PathWay #13 - Cover
15/8/07
10:57 PM
Page 2
PathWay Spring 2007 - Issue #13
Spring 2007 | Issue #13
The food issue
ALLERGY TESTING: A STICKY BUSINESS
PATHOLOGISTS ON THE FOOD BUG TRAIL
SPOTLIGHT ON COELIAC DISEASE
The food issue:
ALLERGY TESTING: A STICKY BUSINESS | PATHOLOGISTS ON THE FOOD BUG TRAIL | SPOTLIGHT ON COELIAC DISEASE
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PathWay #13 - Cover
15/8/07
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Page 3
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PathWay #13 - Text
15/8/07
6:51 PM
Page 1
ADVISORY BOARD
Contents
Dr Debra Graves (Chairman)
Chief Executive, RCPA
Dr Tamsin Waterhouse
Deputy CEO, RCPA
Dr Gary Lum
Vice President, RCPA
Dr Edwina Duhig
Director of Anatomical Pathology QHPS
(Prince Charles Hospital)
Dr Andrew Laycock
Chairman Trainees Advisory Committee, RCPA
PATHWAY
Spring 2007
Issue #13
Dr David Roche
New Zealand Representative, RCPA
Wayne Tregaskis
S2i Communications
PUBLISHER
Wayne Tregaskis
COVER STORY
EXECUTIVE EDITOR
Dr Debra Graves
Rash response:
EDITOR
Kellie Bisset
Misinformation about allergy testing is proving a challenge for
pathologists
ART DIRECTOR
Jodi Webster
FEATURES
ADVERTISING SALES DIRECTOR
Sue Butterworth
Teaching tools
PUBLISHING CO-ORDINATOR
Andrea Plawutsky
PrintPOST approved PP60630100114
14
Viewing platform: online training is unlocking the secrets of
cancer diagnosis for young pathologists
In profile
PathWay is published quarterly for the Royal College
of Pathologists of Australasia (ABN 52 000 173 231)
by S2i Communications, Suite 1201, Level 12,
4 O’Connell St Sydney 2000
Tel (02) 9235 2555 Fax (02) 9235 2455
8
16
A life of distinction: Professor Frank Fenner’s humility is just as
great as his superb reputation
At the coalface
20
When the bad bugs bite: pathologists must employ clever
detective work to solve the food poisoning riddle
Disciplines in depth
25
Chemical attraction: chemical pathology is as broad and varied as
your imagination
The Royal College of Pathologists of Australasia
Tel: (02) 8356 5858
Email: rcpa@rcpa.edu.au
Foreign correspondence
30
Tour of duty: Dr Tim Blackmore learned as much as he taught on
a medical aid trip to Vietnam
S2i Communications Pty Ltd
Tel: (02) 9235 2555
Email: wayne@s2i.com.au
Hot topics
PathWay
Expecting Perfection: pathology diagnoses can be open to
interpretation but patients often think of test results as infallible
32
Email: pathway@rcpa.edu.au
http://pathway.rcpa.edu.au
Searching for answers
FOR FURTHER INFORMATION ON THE ROYAL COLLEGE OF
PATHOLOGISTS OF AUSTRALASIA OR ANY OF THE FEATURES
IN THIS ISSUE OF PATHWAY CHECK OUT THE WEBSITE
37
When death strikes the young: perinatal autopsy rates are rising
and patient management is improving as a result
Spotlight on disease
42
A cereal offence: pathology is vital at each step towards
a diagnosis of coeliac disease
www.rcpa.edu.au
PATHWAY_1
PathWay #13 - Text
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Page 2
a pathology training system
for diagnostic cytology and histology
- Microscopic Examination Training Tool
- Maintenance of Expertise for Trainers
Four Modules now available:
•
•
•
•
Breast cytology
Urine cytology
Breast histology
Cervix histology
For full details, and to order, visit www.rcpa.edu.au
diagnostics
Ph: 61 2 8356 5858 • Fax: 61 2 8356 5828 • Email: inview@rcpa.edu.au • www.rcpa.edu.au
PathWay #13 - Text
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Page 3
REGULARS
From the CEO
TOUR OF DUTY:
VIETNAM
PAGE 30
4
Welcome from RCPA CEO Dr Debra
Graves
Under the microscope
6
News + views
The GP View
36
LIFESTYLE
Eyes wide shut: Dr Linda Calabresi
draws the distinction between
knowing what’s good for you and
acting on it
Travel
Conference calendar
65
Postscript
68
Noah’s lark: Dr Pam Rachootin
exposes the previously undiscovered
link between biblical legend and
pathology
48
Shanghai surprise: Sampling the food is an essential ingredient
of any Shanghai trip
Private passions
53
Some like it hot: Dr Nirmala Pathmanathan brings her exacting
pathology skills to the kitchen
Travel doc
56
Darwin’s playground: Dr Stephen Adelstein was launched into a wildlife
wonderland on the Galapagos Islands
Recipe for success
SHANGHAI SURPRISE
PAGE 48
58
Shock absorber: Philip Johnson ensures allergy sufferers are well
looked after in his Brisbane establishment
Dining out
61
Clean sweep: eating out needn’t be a minefield for those with food
allergy or intolerance
The good grape
64
Great white pointers: Ben Canaider on the best start to spring
Rearview
66
Scourge of the high seas: the cure for scurvy had to run the gauntlet of
English bureaucracy
PATHWAY_3
PathWay #13 - Text
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from the CEO
Welcome
to the 13th Edition of PathWay
T
his is a special edition devoted to the
with coeliac disease. Three different
sure, with Nirmala’s pathology training
topical subject of food and the
branches of pathology are involved in
and knowledge of food hygiene, food
important part pathology and pathologists
diagnosis: immunopathologists look at
poisoning would not be on the menu for
play in assessing the relationship between
very sensitive and specific blood markers
those dining in her home or at one of the
for the disease; anatomical pathologists
many large functions for which she caters.
food and health.
examine the small bowel biopsies needed
Our cover story, ‘Rash reactions’,
looks at a subject that has been very
much in the news in recent years. Food
allergies and food sensitivities are
becoming increasingly common. Indeed
for food allergies alone, in the 10–14 years
age group there has been a four-fold
increase in prevalence. We explore this
growing problem with a number of
immunopathologists and try to demystify
for a definitive diagnosis of the condition;
and more recently, genetic pathologists
have started looking at the genes that
seem to be associated with this disease,
I think I am in need of a sumptuous
but healthy meal after all this talk of food!
There are, however, two very important
articles in this edition that are not food
which occurs commonly in certain
related. Our Hot Topic, ‘Expecting
families.
perfection’, looks at the very important
Our restaurant reviews in this edition
focus on restaurants able to cater for
people with conditions such as coeliac
issue of errors in pathology and what
pathologists do to minimise these errors.
The other important article addresses
disease and other food allergies and
the valuable role of the paediatric autopsy
sensitivities. Indeed, the Sydney
in identifying the cause of foetal deaths
restaurant reviewed - The Peasants Feast
and the significance these findings have in
Another very important issue in
- is run by one of our Fellows, Dr Robert
planning future pregnancies.
relation to food and health is that nasty
Warlow. Robert is an immunopathologist
condition most of us have succumbed to
who considers the restaurant kitchen like
at some stage – food poisoning. Our
his laboratory! He believes “what you put
article ‘When the bad bugs bite’ looks in
in your mouth determines whether you
detail at the organisms that cause food
stay healthy or become ill and how long
poisoning, the difficulties our expert
you live”.
how these allergies and sensitivities can
be diagnosed and managed.
microbiologists sometimes have in
several occasions, it is great to know that
outbreaks, and most importantly, what
something that tastes so good is actually
can be done to prevent them occurring.
good for you too.
food poisoning in Australia each year,
causing around 18,000 hospitalisations
Food and cooking are also a passion
for anatomical pathologist Dr Nirmala
Pathmanathan. PathWay talks with
and 120 deaths, it is a major issue even
Nirmala about her love of cooking and
for a developed country such as ours. The
how she blends this passion with
problems internationally are even bigger.
pathology. My mouth was watering
In our article ‘A cereal offence’ we talk
reading this article. I especially loved the
with one of the College’s own Fellows
sound of her specialty Sri Lankan dish,
about her experiences of being diagnosed
fried coconut-milk lamb. One thing is for
4_PATHWAY
edition of PathWay.
Mind you, after sampling his food on
tracking down the cause of such
With an estimated 5.4 million cases of
I hope you enjoy this special food
Dr Debra Graves
CEO, RCPA
PathWay #13 - Text
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Page 5
Symbion Pathology is fast becoming one of
Australia’s leading private pathology groups,
performing more than 10 million patient
episodes each year.
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our highly experienced pathologists and
medical scientists have access to state-ofthe-art technology and automated workflow
systems to enable high throughput and fast
turnaround of analyses and reports.
At Symbion Pathology we remain at the
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practitioners and communities we serve and
are committed to delivering a service based
on superior quality and customer satisfaction.
Our National Network of
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Because life matters®
www.symbionhealth.com
Symbion Health Ltd ABN 56 004 073 410
PathWay #13 - Text
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Page 6
under the microscope: news + views
Free online service simplifies pathology
for patients
new free online pathology information
A
service is about to take the mystery
out of laboratory testing for patients.
Lab Tests Online will offer easy-tounderstand information about a variety of
tests and conditions. It will also include
information about how labs work, a guide
to recommendations on screening, and
news about the latest developments in
laboratory medicine.
Through using the service, patients
will gain a better understanding of why a
test might be ordered and how to interpret
the results. Specimens required to
perform tests are explained and answers
provided to commonly asked questions.
Developed by the Australasian
Association of Clinical Biochemists with
support from the RCPA and federal health
department funding, the site is also
designed to be a quick reference tool for
medical professionals.
And it will be free of
commercial sponsorship so
patients can be confident of
receiving independent information,
according to project director Dr
Andrew St John.
“Information on medical testing
is not always available or easily
located, and sometimes when it
can be found, it can be inadequate
or difficult to understand,” Dr St John said.
“Lab Tests Online aims to change all
that and unlock the lab door.
“When someone is ill, they are often
least able to absorb the often complex
advice they receive. Lab Tests Online will
provide a continuous and on-going source
of accurate and impartial information.”
The service was originally devised in
the US in 2001 and a sister service began
in the UK in 2004. However, Lab Tests
Online Australasia has been developed
specifically for Australian conditions.
Burgeoning bellies leaving
a heavy forensic burden
T
he obesity epidemic is not just a
challenge for Australia’s consulting
physicians and GPs. Forensic
pathologists and mortuary workers, it
seems, are also feeling the pressure of
our population’s expanding girth.
In a letter to The Medical Journal of
Australia (2007;187:195–6), lead author
Professor Roger Byard said “individuals
of considerable body mass” were
presenting major logistical problems for
pathologists and technicians attempting
to perform standard examinations.
