North Thames LNC Fora and North East London Regional Consultants’ Committee

 

The North Thames LNC Fora and North East London Regional Consultants’ Committee took place on 14th September. At BMA House (3- 6.45 pm)

The  LNC Fora  was chaired by myself  and the NELRCC by Dr Simon Walsh (Barts). The fora was attended by LNC representatives across the North Thames LNCs whilst the NELRCC was represented by NE London Trust Consultant reps. I have  blogged about the previous meetings . The following notes are an amalgam of the two meetings.

  • There is a streamlining of training for new LNC members with completion of on line training followed by two face to face meetings. This should be an agenda item for all staff side LNCs to discuss. Trade Union training is part of Trade Union duties.
  • There was a discussion of the difference between Trade Union duties and activities with the IRO supplying a useful document but the meeting emphasised the ACAS document Time Off for Trade Union Duties and Activities paragraphs 12 and 13 was the most helpful
  • The Guardian of Safe Working (GoSW) for Junior Doctors have been established in all Trusts. There was a largevariability in completion of quarterly reports and whether they have been seen by LNCs. The annual reports of GoSW is due. There was discussion of the PA allocation per GOSW per number of trainees with some variation. Problem of one Trust covering many sites with significant travel distance for the GoSW

The various Trust reps highlighted the following points

  • Problem with a maternity return to work policy
  • Difficulties with new Junior Doctor Contract
  • Terms of reference of JDr Forum are not present in all Trusts.
  • Guidance in Exception reporting some Trust just refer to the NHSE site, other Trusts the GoSW is developing or has developed a guidance. It was discussed that any guidance should adhere to the phrasing of the JDr contract. Any changes that alter this have to be negotiated with the LNC. Some Trusts have viewed it as a benefit in showing where changes need to be made and improvements made to rotas, others are pressurising JDr not to exception report. Exception reports in each Trust have varied. Their number and frequency were discussed . JDr should not be  dissuaded from submitting exception reports. There is a need to share quarterly reports with the forum
  • Some Trusts have yet to give their Junior Doctors their contracts
  • CEAs have been held in various Trusts though in one Trust they are dealing with year 2014-15. Some variation in the mechanism and guidance on CEAs
  • Variability in acceptance of SAS Charter by Trusts
  • Some Trusts do not allow SAS Doctors to be appraisers.
  • Introduction of electronic Job Planning at some Trusts with significant teething problems. The presence of an “Additional to contract” should not be present and if it is,this is an LNC matter.
  • General feeling that Consultaants are not being listened to.
  • Job planning described “as a struggle” at one Trust. Job Planning appeals panel list is held by BMA and NHS England and has been of use in several Trusts
  • Some Trusts have difficulty with study leave in one case there was evidence that this would be unlawful under the Equality Act and BMA Solicitors are being asked for an opinion.
  • Consultants Acting to Preserve Service is a better phrase than Acting Down. These policies are under consideration at a number of Trusts. This was discussed in a number of ways. They should only occur exceptionally and monitored and reviewed. (In one Trust there was a significant use of it because of insufficient doctors on the rota), Consultants act as Consultants not as Juniors and therefore may well not have some practical skills. This may be a MDU/GMC matter if not addressed by Trusts and the document. In the end if it is a safety issue the Department has to close. The remuneration rate has to be punitive to avoid abuse. A minimum is an SpR Locum rate. BMA documents suggest 3PA=1PA. Some Trusts 2PA = 1 PA. If a Consultant On Call Acts down then another Consultant has to be the On Call Consultants. In one Trust the “Acting Down” was described as “a bit of a mess” with severe problems caused by shortages. Three tier rotas have become 2 tier.
  • Consultant Contract remains unclear. The IRO gave a review of the most up to date information
  • There was a discussion of Consultants and ST3 and above being balloted on any contract offer, which has yet to be tabled. The role of UKCC and BMA Council was discussed
  • A new declaration of interest form is to be signed for those on BMA committees. There was a discussion on two particular requests for information
  • Changes to the constitution of all LNC that all should be BMA members.. HSCA is only nationally recognised, if locally recognised HCSA would have to gain recognition on JSCs or have their own local negotiating committee.
  • In one Trust there is a debacle regarding payslips on all staff not ending up with them through the post.
  • One Trust has informed their CCGs of six months notice of withdrawal of provision of a Dermatology Service. Consultations are taking place involving another Trust and/or Private provision on a temporary basis..

 

 

 

 

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Postgraduate Faculty Meeting

POST GRADUATE FACULTY MEETING

This took place in the new education centre on13th September. In attendance was the PGDME , College Tutors , Specialty reps, Junior Doctor Reps and Education Centre Staff and the Library Manager (~ 15 in all)

