STP) has received an STP rating of 3 – making progress.

North London Partners website and twitter


twitter northlondonpartners @nclstp.

Recent News items

Mackey calls on trusts to cull ‘unsustainable’ agency staff spending

CQC chief: There’s a lot trusts can do to improve care without extra cash

Patients to benefit from £325 million investment in NHS transformation projects






Todays Lower GI Pathology Demonstration

For those who were unable to attend today’s General Surgical Pathology Demonstration they missed the following which focused on

Masses in the right iliac fossa

The following conditions were discussed and/or illustrated

Carcinoma of Caecum and ascending colon

  • Including  a “simms pathology PR”!
  • Mucinous Carcinoma
  • TNM Staging of Colonic Carcinoma

Appendicieal pathology

  • Appendix abscess
  • Mucocele of the appendix
  • Appendiceal Tumours including Carcinoid Tumour

Diverticular Disease

Meckels Diverticulum

Crohns Disease of the Terminal Ileum

Ileo-Caecal Tuberculosis

Colonic Polyps

  • Hyperplastic Polyps
  • Tubular and Tubulovillous Adenoma
  • Lipomatous polyp

Hernias with strangulated bowel


  • Radiological appearances
  • Example caused by a lipoma

Ovarian pathology (this will be discussed at an upcoming O&G pathology demonstration)

Renal transplant as a mass in the right iliac fossa

Here are a few links for extra reading


Core subject Hyperlink
Colonic & rectal polyps & carcinoma polyps general
Carcinoma of colon & rectum carcinoma general
Acute appendicitis acute appendicitis
Acute diverticular disease diverticulosis
Hernias, inguinal, femoral, umbilical obstruction
Strangulated hernias hernias

Next Thursdays demonstration will be on Inflammatory Bowel Disease (12pm Thursday)







BMA and other information

The following is part of my regular update on BMA activities and information relevant to North London

STP information

David Stout is the Senior Programme Director North Central London STP (Now called Sustainability and Transformation Partnership) and he gave a report to Haringey Clinical Commissioning Group Governing Body Meeting.


Report to Haringey CCG July 2017

Note the North London Partners in Health & Care website is up and running at

Note their Newsletter

2017-08-10 Newsletter


 The Joint Health Overview and Scrutiny Committee (JHOSC) engages with the NHS on the North Central London Service and Organisation Review and scrutinises the strategic changes relating to health service provision across the five boroughs. The committee is made up of the Chairmen of the Health Overview and Scrutiny Committees from five London boroughs: Barnet, Haringey, Camden, Islington and Enfield. The following are the current members.

Councillor Alison Kelly (Chair)

Councillor Pippa Connor (VC)

Councillor Martin Klute (VC)

Councillor Richard Olszewski

Councillor Graham Old           

Councillor Alison Cornelius    

Councillor Anne-Marie Pierce

Councillor Abdul Abdullahi   

Councillor Charles Wright    

Councillor Jean Kaseki          

BMA information

For regular information from the BMA about your area join the BMA communities group for London (sign into go to connecting doctors) eg the following recent item



 London news update: 20 July 2017

  1. NC London STP and its CEP.Three of the five STP areas in London have been subject to the Capped Expenditure Process (CEP (NW London, NC London and SE London). Following a FOI request by BMA news the NC London STP have expressed their concerns over being told to find a further £61million savings by March 2018. The STP has drawn up radical plans that would be needed to support the savings but have told the BMA they do not support the plans and felt frustrated over this latest process. However, the NHS England chief executive, Simon Stevens, has said organisations in the capped expenditure process “need to get on with” making planned savings, with the current search for further “hard choices” completed in most of them. He added, “They now need to get on with it, don’t they, because we’re in July… The longer you leave it the tougher it is.”
  2. Royal Brompton & Harefield.This Trust is having exploratory discussions with Kings Health Partners in moving their services to the St Thomas’ site. The Trust is facing losing their heart surgery services in a national proposal from NHS England. Royal Brompton and Harefield Trust, which has another site in west London, faces losing some of its services as part of NHS England’s congenital heart disease surgery review. The trust says if it is forced to stop performing Paediatric CHD work the knock-on effects would render other services unviable.
  3. North East LondonAfter seeking advice from lawyers, City and Hackney Clinical Commissioning Group has sent a letter to sustainability and transformation partnership leaders reminding them the agreement between providers and commissioners “does not create any new legal entity, and each organisation remains sovereign”. The partnership proposal was for a single accountable officer to be appointed across the seven CCGs with the CCGs only having one representative on the partnership board. The letter was written in response to the East London Health and Care Partnership agreement, which was created in May and covers 20 organisations in the North East London STP patch. City and Hackney and Waltham Forest CCGs are the only two NHS commissioners yet to sign the agreement. In the letter, City and Hackney CCG makes clear the new partnership board must “talk to” individual CCG boards and adds “the governance at STP level needs to reflect the fact that organisations cannot be bound by majority vote”. Although the partnership agreement said it does not intend to be legally binding it, it does propose that the board’s scope of authority includes “major system changes” such as the system control total and financial strategy, Whipps Cross Hospital redevelopment strategy and the system-wide estates strategy.
  4. North East London STP funding.The £325 million announced in the Budget has now been allocated to 25 schemes across 15 STP areas. Up to £5m has been earmarked to fund the redesign of the urgent care centre at King George’s Hospital in North East London. It is expected the changes will improve facilities for patients and staff, and support the hospital to improve wait times.


The BMA communications team has produced a helpful link to reflect the range of activities that took place at this year’s ARM (Annual Representatives meeting) which I recently blogged about. The digital feature

selects some inspiring and memorable motions and speeches from the event which will be relevant and accessible for both the representatives that attended as well as the wider BMA membership.

Upcoming meetings

 I will be attending on behalf of the North Thames Regional Consultant Committees the July 25th London Regional Council Executives meeting. Items on the agenda for discussion include the following

  • A report from  ARM
  • Updates from the Branches of Practice,
  • NHS structures for medical students
  • Planning  for the Annual business meeting of LRC which takes place on  12 September 2017, note all BMA London Members can attend this and can stand for election to the ececutive.
  • LRC lobbying MPs on STPs,
  • The Capped Expenditure Process  for London