“Mechanical lifting hoists, x-ray
tables and trolleys are often not
designed to cope with such weights,”
he wrote.
“Putrefaction is hastened in morbidly
obese individuals, and associated skin
slippage and purging makes the bodies
even more difficult to handle.”
6_PATHWAY
Professor Byard, Professor of
Pathology at the University of Adelaide,
and co-author and laboratory team
leader Maria Bellis, reviewed the body
mass index of those undergoing coronial
autopsies in South Australia in the first
three months of this year. Of the 255
people in the study, a third were obese
and 6% were morbidly obese.
This compared to 17% of individuals
being obese and 3% morbidly obese
over a similar time period in 1986.
If this trend continued, the
construction of specially designed
mortuaries would be required, with
larger storage and dissection rooms and
“more robust” equipment to cope with
heavier individuals, they said.
“Failure to provide these may
compromise the post-mortem evaluation
of markedly obese individuals in
addition to potentially jeopardising the
health of mortuary staff.”
Pictured top: RCPA Fellow Bruce Campbell,
demonstrating Lab Tests Online;
Above L-R: Health Minister Tony Abbott,
Andrew St John and
AACB Vice President Leslie Burnett.
$100m centre
to accelerate
cancer research
p to 400 cancer researchers will be
housed in a new $100 million
cancer research centre located at the
University of NSW.
U
The Lowy Cancer Research Centre
will be one of the largest dedicated
cancer research centres in the southern
hemisphere and Australia’s only fully
integrated childhood and adult cancer
research centre.
UNSW Vice-Chancellor Professor
Fred Hilmer said the centre would take
cancer research in Australia to a new
level.
“It will be a world-class facility which
will enable us to attract more of the best
and brightest people from around
Australia and overseas,” he said.
Prominent businessman Frank Lowy
has agreed to donate $10 million
towards the cost of the new building,
and other funding has also been offered
by the NSW and federal governments
and the Australian Cancer Research
Foundation.
PathWay #13 - Text
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Page 7
BETTER, FASTER: computer
analysis of Pap tests edging ahead
large new study published in the
British Medical Journal (2007;335:31)
shows that using computer image
analysis of the ThinPrep Pap test
detects more high-grade histological
disease than conventional cytology.
every three years – that is quite a logical
The study, by Douglass Hanly Moir
Pathology in conjunction with the University
of Sydney’s School of Public Health, took
55,000 split samples from women who
chose to have both types of cytology.
disease because of the increased interval.
It showed that the ThinPrep Imager
System detected 1.3 more cases of highgrade disease per 1000 women screened
than manually read conventional slides.
The authors said the increased
detection rate would require 3.1 more
biopsies per 1000 women screened, and
that because the percentage of
unsatisfactory slides was lower (1.78%
compared to 3.09%), fewer women might
be recalled for repeat smear tests than is
currently the case.
Medical Director of Douglass Hanly
Moir Pathology and study co-author Dr
Annabelle Farnsworth (pictured) said the
results suggested that the current twoyearly screening interval could be
increased to three years without any
increase in disease rates.
“Given [this technology] is going to be
more expensive, a way of funding it would
be to increase the screening interval to
option,” Dr Farnsworth said.
“There will be a group that would
argue you could go to three years with
conventional screening. But there is a
known increase in the incidence of
With this new technology, that may be
cancelled out. Appropriate costeffectiveness studies need to be
PHOTO CREDIT: PAUL JONES
A
undertaken.”
The study authors said the ThinPrep
Imager had already been shown to take
less reading time than conventional
cytology.
“Through improved accuracy and
faster reading times, the ThinPrep Imager
might confer both greater laboratory
productivity and enhanced clinical
outcomes, as well as offering the potential
for human papillomavirus testing on the
same sample,” they wrote.
At the time of going to press, ThinPrep
manufacturer Cytyc Corporation was about
Dr Annabelle Farnsworth: strong study
However, Dr Farnsworth said the
study was extremely strong and was
specifically designed to answer the
question of superiority.
“Previous critics of studies involving
ThinPrep have focused on study design.
This is a magnificently designed study,
designed to answer those criticisms.”
to submit a proposal to the Medicare
Services Advisory Committee in a bid to
have the technology publicly funded.
To date, the question of whether
liquid-based cytology is superior to
conventional cytology has been
controversial and the technology has so
Correction
The article Private Schooling in our last
issue incorrectly spelt the name of RCPA
Fellow Dr Iman Alash.
PathWay apologises to Dr Alash for the
error.
far remained unfunded.
PATHWAY_7
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Page 8
cover story
Rash response
PATHOLOGISTS ARE LEADING THE CHARGE TO
CORRECT WIDESPREAD MISINFORMATION ABOUT
ALLERGY TESTING. MATT JOHNSON REPORTS.
8_PATHWAY
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“There is at present no government regulation to control the
bizarre, unorthodox, controversial or unproven tests that are
widely promoted and conducted by non-medical services”
– Dr Karl Baumgart
ith a just phone call Dr Dominic
Mallon can be on nearly every
morning news program in the country.
As a clinical immunopathlogist and
allergist, he knows Australia is leading
many Western countries in the increased
rate and severity of allergies.
W
And people are interested. A recent
world, nearly every parent knows about
proven and may even increase the
severe allergic reactions and is worried
severity of allergic reactions.
their child will fall victim to a sudden, lifethreatening response to an everyday food
Allergies on the march
or product.
“The prevalence of food allergies alone
As President of the Australasian
Society of Clinical Immunology and
study published in The Medical Journal of
Allergy (ASCIA), Dr Mallon is also acutely
Australia (2007;186:618–21) identified a
aware that the term ‘allergy’ is not only
12-fold increase in demand for
widely misunderstood in the community,
consultations related to food allergy over
but also within the medical profession.
a 12-year period in one private ACT
Without a scientific approach to the
practice that provides about half the
disease, literally tens of thousands of
territory’s non-emergency allergy services.
people are being exposed to tests, drugs
And from his patients, Dr Mallon is
and diets that can not only be expensive
acutely aware that, in this web-connected
and inconvenient, but have not been
has risen by a factor of four in the 10 to
14 age group in the past 10 years,” Dr
Mallon explains.
“And while that is quite dramatic, it still
means only 4–5% of children and 2–3% of
adults actually have food allergies.”
Dr Mallon’s challenge is to walk the
fine line between alarmist and scientist to
produce a better understanding of allergic
diseases.
A large part of the immunopathologist’s
role is to provide GPs and non-allergy
specialists with a framework for accurately
assessing allergic disease. Accurate
Peanut panic
ublicity about a number of child deaths from peanut allergies has led to a
rise in the number of parents seeking allergy tests for their children. But the
results of skin tests for peanut allergy in children can be misleading and can
often cause overdiagnosis, according to Australian research published in the
Pediatric Allergy and Immunology journal (2007; 18:231–9). The researchers
found that a weal size larger than that used to indicate a positive test in many
centres around the world was necessary to be predictive of a positive food
challenge.
P
These results came as little surprise to pathologists who, despite valuing
skin tests as a part of the diagnosis, generally require a more complete history
and challenge test before they recommend any extreme measures to restrict
exposure to this common schoolyard food.
Clinical immunopathologists such as Dr Karl Baumgart are also aware that
20% of children with a peanut allergy will outgrow the sensitivity by the age of
six, and he warns that any single test on young children is unlikely to provide the
complete picture.
diagnosis of allergies opens up therapeutic
options that can be extremely effective, but
are useless if applied to the wrong patient.
“A lot of allergy assessment involves
correcting misinformation,” Dr Mallon says.
“Twenty per cent of people will say
they are allergic to food, and we need to
help people who have non-allergic
adverse reactions to foods understand
they probably have an ‘intolerance’ or
‘sensitivity’ that can certainly affect their
quality of life, while accurately diagnosing
the smaller percentage of people who
actually do have allergies.
“Many apparent adverse reactions are
erroneously attributed to allergy. If we are
not able to discriminate between ‘adverse
reaction’, ‘intolerance’ and ‘allergy’ we
“It’s called the ‘atopic march’ and it reflects the maturing of the immune
system,” he says.
lose the ability to manage adverse
“Infants and young children tend to develop allergies to foods that they will
grow out of by four or five years of age, and then during their school years
develop sensitivities to inhaled allergens.
While the word ‘allergy’ can mean
many things to the lay person, to Dr
Mallon, the diagnosis is critically
dependent on identifying the immune
response involved.
“If we test children at different times we expect to get different results and
we need to examine their clinical history as well as their test results to make
recommendations on treatment.”
reactions to foods appropriately.”
Our bodies have a multitude of
defence mechanisms that protect us from
PATHWAY_9
>
PHOTO CREDIT: BILLIE FAIRCLOUGH
PathWay #13 - Text
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Page 10
Allergy symptoms
SYMPTOMS COMMONLY ASSOCIATED WITH ALLERGIES
CAN INCLUDE:
• SKIN RASHES, SUCH AS ECZEMA (ATOPIC DERMATITIS)
OR HIVES (URTICARIA)
the antigens and allergens we are
exposed to every day.
One is the production of antibodies to
target antigens once we have been
• SWELLING OR ANGIOEDEMA
exposed to them. Antigens are generally
• HAY FEVER – ALLERGIC RHINITIS
of foods, pollens, animal hair or venoms,
small proteins that can come in the form
and the normal response to an antigen
• RED, ITCHY EYES – ALLERGIC CONJUNCTIVITIS
coming though the gastrointestinal wall,
the lungs or the skin is for T lymphocytes
• ASTHMA
to bind with the antigen and direct B
lymphocytes to produce immunoglobulin
• ANAPHYLAXIS – THE MOST SEVERE FORM OF
ALLERGIC REACTION. ANAPHYLAXIS CAUSES SERIOUS
BREATHING AND CARDIOVASCULAR PROBLEMS AND
CAN BE FATAL.
– or antibodies – against the antigen.
Upon the next exposure to the same
antigen, the waiting antibodies trigger an
immune response to quickly neutralise the
antigen. It takes only a week to produce
antibodies against a specific allergen, but
10_PATHWAY
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Page 11
threatening anaphylactic reaction. All are
triggered by IgE antibodies causing the
release of excessive amounts of histamine
and other immune substances that, in
normal levels, help the body respond to the
antigen in a controlled manner.
Skin tests helpful
There are three common tests to
determine if patients have a
hypersensitive IgE response. The first is a
skin test where a small droplet of
commercially prepared allergen is placed
on the forearm. The skin is then pricked
with a lancet, allowing the allergen and
“The consequences of overdiagnosing food allergies can
be severe, with a person
subject to a very restrictive
the immune system to interact.