The following are  my bullet points of the meeting and are not minutes

  • PGDME  welcomed all to the new Education Centre education sentre and congratulated those organizing the move
      • Opening of the new Education Centre discussed
      • Admitted there have been some teathing issues
      • Discussed Middle grade appointments
  • Opening of the new Library October 23rd – this will have a suspended ceiling and wi fi
  • Royal Free Hospital – Barnet Discussion
  • Recruitment of Consultants going to ARCP with a record of people going to ARCP interviews eg Medicine
  • Education Exception reporting by Junior Doctors (only 1 last year)
  • Third FTPD has been appointed and a new college tutor
  • New Fy1 and f2 reps reps present
  • Changes to overseeing training now back with HEE, until august most were under UCLPartners. HEE subcontracted to UCLP they have now taken it back with London London split into three. There used to be a way of knowing where everyone was being trained.  The Head of school of medicine should know. The Foundation school has been absorbed. However there is poor communications and loss of experienced staff in the whole process . The major impact is less in FY  but more in CMT etc
  • Some difficulties eg a Gastroenterology Registrar is on maternity leave. In medicine a Foundation Dr withdrew with 5 dys notice and one CMT with 2 weeks notice. One CMT withdrew and moved to Whittington. Horus now on line but it is still not fit for purpose though this is beyond our control. There was a discussion of whether there could be any compensation were loss of trainees at short notice leads to a significant cost to the Trust. An HEE Anaesthetic visit is on 21st September as a potential site for trainees again. There is likely to be an HEE GMC visit regarding GMC survey Trainers survey was done by  70% which better than national average of 53%. GMC Survey was briefly reviewed.  All departments are expected to review the survey based on their area. Resources needed to be worked on . Survey outlier (red) were discussed Noted how Green Paediatrics and Ophthalmology was though workload in Paediatric Red. Haematology did well , GP and emergency medicine is green. Note that in the survey if you hover over the the question this will give a response. CMT, GI amd respiratory are  in red. It has been a tough year with Clinical oncology with recent death of senior Doctor. As a response don’t witchunt. There is no correlation of work load and exception reports. Education governance in area of red – trainees are not feeling they can feedback. Feedback could be better.
  • Presentation on Junior doctor morale was presented to the group (see my summary at last Medical Staff Committee. Role of a “pastoral lead” for Juniors briefly mentioned
  • Junior Doctors Contract mentioned in the context of Education Exception report (only 1 last year) .An education Exception report if you cannot go but the JDr should e-mail and need a valid reason
  • Arcp will come in at the end of the year, all but one signed off last year
  • Last year ES for ED Doctors were not ED Consultants.  This is back to what it was but GMC still has concerns
  • The manager of ncentral foundation school  has resigned
  • There are no known nock on affect of “shared services”
  • Each of the leads present a summary including the following points
    • number of trainees
    • number if any deficient
    • difficulties if any in getting replacements
    • good practice eg getting 13th registrar to cover 6 months 8-5pm and next 6 months on call rota
    • any losses of consultants and how they have been replaced
    • There are 4 em consultants and a 5th wil be appointed this year
    • Faculty meeting , how often taking place and how they fit in with other meetings with minutes sent to the Education Centre
  • Sharing good practice discussed  eg Journal club which will be advertised in the weekly program, Regular teaching . New consultant has expressed an interest in teaching
  • Foundation Years– no major concern    QI projects given to those who have asked. One interested in leadership and management 2 weeks with acute lack of staff with some exception reports now overcome No talk of dropping gp trainees
  • Paediatrics –  one Consultant wins best supervisor in country . Lectures given. Paediatric are 3 registrars short . Educational initiative of a session not medical (to feel like people)
  • Renal medicine – 70% SpR are women half on maternity leave
  • Urology – The GMC survey was not agreed with previous issue of Urology/orthopaedic cover overcome
  • Library report move to pathology due to reopen October 23rd . Access to dyamed versus up to date. Dynamed plus better value. 1652 sessions of activity from 150 users . Dynamed will have a trust wide cost used by anyone as opposed to a pay per license. Up to date charge for the app. Needs Athens pass word to access dynamed . Cost £8000 for the trust .Arranging date October 3rd for next Library Committee Meeting.. Meetings with Royal Free  to compare job titles
  • No finance report. HEE cutting simms budget this year to £16000
  • Fy reps present. They need to be told their regional fy reps. The ALS  weekend  course  you get time of in lieu of 2 dys. It is cheaper to take at north mid  FY1 teaching is the “study leave”. FY2 can use sl for exams. Fy1 study leave is for ALS course and taster week,  5 days in last job. IT training  corporate induction  versus doctors induction has been rectified. IT session was helpful. ? trying to get done in advance . If a gap on a Wednesday a refresher session would be helpful. Not possible to do training at home as there are problems .

 

 

London Regional Council ABM 12th September

LONDON REGIONAL COUNCIL

The annual business meeting of LRC took place on Tuesday 12th September at BMA House.

This meeting functions as a means of annually electing representatives to the executive and receive reports of the LRCs work and its officers and then move to an Assembly meeting. More than 30 people were present. The following are my notes and are not minutes.

Introductions were by Dr Gary Marlowe LRC Chair followed by the election of five representatives from the assembly to LRC Exec. The first talk was by Professor Richard Murphy, Professor of Practice in International Political Economy , City University of London. A Chartered accountant and member of the Tax Justice Network .  In 2012 he was described as the “4th most effective campaigner on twitter”. Further details of books written and documents published see Richard Murphy Biocraphy

Richard Murphy started with a historical background to the establishment of the NHS in post war consensus of 1948 when the UK had a national debt of 250% of GDP. Established to meet the needs of everyone, to be free at the point of delivery, and  based on clinical need, not the ability to pay. There was a clear assumption that the state can work with a central direction and that tax can pay for it. The NHS is popular and it has worked. It is seen as effective by international standards.