“Skin tests have proved very safe and
reliable,” explains Dr David Gillis, a clinical
immunologist and immunopathologist at
the Institute of Medical and Veterinary
Science in Adelaide and a member of the
diet on the basis of a positive
RCPA Immunopathology Advisory
skin or blood test when they
Committee.
“You get results in 15 to 20 minutes
may not actually be allergic
and you’ll leave the specialist’s office with
to that food”
pretty precise information about your
– Dr Dominic Mallon
Skin tests allow immunopathologists
range of allergens, even permitting them
antibodies produced are subtly different.
Known as immunoglobulin type E
(IgE), these antibodies generate the
excessive immune response characteristic
of allergies – and rather than protecting
to test for sensitivities to uncommon
foods.
“If someone is sensitive to, say, a rare
fruit, we can ask them to bring it to test it
and we’ll see if they get a result.”
But the skin tests aren’t perfect, and
the body, the immune reaction actually
Dr Gillis says a positive result doesn’t
causes a problem.
necessarily indicate an allergy to the
The tendency to produce IgE
antibodies can be stimulated from both
substance tested.
“Skin tests are reliable in identifying
genetic and environmental factors, with
triggers, but they’re not so reliable in
environmental factors tending to dominate
screening, as most people who have
in infancy when the immune system is still
positive tests do not have the disease,”
maturing.
he explains.
True allergic responses can be as minor
Testing blood serum for a specific IgE
is usually the second step in identifying
allergies or if skin testing is not available.
“Skin testing is more sensitive than
blood testing and it covers a wider range
of allergens, but serum testing helps when
the skin tests and the clinical history don’t
make sense, or when the patient has, say,
widespread eczema, or a history of
anaphylactic reactions,” Dr Gillis says.
The blood tests for allergy diagnosis
(RAST, or allergen-specific IgE) are highly
automated and reliable, but various
factors can make the results difficult to
interpret.
“Some patients with eczema can have
very high IgE levels directed against foods
without symptoms of food allergy – while
other patients can have very low levels of
IgE to a particular food on blood testing,
yet develop a severe allergic reaction
when they eat it,” Dr Mallon says.
Cautious interpretation
sensitivities.”
such as Dr Gillis to quickly test for a large
in the people who are ‘atopic’, the
This initial history taking and careful
approach is, he says, particularly
important in food sensitivities.
“To have an allergy you need a positive
as a rash or runny nose, as severe as
test plus the symptoms of allergy. You have
chronic hayfever (rhinitis), asthma, eczema
to correlate the history with the symptoms
and dermatitis, or ultimately, a life-
and then look at the test results.”
Measuring the total IgE can help in setting
upper and lower levels for individual
patients, but Dr Mallon reinforces that
results must be interpreted in the context
of the patient’s symptoms and history.
Then there is the problem of funding.
“Medicare currently provides a rebate
for just four allergen tests per patient
episode,” he says. He argues that this
encourages doctors to request RASTs to
mixes of allergens in each test to keep the
cost to the patient down.
“Restricting the rebate to four has the
potential to decrease the sensitivity of the
test,” he says.
He also suggests that the use of
allergen mixes can reflect a lack of
confidence in diagnosing allergies
among GPs.
“Doctors get a relatively small amount
of allergy training during their
undergraduate course and because it’s a
PATHWAY_11
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condition that is managed in primary care
and specialist out-patient clinics, they
don’t get a lot of practical training during
their hospital placements.
“Too many doctors have their first
exposure to allergy-related problems once
they get into general practice, and then
they find it’s up to 5% of their
consultations.”
The lack of supervised training in
assessing these conditions, he says,
results in a lack of confidence in
requesting and interpreting allergy tests.
The ultimate challenge
The final recognised method of testing for
allergies is to conduct a challenge test.
Increasingly being used in diagnosing and
assessing food allergies, challenge tests
involve giving patients rising amounts of
an allergen in an attempt to provoke
symptoms.
“Challenge tests are especially useful
when there is some doubt about other
test results,” Dr Mallon says.
“If the patient ascribes symptoms to,
say, a type of fish, but their skin and blood
tests to that fish were negative, we
introduce that allergen in a safe
environment to see if we can provoke
symptoms.”
The certainty that a negative result can
provide is a major reason for the increasing
appeal of challenge tests.
“Three to five per cent of children are
allergic to cow’s milk or eggs, but the
majority will outgrow this sensitivity. A
challenge test can provide parents with an
assurance the allergy has been outgrown.”
12_PATHWAY
PHOTO CREDIT: ELIZABETH ADAMS
Dr Mallon adds that challenge tests
are being used more widely in testing for
peanut allergy, which approximately 20%
of children will outgrow by the age of six.
These tests should always be
conducted in the clinic of a trained
specialist, who can immediately provide
treatment if a severe reaction occurs, but
Dr Gillis agrees that challenge tests are
worth conducting.
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“Skin testing is more sensitive than blood testing and it covers a wider range of allergens, but serum
testing helps when the skin tests and the clinical history don’t make sense, or when the patient has,
say, widespread eczema, or a history of anaphylactic reactions” – Dr David Gillis
“The consequences of over-
“There is at present no government
Allergy specialists such as Dr
diagnosing food allergies can be severe,
regulation to control the bizarre,
Baumgart are concerned about these
with a person subject to a very restrictive
unorthodox, controversial or unproven
tests because there are effective
diet on the basis of a positive skin or
tests that are widely promoted and
treatments for a number of allergies,
blood test when they may not actually be
conducted by non-medical services,”
provided they are correctly diagnosed.
allergic to that food.”
says Dr Karl Baumgart, Director of
Whacky tests abound
The implications of false positive tests
Avoiding the allergen is not difficult if it
Immunology and Molecular Biology at
has been correctly identified as a
Douglass Hanly Moir Pathology in Sydney.
particular food or pet hair, but is virtually
Dr Baumgart is also a consultant
impossible if the allergen is a seasonal
have become more serious in recent years
physician in clinical immunology and
grass pollen. Over-the-counter
as alternative practitioners offer a number
allergy, and in his practice he regularly
medications such as corticosteroid nasal
of unproven allergy tests. Cytotoxic food
sees patients who have spent hundreds of
sprays or antihistamines can control minor
testing, kinesiology, Vega testing,
dollars on tests, only to be misdiagnosed.
reactions, but more serious reactions may
electrodermal testing, pulse testing, clot
“These tests are promoted by well-
need immunotherapy.
correlation, reflexology and hair analysis
resourced companies and despite there
are all promoted by various companies,
being no evidence to support the tests,
but none of these tests have been
they are very expensive,” he says,
Allergen-specific immunotherapy involves
scientifically validated and many clinical
pointing out that they can cost thousands
subcutaneous injections of increasing
pathologists feel they are unnecessary,
but are not rebatable.
doses of an allergen until the patient
costly and possibly dangerous.
ASCIA (www.allergy.org.au) has a
“These tests exploit patients, confuse
the diagnosis and can result in people
detailed position statement on unorthodox
embarking on treatments or diets they
testing.
might not need.”
For really serious cases
achieves a tolerance. Immunotherapy has
proved especially effective in patients
allergic to insect venoms, with 80–90% of
cases successfully desensitised.
It has also proved effective for
seasonal allergic rhinitis caused by grass
Can allergies be
prevented?
EVERY PARENT WANTS TO KNOW IF THERE IS SOMETHING
THEY CAN DO TO REDUCE THE CHANCES OF THEIR CHILD
DEVELOPING ALLERGIES. THERE ARE NO PROVEN
PREVENTIVE THERAPIES BUT ALLERGY SPECIALISTS DO
RECOMMEND THE FOLLOWING, ESPECIALLY IN CHILDREN
BORN TO HIGH-RISK FAMILIES:
• EXCLUSIVE BREASTFEEDING TO 4–6 MONTHS OF AGE
pollens, with some studies showing a
60% reduction in symptoms.
Recent trials examining the
effectiveness of sublingual
immunotherapy have confirmed its safety
and efficacy, and this delivery method
may prove more acceptable to patients
and parents than subcutaneous
immunotherapy.
Researchers are also working on
allergy ‘vaccines’ and other means of
interrupting or targeting the mechanics of
the allergic response. This work has
shown a great deal of promise, but even
when it does become available, its ability
to provide effective relief to allergy
• USE OF HYDROLYSED MILK FORMULAS FOR BABIES
UNABLE TO BE BREASTFED
sufferers will rely upon an accurate clinical
picture and the use of reliable and proven
pathology tests.
• NO EXPOSURE TO CIGARETTE SMOKE.
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
PATHWAY_13
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teaching tools
VIEWING PLATFORM
A NEW ONLINE TRAINING TOOL LAUNCHED IN AUSTRALIA IS TAKING THE MYSTERY OUT OF
CANCER DIAGNOSES FOR YOUNG PATHOLOGISTS. KIM COTTON REPORTS.
quiet revolution is currently
A
transforming pathology training in
Australia, launching 21st-century
technology into one-on-one teaching.
A new online learning tool – InView –
is reinventing the way in which young
pathologists learn to diagnose cancer.
Not only does it allow anatomical
pathology registrars to analytically assess
cases and test their skills against experts
in their own time, it also has the potential
to train them to make better and more
reliable diagnoses in cancer pathology.
And it has the scope to provide
qualified pathologists with standardised
assessments for ongoing professional
development.
InView uses a combination of virtual
microscopy, diagnostic simulation and
automated assessment. At the click of a
mouse, users can train, test and compare
their diagnostic skills against experts
through a series of modules, which at
present cover breast and urine
cytopathology, and cervical, breast, skin
Professor Peter Hamilton, Head of
Bioimaging and Informatics at Queens
University and Managing Director of i-Path
Diagnostics, says the key advantage of
InView over traditional training methods is
that it allows registrars to practise
diagnostic techniques independently
using authentic pathology cases.
“InView takes [trainees] through the
diagnostic process in cancer pathology, it
teaches the steps that are necessary to
make a decision, it provides the visual
tools that allow [trainees] to interpret the
key clues in making a diagnostic decision
and it allows them to compare their
performance against an expert,” Professor
Hamilton says.
“It gives you feedback on where you
have gone wrong in the assessment so it
helps you to learn by repeating the case
and by understanding exactly where you
have made mistakes and rehearse that
again.”
It also allows teachers and supervisors
to easily identify consistent under- or
over-estimation of diagnostic clues which
their trainees assess.
and prostate histopathology.
InView was developed by researchers
at Queens University in Belfast and
biomedical software company i-Path
Diagnostics in collaboration with the
Royal College of Pathologists of
Australasia (RCPA).
14_PATHWAY
Passing on the flame
Early in-house research conducted at
Queens University suggests InView
improves user performance in terms of
consistency and reproducibility in
diagnoses, Professor Hamilton says.