In 1948 Friedrich Hayek at the London School of Economics promoted Neoliberalism and formed with other like minded individuals the Mont Pelerin Society. They advocate competition will allocate resources. Markets must rule. Neoliberalism wants a small state,  low tax , and pricing in play. Organisations must be slowed in order to fail. Thus NHS must be deprived of funds. These methods operate by way of stealth. Organisations such as the Mont Pelerin Society and Adam Smith Institute never disclose their sources of income. Similar organisation in the United States are supported by Koch Industries

Professor Murphy noted the tactics of working by stealth over long time scales. The Centre for Policy Studies 1988 paper by Oliver Letwin and John Redwood Ideas for the reform of the NHS gave five objectives

  1. Establishment of Independent Trusts
  2. Increased use of Joint Ventures
  3. Extending the principle of charging
  4. Health Credits
  5. A National Health Insurance Scheme

Professor Murphy continued. Austerity was the political choice of 2010 initiated by the Northern Rock collapse. Cutting spending cuts income, ff you save you cut national income. Austerity did not cut borrowing which is currently £70 billion. If you starve resources the state will go private. The 2012 Health and Social Care Act was a neoliberal act. No one now knows who is in charge. Ministers are no longer in charge of the NHS.  Denial of money was the agenda.

But, according to Murphy, there is no shortage of money. There is less unemployment but there is a  lot of under employment. When government spends, money is printed and spent first . Taxation stops inflation. But government prints money to pay for the NHS. The NHS crisis of shortage of money is artificial. The crisis is by political choice. Some health providers are in stress and can fail. There is a drive to make a market and NHS procurement will drive the imposing choice. There is a need to change thinking and believe the current state is sufficient to restate the founding principles, of an integrated care structure centrally funded. Basically this means the reinstatement of regional Strategic Health Authorities. The market cannot save this problem and direct resource as to where they are needed

This talk was followed by Professor Sue Richards a member of Centre for Health and Public Interest(CHPI) and Chair of Keep Our NHS Public and. her on the development of  STPs in London . She noted the Kings Fund and Nuffield Trust had published yesterday a report on STPs but had only just read the executive summary. See the fill document 2017 Kings Fund STPs September-2017

The following are bullet points of her talk

  • 2012 Health and Social Care Act that was the point of turning the NHS it into a market. There is a wide consensus that the Act has not worked. Simon Stevens is driving STPs forward as collaboration.
  • Austerity has resulted in underfunding of the NHS since 2010 with an average 1 per cent increase when what is needed is 3.5 – 4% largely done by capping and freezing pay
  • Simon Stevens 5yr forward view ideas , Professor Richards said,“are bonkers”. The 44 foot prints bear the same boundaries as the Primary Care Trusts. They are suspending the pressure to use competition but not  removing 2012 Act.
  • The £30 billion black hole by 2020/21 may have £8 billion given but this taken from other budgets.
  • Since their establishment in 2015 the STPs are too hurried, too secretive, and too threatening.
  • There is lack of involvement of the public and staff
  • There has been recent re branding such as the NCL STP is is the North London partners in health
  • Questions that need to be asked
    • Will I benefit from care closer to home ?
    • What lies ahead for the vulnerable ?

Turning to London she discussed the role of the Mayor. Sadiq Khan does not have much power in health at the moment but he may get some devolved power with some control over estates. A report has been  commissioned by Sadiq khan. This may make dealing with estates easier (debatable whether this is good or bad. London has had previous reconfigurations. There is a need for more information about STPS in London

CHPI Transforming Services Analysis

London is a radicalised city compared with other parts of the country both in councils and CCG. NHS England is becoming more bullying to deliver change. As an example Hackney CCG have been resisting having one accountable officer for East London Healthcare Partnership.

2017-09 Healthwatch Hackney

She noted that Lewisham CCG has had its power to commission acute care removed this has been handed to Southwark. She questioned whether Simon Stevens the NHS  man in Whitehall or Whitehall man in the NHS. If the London Mayor has the right to sign off assets there maybe a temptation to use family silver to bale out current funding. She noted the advent of Accountable Care Organisations.  STPs have to be statutory bodies to own NHS property and to use it. This is a tempting pot.

The workforce is tired and at the end of their tether. There are pay and workforce issues with new roles and new staff eg physician assistant. There is also going to be a new role under the position of  healthcare assistant. The Kings Fund says there is no alternative to STP but is against the loss of hospital beds. There is an expected 6% increase in population in London with it having1/3rd of the population of children.

Discussions from the floor included

  • There are lots of indicators of serious problem in the morale of the profession
  • Capitalism has run out of ideas
  • The market economy wants rents without risk
  • Accountable Care Systems are different from Accountable Care Organisations. ACOs are legal entities and can be sold on and privatised. ACS have no statutory or legal basis, they can’t own property and have no provision n 2012 act.
  • To reinstate the NHS you need to have Councils as part of Accountable Care Systems
  • ? need for a Judicial review of STP
  • Barts Health has a huge huge burden repaid in 2049 See CHPI Profiting From Infirmaries
  • Why not buy out the PFI’s or a windfall tax on companies with PFI contracts. Interesting that one of the first reversal of PFI was London Underground by Boris Johnson.
  • Appointing and not being accountable requires getting MPs  and councillors to stand up.
  • Are the forces of neoliberalism in retreat ?
  • A need for peoples quantitative easing ie government printing money as they did for the banks when £435 billion was printed. Surprisingly strictly speaking national debt is 65% of GDP.
  • Physician assistants – going to be above FY2  but with only 2 years training. Physician assistant – cannot prescribe. Who is going to bare the cost of insurance.
  • There is a need to campaign and raise awareness. How to oppose people who think they are doing the right thing.
  • Act politically to raise the profile of the issues. Need to engage with people.  Make clear not agree and oppose but will still deal with you as the person. Dialogue is essential . Always question
  • If you are in the state sector you are regarded as second rate.

 

Today’s Medical Staff Committee

The North Middlesex Hospital Medical Staff committee took place today at 5pm in the lovely new Education Centre. Over 25 Consultants were in attendance (and about 14 apologies including MD & CEO). There were no significant changes to the previous minutes or matters arising. The following are not minutes but are my notes of the meeting official minutes are discussed at the next meeting

NMUH Finances

There was a presentation of what NMUH  finances currently look like. The YTD performance is “disappointing”. NMUH income is currently around £268m per annum but spend £290m. This over £2m a month more than earnings. In order to limit this deficit there is a need save £13.9m (~6% of turnover). >60% of acute providers in financial difficulties though some such as Chesterfield Royal. (40%) are not so what are they doing differently.

There is a widening gap of CIP targets and what had happened. We can not rely on income generation. There is a need to address our cost base. There are many ways in to address financial challenges alongside improving patient safety and experience. Deloitte has concluded there work with a cost saving programme (not detailed)

It was noted all North Central London Hospitals are under the Capital Expenditure Program

Payment by results is not happening but there is a push for cost base contracts not price based.

Examples given

Causes Deficit
Winter ward still open –  – owing to sustained operational pressure £744k
Medical staff premia exc A&E -in particular ophthalmology, dermatology, general medicine £675k
Netted by underspends of  (mainly A&C vacancies) £587k
A&E cost pressures –  – bank and agency clinical staff (middle grade rota gaps and nursing staff turnover ì) £460k
Maternity activity shortfall -attrition rate î but still >10% £271k
CIP slippage –  – owing to failure to recruit into PMO, now mitigated £226k

 

There is a need to focus on safety, patient experience and patient flow.

Open winter ward costs over £150k a month to run

  • initiatives like red2green
    • makes a real difference
    • Requires a  team effort from nurses, doctors, pharmacists, therapists and others.
    • 66% of the delays are in our hands
    • Getting patients who are ready to go out also require working with CCG & councils

Delays in ED,

  • can lead to more admissions causing further operational and financial pressure.
  • Does your specialty have a hot phone ?
  • How quickly do you see patients who are referred from ED?
  • There is a need for bold and creative thoughts about what pathways could go directly to AEC/SAU/WAU etc.

£1m per month is spent on agency staff (previously £1.5 million)

  • Less continuity and familiarity than substantive staff offer.
  • Though a lot of this is about rota gaps
  • There is a need to be creative and proactive about recruitment
  • Getting on top of sickness and other employment issues

Getting the basics right is also key

  • Every VTE or HCAI can cost us £25,000?
  • This can be reduced by making sure each patient has had a VTE assessment and it has been acted on will reduce this
  • Good antimicrobial stewardship saves money – up to £120k a year.
  • Pathology and other tests:
    • around a third of tests results are never looked at
    • there is a need to have good testing alogrithms in place and ensure the juniors adhere to these?
      • Comment from the floor of the cost of ESR testing £100k
      • Is it necessary to have fbc every day?

 

Ideas of savings sent in recently

  • Blood cultures
  • Waste management – the orange bin costs 10x more than the rest – is it all clinical?
  • Providing British Sign Language support – online solutions via an app are much more cost effective
  • Reducing medicine waste by simply asking patients “Please bring this medicine with you if you are coming as a patient in the Hospital”
  • Venflons in ED – patients should only have one if they require it – waste of money as well as potentially introducing infection!

Discussions included

  • Something should happen to a patient every day
  • The need to be efficient, discharging patient budget settings
  • Emphasis on Clinical Leadership
  • Upcoming changes in requesting will have its benefits
    • Audicom, results acknowledgement
  • Consultants assignments must be accurate
  • Need to ensure proper use of Consultant time and not needing extra time for tasks that could be delegated
  • Upcoming changes would save consultant time
  • Value of physicians assistants debated briefly
  • Changes to the provision of Dermatology specialist services at the Trust

 

Exception reporting of Junior Doctors

There was a presentation on Exception reporting by the Guardian of safe Working.

All Junior Doctors are on the new contract. Previously diary carding was the only way of assessing whether jobs are fit for purpose. Exception reporting is now the mechanism used by doctors in training to inform the employer when their day-to-day work varies significantly from the agreed work schedule.

Exception reports are logged on the DRS4. All clinical and educational supervisors need access to this (contact HR if not). The Educational Supervisor and HR are informed and HR informs the Clinical Director

There was a discussion of the necessity to discuss with a consultant first. One view was ideally you would receive authorisation from your consultant but this is not required according to the contract. Time of in lieu (ToIL) should be the first form of payment otherwise payment. This does not replace a locum.

The role of the Educational Supervisor oversite of the trainee was discussed. When not in the same clinical specialty there may be a need for delegation.

Floor discussion

  • There is no similar system for Staff grade or SAS Doctors
  • Significant problems with rota gaps which has a slowing effect
  • Significant issue with HEE in that 5 posts were not filled but HEE gave insufficient notice.
  • Attracting Trust Grade Doctors is important
  • What happens if one Junior takes a lot of breaks and the other doesn’t and that latter puts in an exception report
    • This was discussed in the context of involving the ES but also the one taking no breaks may be not taking the statutory breaks which require an exception report being made.
  • Junior Doctors wishing “Clinical experience” did not justify an exception report

 

Undergraduate Education Review

The UGDME gave a short review and discussion covering the following points

North Middlesex Hospital ears £1.5 million per annum from UCL and SGU medical students. There is an expectation of how we are spending the money. (Each full time consultant has 0.5 SPA for Post Graduate and Undergraduate Teaching)

It is important that the Consultants and Senior Doctors show their involvement in teaching to evidence the SPAs allocated to education. And how NMH is delivering teaching to 5th & 6th Year UCL students and SGU Students

The result off the Junior Doctor strike necessitating the exams to occur in the Central Hospitals resulted in a reassessment of the way the OSCE exams are run.