By using it as a tool to teach medical
students how pathological decisions are
made, it is also reviving an interest in
pathology among undergraduates with the
hope they will consider taking up the
discipline in the future.
Professor Richard Williams, the
RCPA’s chief examiner in anatomical
pathology and Director of Anatomical
Pathology at Melbourne’s St Vincent’s
Hospital, has been instrumental in the
development of InView.
He says the system’s value lies in its
explicit teaching of the vital steps that
lead to good diagnostic practice.
Essentially, it takes the mystery out of
how experienced pathologists make a
diagnosis.
“I remember when I was a [new]
registrar I wondered how the heck people
were getting to an answer so quickly. It
takes you sitting down with them for a
long time to work out how they’re really
doing that … whereas InView actually
shows you what people do to reach a
diagnosis,” Professor Williams says.
“Instead of making an intuitive
diagnosis and working backwards and
then trying to find a couple of clues that
will confirm that diagnosis to you – an
approach that is fraught with danger – it
actually teaches people to look through
things systematically.
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“InView provides an objective, standardised approach to assessing
diagnostic skills and this can be used effectively for appraisal and
efficiency testing” – Professor Peter Hamilton
“They get used to analysing rather
than believing that there is some magic in
how [experienced pathologists] make a
diagnosis.”
InView speeds up the learning
process, but it won’t necessarily speed up
the process of a registrar becoming
competent, Professor Williams adds.
“There’s a lot of optical mileage
needed. You have to keep doing it and
doing it and refining what you’re thinking.
What InView does is set you in a pattern
of thinking where you take all the clues
and you weigh them and you’re much
more likely to reach a proper diagnosis. It
trains you to analyse a case. It means
you’re much more likely to get
consistency in diagnosis.”
Developments in train
RCPA CEO Dr Debra Graves says InView
has been introduced to several major
Australian laboratories over the past nine
months.
“The college is encouraging more
public and private laboratories to make
InView accessible to registrars as part of
their training,” she says.
“The idea behind it is to be able to
provide a resource for trainees to be able
to learn in a similar way to how they’re
trained in the apprentice-type model.”
However, that doesn’t negate the role
of traditional training methods in the
laboratory. Dr Graves says InView
provides a flexible way for young
anatomical pathologists to develop good
diagnostic practices.
“With having such a shortage of
pathologists, sometimes these sorts of
aids can be very helpful in relation to
assisting the trainees.”
While InView is gaining a reputation as
a training platform for pathologists, it also
has an “enormous” role to play in
proficiency testing and competency
assessment, Professor Hamilton says.
In the UK, InView was recently
registered for continuing professional
development by the Royal College of
Pathologists. And further plans are
underway to design an independent
library of cases, which may be used in
continuing medical education in Australia.
“One of the real problems in assessing
diagnostic proficiency is that there are no
real standards and assessment varies
from one individual to another,” Professor
Hamilton says.
“InView provides an objective,
standardised approach to assessing
diagnostic skills and this can be used
effectively for appraisal and efficiency
testing.”
The popularity of InView since its rollout is testament to its success. Professor
Hamilton says potential authors are now
queuing up to contribute to the programs,
and within the next 12 to 16 months he
anticipates many new modules will be
available.
But he believes that ultimately, it is the
patients who will have the most to gain
from such innovative technology.
“This will have an impact on the
quality of health care.”
To purchase InView please log onto
www.rcpa.edu.au
PATHWAY_15
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Page 16
in profile
A life of
distinction
MICROBIOLOGY MARVEL PROFESSOR FRANK FENNER IS ONE OF AUSTRALIA’S MOST VENERATED
SCIENTISTS – AND A VERY HUMBLE MAN, FINDS MELISSA SWEET.
fter a stellar career spanning seven
decades, Professor Frank Fenner has
begun the difficult task of packing up his
office – almost 30 years after his official
retirement.
A
When Professor Fenner finally vacates
his room at The John Curtin School of
Medical Research in Canberra, as he
intends to later this year, it will be the end
of an era for Australian science and for
one of its most revered figures.
or graces. Just a quiet and simple:
“Fenner.”
If you didn’t know his pedigree, you
would swear that the blue-eyed, whitehaired gent shuffling down the corridor
could be anyone’s grandfather. What
gives him away is the affection and
respect that is so evident in the greetings
from colleagues.
When awarded an honorary fellowship
“I really have to go home and get
things in order,” Professor Fenner
explains.
of the Royal College of Pathologists of
After all, he will be 93 in December
and doesn’t expect to be able to continue
his current routine – rising at 5am, reading
the latest journals until 8am and then
driving to the Australian National
University – for too much longer.
not only Professor Fenner’s scientific and
Professor Fenner is widely admired,
not only because of the longevity of his
career and the breadth of his
achievements, but also because of his
humility and decency.
Medical Research in 1949, aged 34,
His name may be up in lights on the
main avenue as you drive into Canberra –
just outside Fenner Hall, in fact – but
none of the usual marks of celebrity are
apparent when you meet the man himself.
When I buzz the security phone to
gain entrance to his office building one
chilly Canberra morning, his response is
typically low key, without a hint of any airs
16_PATHWAY
Australasia (RCPA) earlier this year, the
citation noted that the award recognised
medical contributions, but also the
tenacity and humble nature of the man
behind the work.
When he arrived at the newly
established John Curtin School of
Professor Fenner already had quite a
reputation.
His work in controlling malaria among
World War II troops had earned him the
recognition of a Member of the Order of
the British Empire.
A Captain and then a Major in the
Australian Army Medical Corps between
1940 and 1946, he developed an interest
in infectious diseases during service in
Australia, Palestine, Egypt, New Guinea
and Borneo.
Poxes – small, rodent
and rabbity
After the war, he worked alongside Sir
Macfarlane Burnet at the Walter and Eliza
Hall Institute of Medical Research in
Melbourne, where he studied mousepox,
a close relative of the smallpox virus. It
was the beginning of a lifelong interest in
pox viruses.
Much of his first 15 years at the ANU
were absorbed by research into another
pox virus – myxomatosis.
This work, which contributed to the
control of the rabbit plague that had
decimated the Australian countryside, is
widely judged as one of his key
achievements.
However, it was a single unorthodox
experiment in 1951 which really caught
the general public’s attention.
In an effort to reassure those anxious
about the safety of releasing
myxomatosis, Professor Fenner and two
other scientists injected themselves with
the virus.
All they suffered was a slight
reddening at the injection site.
Professor Fenner’s work on
myxomatosis also led him into the study
of the vaccinia virus, which was to prove
such a useful background for the work on
smallpox that later brought such
international acclaim.
>
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PHOTO CREDIT: ANDREW CAMPBELL
PathWay #13 - Text
“I am temperamentally unable
to do research without being
personally involved, hands-on
at the bench”
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“Everybody that lectures on
climate change has to end up
on a hopeful note, so I try to
avoid giving lectures on it
because I find it very gloomy”
After becoming director of The John
Curtin School in 1967, Professor Fenner
made a conscious decision to cease
scientific research because he didn’t want
to do it through assistants or students.
“I am temperamentally unable to do
research without being personally
involved, hands-on at the bench,” he
once told a radio interviewer.
Instead, he concentrated on writing
and other work. Serendipitously, this
allowed him to answer the critical call of
his career – to assist the World Health
Organization with ridding the world of
smallpox transmission, a task requiring a
grinding schedule of constant travel.
In a career noted for many awards
and prizes, Professor Fenner says his
proudest moment came on 8 May, 1980,
when he stood before the World Health
Assembly in Geneva, as chair of the
Global Commission for the Certification of
Smallpox Eradication, and declared its
mission accomplished.
“Everybody was delighted about it,”
he recalls. “That was the great moment.”
Not so quiet convictions
In latter decades, Professor Fenner’s
focus turned to environmental issues,
inspired by one of his great mentors,
René Jules Dubos, a French-born
CV in brief
PROFESSOR FRANK FENNER, AC, CMG, MBE, FAA,
FRS, FRACP, FRCP
American scientist and environmentalist
credited with coining the maxim “think
globally, act locally”.
Professor Fenner is known among
colleagues as a cautious scientist, but he
has no hesitation in sharing his alarm
about global warming and the failure of
the United States and Australian
governments to respond appropriately.
“You couldn’t but be very concerned,”
he says. “Everybody that lectures on
climate change has to end up on a
hopeful note, so I try to avoid giving
lectures on it because I find it very
gloomy.”
Professor Fenner is similarly upfront
about sharing his political convictions. He
has never voted for the conservative
parties, he says, preferring to support the
“underdog”.
Nor has he been reticent about
digging into his pockets to support the
causes close to his heart. After winning
the prestigious Japan Prize in 1988 –
sharing the ¥500 million bounty with two
others involved in smallpox eradication –
he established two endowment
foundations, to help fund conferences on
the environment and medical research.
Writing is another passion.
1983–present
Visiting Fellow, John Curtin School of Medical
Research
1977–80 Chairman, Global Commission for the Certification of
Smallpox Eradication, World Health Organization
1973–79 Director, Centre for Resource & Environmental Studies, ANU
1967–73 Director, John Curtin School of Medical Research
1949–67 Professor of Microbiology, and Head of the Department of
Microbiology, John Curtin School of Medical Research
2002
Prime Minister’s Prize for Science
2000
Albert Einstein World Award for Science
1995
Copley Medal of The Royal Society
1989
Companion of the Order of Australia (AC) for service to
medical science, public health and the environment
1988
Japan Prize for Preventive Medicine
1976
Companion of the Order of St Michael and St George (CMG),
for medical research
1945
Member of the Order of the British Empire (MBE, Military)
for work in malaria control
18_PATHWAY
He has published more than 300
scientific papers and written or
contributed to 14 books, including a bestselling textbook, Medical Virology.
He refers often to the role of both
chance and his father in his successes,
so it is no surprise that both feature in the
title of one of his most personally
revealing books, Nature, Nurture and
Chance: The Lives of Frank and Charles
Fenner. It examines the similarities and
differences between the lives and
opportunities of the father and son.
Abiding passions
When the young Frank, an enthusiastic
collector of fossils, was contemplating a
career as a geologist, his father
suggested medicine would offer more
opportunities.
Charles Fenner, a teacher who
became a senior education administrator
in South Australia, was also a keen
scientist and writer. And clearly an
influential role model for his son.
Another central figure in Professor
Fenner’s life and work was his wife
Bobbie, a nurse.
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Page 19
Family snap: Professor Fenner (second from right) with his parents and siblings
They met at work at a hospital in
Hughenden in central Queensland and
married in 1943, although much of the
first two years of their marriage were
spent apart while Fenner was posted to
New Guinea.
He wrote to her at least once a day
during their separation and was moved,
many decades later, to discover she had
kept all these notes, which he once
described as “pretty torrid love letters”.