The Mock OSCEs will reflect these changes and will now take place over two days in November and January. This will require more examiners and more patients.

It is expected UCL will arrange more actors as patients for NMH MOSCEs

It was pointed out that Year 8 UCL students are acting as FY1 and should be treated as and used as  Doctors.

The UCL Study Guide is useful and will be circulated by e-mail

  • It includes core conditions that is a useful framework for developing teaching

See also for Year 5

https://www.ucl.ac.uk/pcph/undergrad/cbt/year5/y5-student-study-guide

 

There has been minor changes to the SGU Curriculum with a requirement to do Multiple Choice Questions at the end of the rotations requiring a 60% minimum to pass.

New Display Boards are being brought into help in identifying teaching events.

 

Today’s UCL & SGU Surgical Pathology Demonstration

For those who attended today’s General Surgical Pathology Demonstration this focused on

Causes of masses in the right iliac fossa

Pathology tends to vary with the age of the patient

The following conditions were discussed and/or illustrated

Carcinoma of the Caecum and ascending colon

  • Including  a “simms pathology PR or DRE” !!
  • Mucinous Carcinoma
  • TNM Staging of Colonic Carcinoma (refered to)

Appendiceal pathology

  • Appendix abscess
  • Mucocele of the appendix (cassed by Mucinous Cystadenoma)
  • 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
  • Villous Adenoma
  • Lipomatous polyp (uncommon)

Hernias with strangulated bowel

Intussusceptions

  • Radiological appearance Donut
  • Lead usually caused by a lipoma, adenoma or lymphoma)

Ovarian pathology (this will be discussed at an upcoming O&G pathology demonstration)  examples shown a Serous Cystadenoma and an abnormally large example of Struma Ovarii

Renal transplant as a mass in the right iliac fossa (nb abdominal examination includes examining the back for renal tenderness and scars such as nephrectomy scars)

Here are a few links for further reading

Abdominal Exam

Core subject Hyperlink
Colonic & rectal polyps & carcinoma polyps general
Carcinoma of colon & rectum carcinoma general
 Crohn’s Disease small bowel crohns disease
Acute appendicitis acute appendicitis
Acute diverticular disease diverticulosis
Hernias, inguinal, femoral, umbilical obstruction
Strangulated hernias hernias

Next Thursdays demonstration will be aimed at O&G students and SGU students and will be on Uterine and Ovarian Pathology   (12pm Thursday)

Answers to today’s FY2 Quiz

Q1 Microscopic photograph of large bowel

The histology shows colonic mucosa with dissolution of crypts with an eruptive exudate on the surface of purulent material. The low power appearance is typical of a mushroom like appearance to the surface debris. The appearances of Psudomembranous Colitis

Q2 Patient had been in a psychiatric hospital for 3 months with onset of diarrhoea..

Shown is the surface slough with no epithelium. The smaller dots are  inflammatory cells. The large eosinophilic organisms are single cells at least 4 x the size of lymphocytes in which red cells have been phagocytosed.  The appearances are of Amoebic Colitis. Emperipolesis of red cells is pathopneumonic

Q3 Biopsy of gastric mucosa with H&E and Giemsa staining with the surface showing organisms on the surface. Classically these are spiral or “seagulls” of Helicobacter like organisms.

Q4 Erythematous plaques on the neck. \histology shows  full thickness dysplasia of squamous epithelium ie Squamous Cell Carcinoma in situ (Bowens Disease) named after John Templeton Bowen.

Q5 Keratoacanthoma versus Squamous Cell Carcinoma . Both can look clinically the same. Both can have similar histology. The important difference is the length of clinical history.

Q6a Photograph of a classical example of cobblestone mucosa of Crohn’s disease affecting the terminal ileum.

Q6b Four photographs the link in Crohns Disease

  • King Alfred the Great – said to have symptoms of Crohn’s disease
  • President Eisenhower – suffered from Crohn’s Disease
  • Dr Burrill Bernard Crohn who described the condition in 1932
  • And Antoni Bniowski described the condition in 1904, it is called Bniowski Crohn’s disease in Poland

Q7 Microscopy of a patient with malabsorption showing the three  features of Coeliac Diseae namely

  • Increase in intra-epithelial lymphocyte
  • Villous atrophy
  • Crypt hyperplasia

Microscopic photograph of a patient with abdominal symptoms and anaemia. The duodenal biopsy shows organisms on the surface. On high power on edge  they have a sickle shape , on side you might see the flagella and two nuclei. They do not invade the mucosa. The appearances are of Giardia,

Q8 Four microscopic photographs showing typical example of

Tubular Adenoma , Hyperplastic Polyp,  Villous Adenoma and a Peutz–Jeghers Polyp

Q9 Macroscopic picture of a polypoid gastric tumour with surface ulceration. Endoscopic picture of a similar tumour. Typical example of a Gastro Intestinal Stromal Tumour (GIST) which arise from Intestinal Cells of Cajal. These are spindle cell tumours which are positive for CD117 and Dog1 immunochemistry.