He found her reading them as she lay sick
with inoperable cancer.
Professor Fenner has many times paid
public tribute to his wife, both for her
support of his career, and for her
community work, which was recognised
with a Medal of the Order of Australia.
Professor Jane Dahlstrom, Professor
“Frank is an incredible example of
of Anatomical Pathology at the Australian
what one can do, post-65, by staying
National University, recalls that she first
active,” he says.
came to know Professor Fenner because
Professor Fenner has no plans to hang
he was part of a group of scientists who
up his hat when he moves his office back
regularly played tennis next door to her
to the home shared with his daughter
home.
Marilyn. He hopes to devote more time to
As she grew to know him more,
bumping into him at various functions and
meetings, she came to appreciate him,
his beloved vegetable garden, whose
produce is regularly shared with friends.
But he has no ambitions to fight
both as a person and a scientist, and
against the inevitable. After seeing his
resolved to surprise him by nominating
good friend ‘Nugget’ Coombs debilitated
him as an Honorary Fellow of the RCPA.
and lingering on for many months after a
“He genuinely seemed really pleased,”
stroke, Professor Fenner wrote an
she says. “The day after the function he
advanced care directive which he carries
wrote me a lovely email, thanking me.”
in his wallet.
For Dr Peter McCullagh, a
“It says, ‘If I am found unconscious on
He was devastated by her death in
1995, and has talked of the bleak years
which followed.
developmental immunologist who retired
the road, don’t do anything to revive me’,”
from The John Curtin School in 1991,
he says. “I don’t want to live for a long
three things stand out about the man who
time. I want a quick death.”
But he picked himself up, helped by
the friendships cemented over many
decades at regular tennis matches (he
gave the game away only last year
because of an injury).
has been a colleague and friend for more
Whenever and however his last
than 40 years. These are his enormous
moment comes, one thing is certain.
work ethic, his remarkable knowledge of
Frank Fenner’s memory will be writ large
virology, and his example of healthy,
in the history of Australian science and
active ageing.
medicine.
PATHWAY_19
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at the coalface
When the bad bugs bite
WHAT KINDS OF BUGS LIVE IN OUR FOOD, AND WHAT DETECTIVE WORK MUST A PATHOLOGIST DO
TO FIND THEM? BIANCA NOGRADY INVESTIGATES.
D
1.2 million medical consultations and
300,000 antibiotic prescriptions.
The Grim Reaper: (pointing with a
And it can be very hard to see the
funny side when you are curled into the
foetal position wracked with stomach
cramps, vomiting and diarrhoea.
ebbie: ... How can we all have died at
the same time?
skeletal finger) The salmon mousse!
Geoffrey: Darling, you didn't use tinned
salmon did you?
Angela: I'm most dreadfully
embarrassed...
Monty Python managed to make light
of it in this sketch from The Meaning of
Life, but in reality, food-borne illness is no
laughing matter.
An estimated 5.4 million cases occur
in Australia each year, causing around
18,000 hospitalisations and 120 deaths.1
It leads to 2.1 million lost days of work,
20_PATHWAY
The culprits behind this mayhem are
pathogenic bacteria, viruses and
parasites.
In total, approximately 290 different
organisms have been identified as being
potential causes of food-borne illness.
Many of these pathogens are ubiquitous
in our soil, water, animals and even in our
own bodies, but it’s when they turn up
where they are not supposed to that
trouble starts.
The symptoms vary according to the
pathogen, but most of us have
experienced the unpleasantness of a dose
of food-borne illness – vomiting, nausea,
diarrhoea, fever, abdominal cramps and
headache.
The term ‘gastroenteritis’ is often used
when talking about food-borne illness.
Gastroenteritis simply means
inflammation of both the stomach and the
colon, says microbiologist Dr Gary Lum,
Royal College of Pathologists of
Australasia (RCPA) Vice-President and
Chair of the college’s Microbiology
Advisory Committee.
“What it means is you’ve got vomiting
and diarrhoea.”
“Tracing the cause of illness can be quite complex, and trying to link
illness to a particular organism in a specific food vehicle requires
good detective work and often a lot of luck” – Dean Mahoney
Most gastroenteritis is caused by
food-borne pathogens – and these are
more often viral pathogens such as
rotavirus and norovirus – but
gastroenteritis can also occur as a result
of a reaction to a new food or medication.
Some food-borne pathogens only cause
inflammation of the colon alone, called
enteritis, which leads to diarrhoea but not
vomiting.
Long term problems
While most food-borne illness runs its
course within a day or so, some patients
experience longer-term clinical problems.
These include jaundice, irritable bowel
syndrome, reactive arthritis and
haemolytic uraemic syndrome, where
toxins from the bacteria lead to acute
renal impairment.
Pregnant women are particularly
vulnerable as infection with pathogens
such as Listeria can cause miscarriage,
premature delivery or infect the fetus.
Public health enemy number one and
two of the food-borne pathogen
community would most likely be the
bacteria Salmonella and Campylobacter,
according to Associate Professor Graeme
Nimmo, clinical microbiologist with the
Queensland Health Pathology Service.
Salmonella – commonly found in
undercooked poultry, raw egg desserts,
mayonnaise, sesame seed paste and
sprouts – were responsible for around
81,000 cases of food-borne illness in
1
Australia in 2000.
Campylobacter is most closely
associated with chicken meat, according
to Mr Deon Mahoney, Principal
Microbiologist with Food Standards
Australia New Zealand.
“It’s a real battle because about 80%
of chicken meat is contaminated with
Campylobacter,” Mr Mahoney says.
Backyard chooks, petting zoos and
visiting farms are also sources of the
bacteria.
Campylobacter was blamed for
approximately 208,000 cases of foodborne illness in 2000.
But these two pathogens are just the
tip of the iceberg.
Host of other culprits
Other bacteria associated with food-borne
illness in Australia include Listeria
monocytogenes, Staphylococcus aureus,
Clostridium perfringens and Aeromonas.
There are a number of different
Salmonella species, one of which causes
typhoid fever.
Then there are the viral causes of
food-borne illness. These pose an extra
hazard because they are not only
transmitted through food, but can also
spread from person to person. Norovirus
is one of the most common known
causes of gastroenteritis in the developed
world, and was linked to around 446,000
cases of illness in Australia in 2000. It is
often associated with cruise liners, not
only because close quarters increase
spread of the disease, but also because
illness outbreaks on cruise liners are often
tracked and monitored more closely than
outbreaks on land, leading to increased
reporting.
Thankfully, typhoid is rare in Australia;
however, other non-typhoidal species of
Another virus, hepatitis A, is often
contracted from eating contaminated
“Food poisoning from Salmonella and
Campylobacter don’t have high mortality,
but their numbers are large and there
would be considerable morbidity in terms
of lost work, ill-health and personal
discomfort,” Professor Nimmo says.
Salmonella – named in 1885 after
American veterinary pathologist Daniel
Elmer Salmon – is a bacterium found in
animal faeces.
seafood. A major outbreak of hepatitis A
in 1997 was traced to oysters from Wallis
Lake in NSW.
There are also, of course, the
parasites, such as Cryptosporidium and
Giardia, but one of the most notorious
food-borne pathogens, particularly in
Australia, is Escherichia coli.
It is one of the main species of
bacteria found in animal and human
intestines, and plays a fundamental role
as one of our essential gut flora. However,
some strains can be deadly. In 1995, the
enterohaemorrhagic strain E. coli O157:H7
caused the Garibaldi outbreak in South
Australia which hospitalised 35 people,
including 22 children, and claimed the life
of a young girl. This outbreak caused
such public outcry that it prompted the
creation of new uniform national food
safety standards.
But not all food-borne bacteria are
bad. Many yoghurts and milk products
contain ‘friendly’ bacteria such as
Lactobacillus acidophilus, Streptococcus
salivarius and Bifidobacterium, which are
not only part of the yoghurt culture
process, but play benevolent roles in the
human body, hence the name ‘probiotics’.
These probiotics are claimed to offer a
range of health benefits, from treating
thrush to restoring and maintaining
healthy gut flora. While the medical
evidence is mixed on whether these
claims are true, probiotics certainly do no
harm, unlike their pathogenic colleagues.
An intricate trail
Food-borne illness is a problem that
governments take seriously.
In 2000, the federal government
established OzFoodNet – a collaborative
initiative of state and territory health
authorities with the sole purpose of
investigating outbreaks of food-borne
illness.
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“In a situation where you’ve got
large groups of people,
particularly if they are senior
Australians or people who are ill
or immunocompromised, that’s
the last situation where you
want poor food handling”
– Dr Gary Lum
“That’s just one faeces sample, and
we get something like 40,000 a year,” Dr
Robson says.
If this process, which can take around
60 hours, identifies a notifiable disease,
the state or territory health department is
notified and the sample forwarded to the
Public Health Laboratory Network for
specialised typing.
PHOTO CREDIT: MONICA NAPPER
Typing is an essential step in the
process of identifying outbreaks of foodborne illness and tracing them back to the
cause.
The process of such an investigation
starts when a faecal sample is sent to a
pathologist such as Dr Jennifer Robson,
microbiologist and infectious diseases
physician at Sullivan Nicolaides Pathology
in Brisbane. The pathologist’s role is to
quickly analyse the sample to discover
what, if any, pathogen is to blame. But it’s
far from a straightforward procedure.
“One of the things that is difficult to
appreciate is how complicated faecal
processing is,” Dr Robson says. “To get
out these pathogens from the billions of
flora that are in normal faeces, we need
6–7 different selective agar plates (petri
dishes containing a substance to cultivate
micro-organisms) and with every sample,
we look at it under the microscope and
look for red cells and white cells to see if
there is inflammation.”
22_PATHWAY
The sample is then examined and put
through an enzyme-linked immunosorbent
assay to look for parasites or viral
pathogens, and put on the specialised
agar plates to culture for the most
common bacterial causes.
Normally, the plates will indicate the
presence of Salmonella, Campylobacter,
Aeromonas, Yersinia and Shigella, but if
the patient has consumed seafood
recently, the pathologist will also plate for
the bacteria Vibrio parahaemolyticus.
Finally, the sample might also
undergo polymerase chain reaction (PCR)
testing for shiga toxin – the toxin
produced most commonly by Shigella
and some strains of E. coli.
“The importance is not so much the
diagnosis, but the type of each isolate
because if we know that an isolate is the
same from multiple people then we know
there is an outbreak,” Dr Lum says.
Once an outbreak has been
confirmed, the next step is to trace the
isolate back to its source.
Most people who experience a dose
of food-borne illness assume that it was
caused by something in the last meal they
ate, but Mr Mahoney says it can be far
more complicated.
“Tracing the cause of illness can be
quite complex, and trying to link illness to
a particular organism in a specific food
vehicle requires good detective work and
often a lot of luck,” he says.