Q10 Macro photo T scan and ultrasound latter two showing “donut sign” of intussusception

Q11 Circle of Willis photogaph of a Berry Aneurysm shown.  The book Cerebri anatome of 4written by Thomas Willis in 1664 was illustrated by Christopher Wren

Q12 Photograph of a brain slice with haemmorhagic infarction of Mamillary Bodies which can be seen in Wernicke-Korsakoff Syndrome

Q13 Three photograph of nails

Terry-s Half and Half where the proximal portion is white due to oedema and anaemia and the distal portion is dark associated with liver disease – if a brown band renal disease

Mees Lines can occur in any acute illness, chemotherapy or toxicity to Arsenic or Thallium

Beau’s Lines decribed by Joseph Beau is associated severe infections, MI , shock , hypocalcaemia, surgery ,immune or chemotherapy, zinc deficiency.

Q14 Photograph of a hand with Dupytren’s Contracture with low power and high power histology. This better termed Plantar Fibromatosis similar pathology is seen in Plantar Fibromatosis an Peronie’s Disease. Dupuytren cured Napoleon’s piles and was made a Baron.

Q15 Photograph of a tender temporal artery. Histology shows a  Giant Cell Arteritis

Q16 Paco photograph with metastatic carcinoma of unknown origin

Useful immune for identifying origin

  • CK20 CDX2   Large intestine and Pancreas
  • CK7   Stomach Biliary  Pancreas Breast
  • ER Breast and Ovary
  • TTF1 Lung
  • Chromogranin Synatophysin CD56  Neuroendocrine
  • Gata 3   Breast

Q17 Photo of Anchovy Sauce Bottle .CT of a Liver Cyst . Diagnosis Amoebic Cyst.

 

 

 

Surgical Pathology Oncology quiz

Todays Surgical Pathology Oncology quiz

Q1 Robert Hook in his book Micrographia in 1665 introduced the term cell to describe the microscopic structure of cork that he thought resembled monks’ cells

Q2 Eos the Titan the goddess of the Dawn opened the skies with her pink finger to allow the Sun God to travel the sky. Hence the term is used for Rosin a pink eosinophilic (acidophilic) stain is part of the basic histological stain,

Q3  Salivary Gland Tumour shown Adenocid Cystic Carcinoma

Q4  Salivary Gland Tumour shown Mucoepidermoid Carcinoma

Q5  Basophilic area of ringed calcification which is derived   from the Greek word meaning “sand“ (ψάμμος ) = Psammoma bodies., They are classically found in Papillary Carcinoma of the Thyroid, Papillary Adenocarcinoma of the Ovary

Q6 Adenocarcinoma of the oesophagus arising in Barrett’s Oesophagus. Barrett was a south London based Australian Surgeon who reported it in the 1950s. Other than smoking, alcohol, GORD and Barrett’s Oesophagus two other factors associated with Esophageal Cancer.include Hot tea drinking and Achalasia,

Q7  Example of Clubbing shown. This was first described by Hippocrates.

The angle is called the Angle of Lovibond

Q8 The Sister Mary Joseph nodule is a perumbilical metastatic deposit of malignancy usually from an intrabdominal  Adenocarcinoma. She was a religious sister but also Mayo’s theatre nurse. Mayo wrote it up in 30’s and Bayliss attributed the name in 1950s

Q9 Gastrointestinal Stromal Tumour shown, These are said to come from the Interstitial Cell of Cajal and are CD117 and Dog1 positive spindle cells.

Q10 Histology shown of a Fibrolamellar type Hepatocellular Carcinoma.

Pleomophic, fibrous with a radiological central scar.

Q11 Pattersn of Prostate Carcinoma shows “Cribriform”  and Perineural invasion

Q12 Macro and micro of Carcinoid tumour. Histology shows a “salt and pepper” nuclear chromatin patterm.

Q13 Histology of a lymph node with metastatic Adenocarcinoma

Q14 Histology of kidney with Renal Cell Carcinoma of clear cell type due to glycogen. (PAS positive PASD negative)

Q15 Macro of renal tumour histology of Transitional Cell (Urothelial)Carcinoma

Q16 Histology of a poorly differentiated Urological Carcinoma with micropapillary pattern

Q17 Macro of a normal ovary Left Ovary associated with clinical  Meigs’ syndrome

Right Ovary Histology showed Call Exnar Bodies indicating Granulosa Cell Tumour

Q18 Macro of Endometrial Carcinoma. Assuming no invasion of adnexa, lymph nodes or serosal involvmenent the possible Figo stage this Endometrial Carcinoma could be 1a Not invading more than 50%  1B invading more than 50% II invading Cervix.  This was 1B

Q19 Hysterectomy with Histology showing Adenocarcinoma of the cervix

Q20  Microscopy of cells showing cytoplasmic vacuolation , Koilocytosis,  indicating HPV infection. Derived from the greek term for “hollow” koilo

Q21 This vulval biopsies shows intraepithelial extension of adenocarcinoma cells. The diagnosis is Extramammary Paget’s Disease. There is likely to be an underlying Adenocarcinoma of the Vulva.

Q22 Two macros of testis with similar appearances but younger (age 25) typical of a Seminoma. The 80 year olds Testis is a Lymphoma

Q23 Leydig Cell Tumour of the Testis are yellow in colour. The histology shows classical Reinke Crystals.

Q24 Macro picture of a Breast showing Peau d’orange. Theis is due to Breasst carcinoma cells invading dermal lymphatics causing oedema.

Q25 Microscopic picture of Invasive Lobular Carcinoma with  Lobular Carcinoma in situ. The invasive element shows the typical “Indian file pattern”

Q26 Microscopic picture grade 1 invasive ductal carcinoma of the breast (Tubular Carcinoma)

Q27  Keratoacanthoma Versus Squamous Cell Carcinoma ALWAYS state the length of history (short KA long SCC) as they can have identical histology.