“It’s usually multi-factorial, and can be
a conspiracy of a whole lot of things that
go wrong at one time.”
Take, for example, a recent outbreak
of salmonellosis that affected about 300
people in Sydney and was traced back to
a food outlet.
“It was probably traced back to eggs
that were in a mayonnaise that sat around
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Page 23
for a long period of time,” Mr Mahoney
says.
But that was just part of the picture.
While the eggs may have been the initial
source of the pathogen, the mayonnaise
wasn’t acidic enough to suppress growth
of the bacteria – a side-effect of the
modern palate’s evolving preference for
sweeter, less acidic foods.
The mayonnaise might have been left
for a long time on a bench, providing the
perfect conditions for a pathogen to
multiply.
Another complicating factor in tracing
the source of an outbreak of food-borne
illness is that the many different
pathogens that could be responsible have
different incubation periods.
“That is problematic for us,” Mr
Mahoney says.
If someone suddenly becomes ill with
violent vomiting within four hours of eating
something, it can be relatively easy to
pinpoint the source.
“But if it’s something else, if it’s got an
incubation period of 36–72 hours it can be
really difficult to trace back to what you
ate.”
A further complication is that people
who suffer from food poisoning don’t
always report it to authorities. “Most of us,
when we get ill, we curl up in bed and
don’t go anywhere,” Mr Mahoney says.
Most food-borne illness is self-limiting,
so often people will just ride it out rather
than leave the safety of the toilet to seek
medical help.
But sometimes, all the pieces of this
complex puzzle fall into place, and an
outbreak of illness is traced to a particular
source. The Garibaldi outbreak in South
Australia, for example, was traced to a
contaminated batch of Garibaldi garlic
mettwurst.
While high-protein foods such as
mettwurst, chicken and eggs are usually
thought to be the most common source of
contamination, Mr Mahoney says
increasing numbers of outbreaks are
being traced to fresh horticultural
produce. The United States has recently
experienced significant outbreaks of foodborne illness caused by E. colicontaminated spinach and lettuce.
Australia has also suffered outbreaks
traced to contaminated batches of fresh
sprouts and rockmelons.
A dose of perspective
Thankfully, large food-borne illness
outbreaks such as the Garibaldi incident
are relatively rare here.
“Australia’s got a fairly good track
record when it comes to hygiene
standards and food practices in the
restaurant and food industry,” Dr Lum
says.
“So long as people meet proficiency
testing standards and meet the education
standards and qualifications necessary to
work in these environments, then I think
we’re doing about as well as we could.”
councils, who are not legally obliged to
carry them out, was putting food safety
standards at risk. While some councils
took food inspection seriously, others
conducted no inspections at all, the
reports said. And until recently, none of
them made the results of their inspections
public.
However, some state governments,
including NSW, have now decided to
‘name and shame’ food premises that
have been prosecuted for breaches of the
Food Act.
Mr Mahoney says it’s important,
However, in NSW, the performance of
local councils on conducting inspections
of food premises has been recently
exposed to scrutiny.
though, to keep the statistics on food-
A series of articles published in The
Sydney Morning Herald raised concerns
that the level and quality of inspections by
meals a day by 365 days, there are a lot of
borne illness in perspective.
“When you consider that there are 21
million Australians, assume people eat three
meals out there that aren’t contaminated,
that don’t make people sick.”
How to avoid
food-borne illness
• KEEP HOT FOOD HOT (ABOVE 60ºC) AND COLD FOOD COLD
(BELOW 5ºC).
•
THAW FROZEN FOOD IN THE REFRIGERATOR OR THE
MICROWAVE, NOT AT ROOM TEMPERATURE.
•
COOK FOOD THOROUGHLY AND REHEAT TO STEAMING HOT
(ABOVE 75ºC) BEFORE SERVING.
•
KEEP RAW AND COOKED FOOD SEPARATE, USING SEPARATE
CHOPPING BOARDS, UTENSILS AND PLATES, AND WASH
HANDS AFTER HANDLING RAW FOOD.
•
THOROUGHLY WASH RAW VEGETABLES BEFORE
PREPARATION AND EATING.
•
STORE FOOD AND LEFTOVERS IN COVERED OR SEALED
CONTAINERS.
•
AVOID HANDLING FOOD IF YOU ARE ILL.
•
KEEP YOUR KITCHEN AND UTENSILS CLEAN.
•
WASH AND DRY YOUR HANDS PROPERLY WHILE COOKING.
•
IF IN DOUBT, THROW IT OUT.
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Some home truths
While outbreaks traced to restaurants or
food producers garner considerable
media coverage, Dr Lum says many
outbreaks also occur because of
consumers mishandling food in their own
environment.
One statistic suggests up to 20% of
outbreaks can be blamed on consumers,
rather than commercial premises.2
“Probably the worst situations occur
when you get gatherings of people or
family at social get-togethers, and people
just don’t realise how important it is to
keep food properly,” Dr Lum says.
“Instead of proper refrigeration, they will
put a bag of prawns on ice but won’t
cover the container.
“In a situation where you’ve got large
groups of people, particularly if they are
senior Australians or people who are ill or
immunocompromised, that’s the last
situation where you want poor food
handling.”
But sometimes the crime has been
committed before the food even arrives in
the country.
While the Australian Quarantine and
Inspection Service regularly screens
imported food – particularly higher-risk
foods such as oysters – sometimes a
contaminated product can slip under the
radar.
Dr Robson cites one case where three
women contracted cholera, caused by the
bacterium Vibrio cholerae, from whitebait
that had been purchased from their local
fish market but which came from
Indonesia.
Thankfully, that outbreak was limited
to just three people, who all happened to
be taking a particular medication that
suppressed acid production in the
stomach and therefore made them more
vulnerable to the infection.
While contamination can come from
any number of sources, and may even be
endemic in a particular product such as
chicken, it is when food is kept in
suboptimal conditions that bacteria and
viruses have the chance to flourish.
“The very basic thing is the danger
zone from 5ºC to 60ºC,” Dr Robson says.
“Food held for any length of time should
be kept below 5ºC or greater than 60ºC.”
Other risky practices include using the
same utensils and chopping boards for
raw and cooked foods, not adequately
washing raw vegetables before serving,
not storing foods properly in sealed or
covered containers, and not cooking or
heating food adequately.
But in the heat and throng of a busy
commercial or domestic kitchen, it can
sometimes be hard to follow all the rules
to the letter.
“I’m not totally fastidious,” Dr Robson
admits, although she says she is certainly
more aware of the importance of not
leaving food on the sideboard and always
putting it in the fridge.
“You can forget those things if you
don’t have a knowledge of what those
bacteria do and how they grow.”
References:
1.
Hall G, Kirk M. Foodborne Illness in
Australia. Canberra: Australian
Government Department of Health and
Ageing, 2005.
2.
Food Safety Information Council.
Food Poisoning Bacteria
http://www.foodsafety.asn.au/publications
/factsheets/foodpoisoningbacteri2249.cfm
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disciplines in depth
CHEMICAL
ATTRACTION
PHOTO CREDIT: EAMON GALLAGHER
Associate Professor Hans
Schneider: box seat position
THEY MIGHT WORK IN THE LAB, BUT CHEMICAL PATHOLOGISTS ARE AT THE HUB OF PATIENT
CARE. TONY JAMES REPORTS.
ext time the dinner party conversation
N
turns to cholesterol levels and you
proudly claim that yours is 3.5 mmol/L, or
are worried because it’s 6.5 mmol/L,
thank a chemical pathologist for the
information.
Chemical pathology is based on
analysing substances, numbering
thousands, in blood and other fluids such
as urine or saliva. These substances
range from electrolytes like potassium
and sodium to a very wide range of
normal and abnormal biological products
such as enzymes, lipids (blood fats
including cholesterol and triglycerides),
hormones, tumour products and the
constituents of genes.
Chemical pathologists also examine
toxins, therapeutic medications, illicit
drugs, and legal drugs such as alcohol –
perhaps at the order of police after driving
home from that dinner.
Sometimes known as clinical
biochemists or laboratory medicine
specialists, they take responsibility for the
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“It’s been thrilling to remember
learning something in medical
school 20 years ago, and finally
understand how it fits together
as part of a much bigger
picture. I’ve also been surprised
that interpreting laboratory tests
involves some art as well as
science”
– Dr Amanda Caswell
only apparent adverse effect of the
mutation is some accumulation of fat in
the liver, but this seems to cause few
problems.
Understanding these naturally
occurring low-cholesterol states is one
approach that might ultimately provide
new treatments for lipid disorders –
whether new medications or perhaps even
gene therapy.
PHOTO CREDIT: IAN BARNES
“This type of project requires clinical,
biochemical, cellular and molecular skills
and experience,” Professor Burnett says.
quality of the laboratory services that
conduct the tests, interpreting the results
in light of the patient’s history and illness,
and communicating with other doctors
about the next steps in diagnosis and
treatment.
Their other responsibilities include
technical guidance and recommendations
on when and how to introduce new tests,
and guiding colleagues about appropriate
testing.
Rich vein of enquiry
Professor John Burnett is one chemical
pathologist with a special interest in that
dinner conversation about cholesterol.
Head of the Department of Core
Clinical Pathology and Biochemistry at
PathWest and Clinical Professor in the
School of Medicine and Pharmacology at
the University of Western Australia,
26_PATHWAY
Professor Burnett also works with patients
in a lipid disorders clinic and is currently
investigating healthy individuals with a
genetic mutation that alters the
metabolism of lipoprotein – the
compounds of protein that carry fats in
the blood.
“Apolipoprotein B – apoB – is the
main protein component of LDL
cholesterol,” he says. “One in every 3000
to 5000 people has a mutation of the
[relevant] APOB gene,which results in
abnormally low total and LDL cholesterol
levels – as low as if they were taking
cholesterol-lowering medication.”
On average, people with the gene
mutation generally live about 10 years
longer than unaffected members of their
families, even though they might still
develop other cardiovascular risk factors
like obesity, diabetes or hypertension. The
“As a chemical pathologist, I’m able to
be involved in most aspects of the study.”
Chemical pathologists also work
collaboratively with scientific and
technical staff in the laboratory.
High-technology laboratories conduct
large numbers of routine tests, with a
minority having results well outside the
normal range that are flagged for
attention. Rare or unusual tests often
require close supervision, interpretation
and follow-up with the referring doctor,
but routine tests often also need input
from specialist pathologists.
“In a patient with something that
seems relatively straightforward such as a
high cholesterol level, we need to check
that hypothyroidism, diabetes, liver or
kidney disease, or an inherited problem is
not the cause,” Professor Burnett says.
“In a patient with abnormal liver
function tests, we might need to guide the
treating doctor on the next options, which
could include testing for hepatitis
antigens, haemochromatosis, or less
common conditions such as alpha-1antitripsin deficiency or a copper storage
disorder.”