Q28 This primary skin tumour is in the dermis only Negative stains – S100  & Melan A  (Excludes melanoma) BerEP4   (excludes BCC)

Positive stains – Synatophysin  & Chromogranin  are Neuoendocrine markers CK20(dot positive) is often seem. Diagnosis id Merkel Cell Carinoma. Note association with Merkel Cell Virus.

Q29  Not used

Q30  Three histologies of Sarcomas with different patterns

Herring bone patterm – eg fibrosarcoma amd synovial sarcoma

Storiform pattern – eg Dermatofibrosarcoma protuberans, Malignat Fibrous Histiocytoma

Chicken wire pattern – some Liposarcomas

Q31 32 Microscopy of Reed Sternberg Cell and Popcorn Cell

Q33 & 34  Microscopy of Follicular lymphoma – retention of follicular pattern but loss of polarity of germinal centres giving a uniform appearance.

Burkitt Lymphoma – Starry sky appearance due to tingeable body macrophages.

Q35 Microscopy of Plasma Cells (eccentric nuclei , cartwheel nuclear pattern and prominent golgi apparatus). Peppercorn skull. Diagnosis Multiple Myeloma

Surgical Pathology of the Testis

Urological Surgical Pathology II

The following topics were illustrated or referred to please click hyperlink for further information

Discussed

Viral Warts – Condyloma Acuminata of the Penis

Balanitis including Balanatis Xerotica Obliterans and Zoon’s Balanitis

Bowen’s Disease (Erythroplasia of Queyrat) Squamous Cell Carcinoma in Situ

Squamous Cell Carcinoma of the Penis

Additional reading

Phimosis, Adult Circumcision

Paraphimosis Pathology

Balanitis

Balanitis Xerotica Obliterans

Balanitis of Zoon

Illustrated cases non tumour

Testicular torsion Testicular Torsion

Testicular abscess

 

Testicular Cancer (frequency)

Seminoma                             40%

Non Seminomatous Germ Cell tumour (NSGST)  40%

Mixed                                      15%

 

Seminomas

  • Colour white and solid
  • Clear cells rich in glycogen
  • Prominent lymphocytic infiltrate
  • 25 – 45 year old
  • Serological marker Placental Alkaline Phosphatase

 

NSGST

  • Undifferentiated Embryonal Carcinoma
  • Varying differentiation of Teratoma
  • 20 – 40 years
  • Serological marker  AFP &  HCG

 

Pure Choriocarcinoma and Yolk Sac Tumours very rare in adults

 

Yolk Sac Tumour

occurs in children less than 4 years

 

Other Testicular tumours

Sex Chord Stromal Tumours

Leydig Cell Tumour   –

Sertoli Cell Tumour

 

Testicular tumours in elderly are rare but when occur are likely to be Lymphoma (example shown)

Further reading

Testicular Cancer

Testicular Cancer – Spermatocytic Seminoma

Testis general

 

Surgical Pathology of the Kidney and Bladder

The following  were discussed or illustrated in todays SGU Undergraduate demonstration

Renal Cell Carcinoma

Clinical presentation  Haematuria  (60%)  Pain (45%)

Mass ,Fever, Metastasis, Paraneoplatic syndrome less frequently

Yellow macro appearances is due to microscopic cytoplasmic Glycogen

Periodic Acid Schiff stain positive but removed with Diastase

Other variants papillary and Chromophobe less common

Usually solid , maybe necrotic , rarely cystic.

Associated with Von Hippel-Lindau Disease

  • Retinal Haemangiomas
  • Cerebellar Haemgioblastoma
  • Defect on Chromosome 3

Local invasion

  •    through capsule
  •    into preinephric fat
  •    invasion of renal vein
  •    extension into inferior vena cava

Lymphovascular invasion

Haematogenous spread to Bone and other organs

Paraneoplastic sydrome

eg Erythropoetin leading to polycythaemia

Hypertension (renin)

Amyloid (not mentioned)

 

Renal Oncocytoma

  •   Brown macro
  •   Central scar which can be seen on CT scan
  •    Cell are very eosinophilic due to increase numbers of mitochondia

 

Transitional Cell (Urological) Carcinoma of the Renal Pelvis and Ureter

Difference in appearance to RCC Pathologically and Radiologically

Papiillary appearance

Value of Urine Cytology (always do 3)

 

Refered to

Wilms Tumour in Children (not illustrated)

 

Prostate

Normal size and feel was shown

Nodular hyperplasia shown

How to deal with a radical prostatectomy for carcinoma of the prostate

Spread of Prostatic Carcinoma

  • Haematogenous – bone
  • Lymphovascular – nodes
  • Perineural

Other Tumours that invade perineurlally

Parotid Carcinoma . Melanoma, Pancreas

Less often  BCC , Breast , Colon

Urinary Bladder

Transitional Cell (Urinary) Carcinoma

Association with Smoking, amd Aniline Dye and Schistosomiais haematobium

Microscopic stageing

  • pTis      Mutifocal carcinoma in situ, use of BCG as treatment
  • pT1     Stromal invasion
  • pT2      Muscular invasion
  • pT3       Through Muscle (only assessed radiologically or in cystectomy|)

Grading of TCC  1 & 2 Low Grade    Grade III = High Grade

Squamous Cell Carcinoma is associated with Sch Haematobium

Non malignant Squamous (Vaginal Type) Metaplasia) seen in women’s trigone (“Pseudomembranous Trigonitis”)

 

 

News items (including BMA Comms)

News items

NHSI

New director-level nursing appointment for  London region

HEE

In London eight Lead Providers currently hold some of the responsibility for  the training, education and supervision of the future medical and dental workforce in partnership with local HEE teams, Following a review in March 2016 HEE  decided to take back the majority of administrative support functions for post-graduate medical and dental education.in London and South East region.and develop Education Provider Networks (EPNs) to support innovation and best practice.

See UCLPartners update August 1st

Transfer of education Lead Provider responsibilities from UCLPartners to Health Education England (HEE)

HEE Targeted GP training support proposals including extensions to training

Following the recent announcement by the Government about funding for additional clinical placements, HEE has now written to Higher Education Institutes with the detail about how the money will be allocated.

A sample copy of the letter to HEIs

Brexit

The BMA comments on a paper published which suggests that the UK government does not want any border posts between Northern Ireland and the Republic of Ireland post Brexit.

BMA responds to UK position paper on Ireland border 16 August 2017

STPs

The North London Partners in Health & Care  most up to date Sustainability and Transformation Plan (STP)  produced by all the main healthcare organisations and local authorities within North Central London can be found at

2017 NLPSTP July 2017

Other documents worth a read related to North Central London

Response to North Central London Joint Health Overview and Scutiny Committee ReportDecember 2016

2017 NLPartners Programme delivery board minutes July 2017

2017 NLPartners Minutes of the Health and Care Cabinet June 2017

BMA Response paper

2017 BMA Summaries of STPs   NCL is p86

Healthwatch Enfield

Affected by an MSK, Pain, Urology or Gyneacological condition? Share your views with Enfield CCG

Enfield Council want to hear your views on local pharmacies by September 5th

 

From BMA Comms

BMA chair speaks to GP Online

In one of his first full interviews with trade publication GP Online, BMA council chair Dr Chaand Nagpaul discussed the challenges facing the NHS and his plans to lead the medical profession. Dr Nagpaul said it was a ‘huge privilege’ to be elected chair which comes with ‘high expectations’ that he wants to deliver for the whole profession. The chair stressed the importance of a properly-resourced NHS. He said: “At the heart of the problem is that we have an NHS that spends £10bn less than equivalent leading nations.’ Politicians cannot expect to get away with that.” Dr Nagpaul added it is ‘critical’ that NHS organisations and regulators recognise the often ‘impossible constraints’ doctors are placed in by the system. You can read the full interview here.

According to the magazine, Dr Nagpaul said the ‘mere fact’ the ballot was happening speaks volumes about the frustration of GPs and the biggest problem is operating practices with an inadequate NHS budget.

   

Overseas GPs to be recruited by April

 GP practices will be able to recruit 600 more fully qualified overseas GPs by April 2018 – and 1,000 by December – as NHS England massively expands its international GP recruitment reports Pulse.

In response to the plans, Dr Richard Vautrey, BMA GP committee chair: ‘Plans to recruit more doctors from overseas may help to provide much needed GPs in the short term. These professionals have a strong track record of providing first rate care to patients in the NHS over many decades.

‘However, more needs to be done by the government to create a sustainable, long term basis on which to remedy the huge workforce problems threatening to overwhelm GP services across the country.’

 

Hospital doctors offered easier route into general practice

 The RCGP and Health Education England will develop a programme to support doctors qualified in other specialities to become GPs. The plans will also provide struggling GP trainees with more personalised and make it easier for overseas GPs to join UK general practice.

Speaking to Pulse, Dr Krishna Kasaraneni, BMA GP committee workforce lead, said: “We are pleased that the review of evidence from HEE supports the BMA’s calls for personalised training. There are a number of reasons why some trainees may fail their exams and the current system and time limits unfairly disadvantage some of the more diverse groups of doctors.

He added: “It would be pointless to simply increase the number of attempts without targeted support. While it is important that the bar for qualifying as a GP remains at an appropriate level, doctors who have been unsuccessful in their assessments should be supported to re-apply for further training to help them to become independent practitioners in the future.”

 Hunt v Hawking

 Channel 4’s Fact Check team examined the furore between Professor Stephen Hawking and Jeremy Hunt after the theoretical physicist accused the health secretary of caving into private healthcare companies.

The article cites the BMA’s report on private care in the English NHS which found 44 per cent of money spent private sector care in the NHS is now spent on community healthcare services – a 271 per cent increase in privatisation since 2010-11.

The article continues that, according to the BMA, 25 per cent of NHS privatisation spending is on ‘general and acute care’ while just over 10 per cent is spent on learning disability and mental health services.

Arthritis

Dr Vautrey was interviewed live on BBC Radio Leeds yesterday at 8.10am about what more can be done to cater for arthritis sufferers. 

 Other news

The Guardian reports on the launch of a new UK charity, the Difference, aimed at recruiting teachers who are trained to deal with mental health problems.

Radical new NHS proposals could see families getting supermarket discounts if they hit NHS exercise targets according to the Telegraph.

The Sun reports that thousands of patients have been put at risk at Portsmouth Hospital following failure to book follow up appointments.

 

Recently published data

Diagnostics Statistics for April 2017 for NMUH

North Middlesex University Hospital NHS Trust  
Computerized Axial Tomography 1,915
Diagnostic Ultrasonography 3,070
Fluoroscopy 330
Magnetic Resonance Imaging 680
Medical  Photography 0
Nuclear Medicine 155
Plain Radiography 9,420
Positron Emission Tomography 0
Single Photon Emission Computerized Tomography 0

For other providers go to  NHSE Diagnostics Stats