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Professor Burnett was attracted to
chemical pathology early in his medical
career, intrigued by the biochemistry and
physiology that can explain the
mechanisms of health and disease. There
is strong demand for the 106 chemical
pathologists in Australasia, providing a
chance to shape career opportunities in
the public or private sector.
“The lifestyle is better than many other
medical specialities,” Professor Burnett
says. “We work regular hours, and can get
the right balance between work and the
rest of life.”
Where art meets science
Dr Amanda Caswell is a late convert to
the appeals of the discipline.
Initially a hospital intern and resident,
she then shifted direction by completing a
one-year qualification in journalism. For
seven years she worked as a medical
writer and editor for GP newspaper
Australian Doctor and was recruited by
MIMS Australia (an independent company
that produces medication reference
guides), where she was managing editor
for nine years.
After all that experience in publishing,
another career change beckoned, and this
time it was chemical pathology that drew
her attention.
She is now a second-year
biochemistry registrar – a chemical
pathology trainee – at Sydney’s Royal
North Shore Hospital.
“I felt at home in medical publishing
but wanted to be closer to the coalface
and provide something of more direct
value to other doctors and patients,” Dr
Caswell says.
“I had developed a lot of experience in
working with large amounts of information
and pulling it together to produce
something useful. Chemical pathology is
similar, working with a patient’s history,
information from the treating clinician and
the laboratory results, to produce a
diagnosis, guide the treatment, and help
the patient. I am still in the business of
communicating with other doctors to
provide information and education, but
now it has a direct effect on patient care.”
Dr Caswell is impressed by the variety
and unpredictability of her current role.
She provides information and advice to
the entire hierarchy of hospital medical
staff, never knowing what the next query
will be.
Becoming a
chemical
pathologist
hemical pathology is a distinct
discipline requiring Fellowship of
the Royal College of Pathologists of
Australasia. Five years of supervised
training in an accredited post as a
registrar includes an initial basic
pathological sciences examination,
‘Part 1’ examinations after a
minimum of three years, and a ‘Part
2’ examinations usually taken in the
fifth year of training.
C
Training usually involves intensive
exposure to the laboratory
environment in the first year, to
ensure that candidates understand
the technical and scientific aspects of
the discipline. Clinical, administrative
and interdisciplinary responsibilities
develop throughout the training
program.
There is also a combined training
stream with the Royal Australasian
College of Physicians. Trainees
typically complete general physician
training and the physician Part 1
examination, then enter a combined
endocrinology/chemical pathology
training program for four years.
“I have been amazed at the very
broad spectrum of medical knowledge
that’s needed,” she says.
“It’s been thrilling to remember
learning something in medical school 20
years ago, and finally understand how it
fits together as part of a much bigger
picture. I’ve also been surprised that
interpreting laboratory tests involves some
art as well as science.”
Breaking new ground
Like about half of Australasia’s chemical
pathologists, Associate Professor Hans
Schneider is also a physician. He is
Director of Pathology Services at The
Alfred Hospital in Melbourne, as well as
head of the biochemistry laboratory.
His involvement in patient care
includes detailed discussion with other
clinicians about the appropriate use of
chemical pathology tests. The services of
each laboratory depend partly on local
circumstances and the special needs of
the hospital, and it requires careful
analysis to ensure that investment in new
technology will directly influence decisions
about patient management.
Professor Schneider’s box-seat
position also incorporates valuable
chemical pathology research.
He and his colleagues recently
investigated the use of B-type natriuretic
peptide (BNP) in patients presenting to
the hospital emergency department with
shortness of breath.
The test has the potential to quickly
identify patients in whom breathlessness
is caused by heart failure, allowing rapid
and specific treatment for their underlying
disease. If heart failure is not the cause,
then the search can continue for other
diseases.
Results from the study are expected
shortly.
Last year, Professor Schneider and
colleagues also reported on possible links
between high-sensitivity C-reactive
protein (hsCRP) – a marker of chronic
inflammatory diseases – and fracture risk
in elderly women.
Using data from participants in the
Geelong Osteoporosis Study, they found
that increasing levels of hsCRP predicted
fractures independent of well-recognised
risk factors such as bone mineral density,
history of previous fractures, bone
turnover, diet, lifestyle, medications and
other illnesses. The research exemplifies
the links that can exist between laboratory
science, clinical practice and population
health.
Professor Schneider has also been
closely involved in discussions about new
methods for measuring and reporting
glycosylated haemoglobin (HbA1c), a
marker of long-term glucose control in
people with diabetes.
New laboratory assays mean that
results are more accurate and reliable, but
the normal values will change and
treatment targets will change, with
substantial implications for patients and
diabetes nurses as well as doctors.
“One of the attractions of chemical
pathology is that you are often at the
‘sharp edge’ of medicine,” he says.
“We have the chance to provide
leadership in science, technology and
clinical services. The work is varied, and we
make a real difference to patient care.”
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close up
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Salmonella bacteria (green), coloured
scanning electron micrograph (SEM).
Salmonella bacteria can cause food
poisoning when they are eaten in
contaminated food. Symptoms include
abdominal pain, nausea, diarrhoea and
vomiting.
PHOTO CREDIT: SUSUMU NISHINAGA / SCIENCE PHOTO LIBRARY
PathWay #13 - Text
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foreign correspondence
Tour of duty
A MEDICAL AID TRIP TO VIETNAM SHOWED DR TIM BLACKMORE THAT DEVELOPED AND
DEVELOPING COUNTRIES MIGHT HAVE MORE IN COMMON THAN THEY THINK.
KELLIE BISSET REPORTS.
Z microbiologist Dr Tim Blackmore
expected to enjoy his stint in Vietnam,
passing on knowledge to local doctors as
part of a medical aid project between the
two countries.
N
But his experience surpassed
expectations: not only did he thoroughly
engage with the warm and open medical
staff, he came home having learned just
as much as he taught.
“I learnt a huge amount from the
experience,” says Dr Blackmore, an
infectious diseases physician and
microbiologist at Wellington Hospital.
“From outside you might see Vietnam
as a developing country and when there,
you say, is it so different? Over there they
don’t do invasive tests, but is it so
different from doing too many?”
Dr Blackmore’s trip was funded by the
New Zealand/Viet Nam Health Trust under
the auspices of New Zealand’s international
aid and development agency, NZAID.
He visited Binh Dinh province, on
Vietnam’s central coast, in 2004 and
2005, to give a series of talks to local
medical staff as part of a two-year
infection control project being run by a
nursing colleague.
The idea was to better tackle infection
control by improving the understanding of
microbiological principles. While there was
30_PATHWAY
much ongoing work being done,
Dr Blackmore’s role was to reinforce the
day-to-day message.
“I got a good response,” he says.
“Vietnamese doctors are like doctors
anywhere – they like shiny toys – whereas
sometimes it is doing the basics better
that is more important.”
The challenge, though, was getting
this message across in an effective way.
“You need to present a pragmatic
approach rather than coming in from NZ
saying this is the way we do it – you
should do it like us.
“It is about getting better, rather than
aiming for perfection and failing.”
Attitudes and latitudes
Another hurdle was reinforcing the
importance of the laboratory. Labs are not
routinely used in Vietnam – and are often
relied upon in crisis, rather than
diagnostically.
This, it seems, is partly because of a
cultural reliance on pharmaceuticals, and
also because pathology does not have a
strong presence in the health system.
There is no postgraduate pathology
training offered in Vietnam equivalent to
that provided in Australia and New
Zealand. And once they have graduated,
Vietnamese doctors often don’t have a
choice in which specialty they work.
“Someone who wants to be a surgeon
might be told they have to run the
haematology lab,” Dr Blackmore says.
“The microbiologist I worked with was
very good and interested in what she was
doing, but the quality of the lab staff is
incredibly variable.
“I was there to try to integrate clinical
practice along with laboratory practice
and infection control practice. It turned
out to be quite a lot of fun really.”
One aspect of the project that needed
a lot of reinforcement was hand washing
and hand hygiene – and this involved his
nursing colleague working to acquire a
locally produced hand rub.
But it occurred to Dr Blackmore that
many of these issues were really just
matters of degree.
“If you can’t get people to wash their
hands in Sydney or Wellington and they
never wash them in Vietnam is it so very
different?”
He also saw similarities in the way
non-medical factors can influence medical
behaviour.
“If you really think about it there are a
lot of perverse incentives as to why
people behave in particular ways, such as
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Five things you didn’t
know about Vietnam
•
Infant mortality rate: 16 per 1000 live births
•
Life expectancy at birth: 70.65 years
•
HIV prevalence
(% of population aged 15–49): 0.5
•
Child measles immunisation rate: 97%
•
Physicians per 1000 people: 0.5
Source: World Bank
the business of using ‘sexy’ drugs
because the person can afford it.”
Antibiotic love affair
And as fancy drugs go, antibiotics come
top of the pile in his host country.
“There is a lot of incentive to
prescribe drugs but they won’t do lab
tests – 100% of people there are on
antibiotics,” he says.
“On the first visit I discovered what
was going on and started sowing the
seeds. We came up with doing a
surveillance project on MRSA [methicillinresistant Staphylococcus aureus] and
resistance.”
The results were not surprising.
“What it showed was high rates of
multi-drug resistant bacteria and that
MRSA was being transmitted in hospital,
which we suspected. But also people
were coming into hospital with some very
resistant Gram-negative bacteria.
mainly on Province Hospital and Bong
“The real challenge I had was
convincing doctors that if a test was
going to cost the patient’s family $10 or
$20 that would be money well spent, but
spending $10 or $20 for a drug would not
make the patient better.”
some momentum on infection control.
New Zealand’s links to Binh Dinh
province date back to the Vietnam War,
when a New Zealand surgical team set up
a field hospital in the area.
in a karaoke bar saw him croaking out
The good relationships that were
formed with the Vietnamese people have
continued, a sign of which is the ongoing
aid delivered to the area through the New
Zealand/Viet Nam Health Trust and
Volunteer Service Abroad.
While there are many hospitals in the
area, Dr Blackmore’s project focused
Son Hospital – outward-looking
institutions they thought could build up
And while Dr Blackmore succeeded in
building many successful bridges, he did
so at the occasional expense of his pride.
The Vietnamese love of a good drink
‘Girl From Ipanema’ on at least one
occasion while his colleagues sang
beautifully around him.
But perhaps his singing has been
forgiven – Dr Blackmore assures PathWay
they were keen for him to return.
And he’d like to oblige too.
“I would like to go back again. Each
time I go back it changes. They are lovely
warm people.”
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hot topics
Expecting perfection
THE PUBLIC HAS UNREALISTIC EXPECTATIONS OF PATHOLOGY’S ABILITY TO DELIVER PERFECT
RESULTS, WRITES BIANCA NOGRADY .
ne of the most spectacular errors in
pathology history might indirectly be
credited with claiming nearly 20 million
lives. It’s even more astounding to learn
that the pathologist behind it was in fact
the founding father of histopathology,
Rudolph Virchow.
O
Virchow failed to diagnose German
Emperor Friedrich III’s laryngeal cancer
until it was too late. The politically
moderate and liberal Friedrich died in
1888 after ruling for just 99 days, and his
militaristic son Wilhelm II inherited the
throne, setting Europe on the path to the
slaughter of World War I.
To err is human, even if you do
happen to be a world expert in the field.
And at its heart, pathology is a very
human practice, says Dr Stewart Bryant,
President of the RCPA.
“If you’re talking about anatomical
pathology, it is a subjective interpretation
of what the pathologist is seeing down the
microscope,” Dr Bryant says.
“It’s a bit like a clinical diagnosis.”
This means five experienced
pathologists looking at the same biopsy
may come up with five different
interpretations.
“You might only know in five years
time which of them was right.”
The trouble is, there’s a prevailing
community perception that pathology is
infallible. And this leaves the profession
wide open to undue criticism when things
go wrong.
32_PATHWAY
Professor Anthony Leong, Medical
Director of the Hunter Area Pathology
Service and Professor of Anatomical
Pathology at the University of Newcastle,
writes that the use of the words ‘test’ and
‘results’ when referring to anatomical
pathology diagnoses “inappropriately
reinforces the public’s misconception that
the cognitive process of interpreting the
features seen in a small piece of tissue is
infallible” (Pathology 2006;38:490–7).
Overcoming this perception is no easy
task, but Dr Bryant says it’s a matter of
reminding people that as with any human
endeavour, there is a basic error rate.
So what exactly is an error in
pathology? There’s no universally
accepted definition of ‘error’, but generally
errors can be described according to who
makes them, why they occur, when they
occur and what impact they have on the
patient.
Degrees of separation
To start with, it’s important to realise that
pathology errors aren’t always made by
pathologists.
“There are about 50 steps that happen
between the time the biopsy is taken and
the slides come to the pathologist, so
things can go wrong at any of the steps in
between,” says Associate Professor
Sanjiv Jain, anatomical pathologist and
Director of Anatomical Pathology at ACT
Pathology.
For example, a biopsy could be
mislabelled as being from the colon
instead of the stomach, or the wrong
patient name or history could be put on
the patient request form.
Samples can also be mislabelled after
they arrive at the laboratory – the wrong
specimen could be put into the cassette,
or slides could be incorrectly labelled.
These sorts of patient identification
errors can also be made by the
pathologist, who may accidentally record
a diagnosis on the wrong patient form.
Even after a diagnosis is correctly
made for the right patient, things can go
awry in the ‘post-analytical’ stage.
As Professor David Davies explains,
the simple word ‘no’ can make a 180degree difference.
“This happened with a fax system we
were using,” says Professor Davies, an
anatomical pathologist at Sydney’s
Liverpool Hospital, and Joint Area Director
of Pathology for Sydney South West Area
Health Service.
“To be emphatic, the word ‘no’ was
printed in capital letters, and the
computer program failed to recognise
characters of capital letters so the word
just dropped out of this report.”
Thankfully the glitch was spotted in
time and corrected, but Professor Davies
says the incident highlighted the need to
look at the entire system in which
anatomical pathology is practised.
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Australian anatomical pathologists have,
for many years now, adopted a range of
processes to reduce the risk of errors.
PHOTO CREDIT: PETER STOOP
- Professor Anthony Leong
Grades of error
Finally, there are what Professor Jain calls
interpretive errors, where the conclusion
one pathologist reaches about a slide is
different to what another pathologist
might conclude.
“Within that context there are types
and grades of errors,” he says.
“The worst grade of error is when a
biopsy is benign and we call it malignant,
or the biopsy is malignant and we call it
benign.”
Several decades ago, a simple verdict
of benign or malignant was all a
pathologist was expected to deliver.
But these days, pathologists must
extract far more information from a much
smaller biopsy to help guide patient
treatment, and many of these judgments
are less black and white than ‘malignant
versus benign’.
“With breast cancer, the diagnosis
itself is not difficult – but that’s not the
only diagnosis we give on breast cancer,”
Professor Jain says.
“We talk about the type of breast
cancer, the grade of breast cancer, we
talk about whether breast cancer cells
have gone into the blood vessels or
whether the cancer has gone into the
lymph nodes, we talk about whether the
breast cancer has got oestrogen or
progesterone receptors.”
hospitalisation or surgical intervention, but
without causing ‘major’ morbidity.
At its worst, a mistake could lead to
loss of an organ, limb or even life.
These most serious errors tend to
involve a change in categorisation – the
most obvious being from benign to
malignant or vice versa.
Human impact
Ultimately, however, a major test of an
error’s significance lies with its impact on
the patient.
Community consternation
Thankfully, serious errors are rare,
occurring in approximately 0.5–1% of
Professor Leong suggests one
accepted approach to defining diagnostic
error is to judge it by the impact on
patient management (Pathology
2006;38:490–7).
cases. But unfortunately, this distinction
A minor error may have absolutely no
impact on management, or it could lead
to minor morbidity, such as fever, where
there is an impact, but hospitalisation or
surgery is not required.
pathologist Dr Farid Zaer.
A more serious error could affect
patient care enough to require
of three pathologists in a laboratory in
between major and minor errors is not
always obvious to outside observers, as
happened during the recent media frenzy
over an inquiry into the work of NSW
The inquiry was initiated after
concerns were raised about Dr Zaer’s
quality of work during his time as a solo
pathologist in Tamworth and later as one
Wollongong.
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>
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“In pathology, there’s nobody that goes around and says ‘you’ve looked at 50
biopsies today, you’re not going to do any more’.”
- Professor David Davies
The review of 7432 tests in Tamworth
found ‘minor diagnostic variations’, with
no impact on patient management, in
30.27% of cases, and significant
diagnostic variation in 2.92% of cases.
However, among those 217 significant
diagnostic variations, only 38 cases –
0.51% of the total case load reviewed –
were assessed to have potential clinical
impact – well within what is considered an
acceptable error rate.
The experience highlighted that the
majority of people do not realise or accept
that errors do occur in pathology,
Professor Leong says.
“The managers were not aware of
what was an acceptable error rate, so
they thought you should have a perfect
zero-error rate.
“Obviously the pathology community
has not educated the public and the
media and the administrators to the fact
that this is a cognitive interpretation, and
there are obvious errors inherent in the
process.
“If God did not accept errors he would
have made us all perfect.”
No-one has yet established baseline
error rates for Australia, so there is no
accepted benchmark point for the public,
management and the pathology
profession.
“While we may simply embrace the
American rates… our conditions are
different,” Professor Leong says.
“Error rates need to vary, as
pathologists practise under different
KEPT IN CHECK:
METHODS PATHOLOGISTS USE TO
MINIMISE ERROR
•
Clinicopathological meetings where
biopsies are reviewed
•
External quality assurance programs
•
Internal clinical audit
•
Continuing medical education
34_PATHWAY
conditions – alone, in groups, as
specialists or as general trained
pathologists.”
think is a bit different or funny, they will
walk next door and ask a colleague,” he
says.
Dr Bryant agrees that researching
baseline error rates would help establish
what is a reasonable level of proficiency
for pathologists, but says it would be a
complex and massive undertaking.
In particularly tricky cases, a group of
pathologists might gather to discuss the
case to reach a team consensus or even
refer the case to a national or
international expert.
“To actually get enough data in and
stratify according to complexity of
diagnosis would be an enormous task,”
he says.
“It’s a matter of the pathologist
knowing what they don’t know, and
having a back-up system,” Dr Bryant
says.
Pressures on pathologists
Unfortunately, the pathology
workforce crisis means there will
inevitably be pathologists in rural and
regional areas working alone and under
pressure.
Apart from defining baseline error rates,
the issue of the impact of workload on
error is another unresolved question. This
problem is being exacerbated by the
workforce crisis in pathology.
The Zaer case also drew attention to
the overwhelming workload many
pathologists handle due to isolation and
lack of back-up. The pathologist in
question had examined 7432 biopsies in
just 13 months – 70% more than the UK
Royal College of Pathologists’
recommended annual case load of no
more than 4000 biopsies. (Australia does
not have a recommended equivalent case
load but the UK recommendations are
accepted here.)
Professor Davies suggests pathology
could benefit from a similar approach to
that taken by the airline industry in terms
of managing workload, where pilots must
have ‘time out’ after so many hours of
flying time.
“In pathology, there’s nobody that
goes around and says ‘you’ve looked at
50 biopsies today, you’re not going to do
any more’.”
Dr Zaer was also working alone in
Tamworth – a scenario the UK College
advises against. Anatomical pathology is
by necessity a very collegiate activity, Dr
Bryant argues.
“Most pathologists work in groups or
teams, and it’s very common if
pathologists find something that they
These solo practitioners are also
expected to be a jack-of-all-trades,
Professor Leong says.
“Just because the rubric ‘pathologist’
is used, this man probably had to run
chemistry, microbiology, haematology and
also do anatomical pathology on the
side.”
More importantly, he was expected to
diagnose a range of materials that would
sometimes require the highly specialised
expertise found only in larger pathology
practices.
The shortage of pathologists is
unlikely to be solved in the near future,
despite continued lobbying of
governments to provide adequate training
positions. This raises the question of what
other steps can be taken to reduce the
risk of errors. While considerable effort is
being made in laboratories around
Australia to reduce errors, there’s no
doubt Australia is already far ahead of the
game, with a consistently and uniformly
high standard of pathology practice.
But Dr Bryant says it’s important not
to rest on our laurels.
“I think we’ve achieved a very high
standard – as good as it gets in the
Western world – but we have to make
sure it doesn’t deteriorate.”
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“It’s a matter of the
pathologist knowing what
they don’t know, and having
a back-up system.”
- Dr Stewart Bryant
directed reviews of particular organ or
occur simply because of a lapse in
cancer-type biopsies. The lab also
Professor Leong says Australian
concentration. These errors can be made
launched a Histology Practice
anatomical pathologists have, for many
by even the most experienced and
Improvement project in 2005, which aims
years now, adopted a range of processes
focused pathologists, although Professor
to decrease non-pathologist-generated
to reduce the risk of errors. One is the
errors and improve laboratory efficiency.
Keeping errors in check
conduct of clinicopathological meetings
with multidisciplinary teams, where
biopsies are reviewed by expert
pathologists independently in the context
of the individual patient’s presentation.
Professor Jain, who designed the audit
Jain says people are less likely to make
slips when there’s a good chance their
work will be subject to a random review.
program, says it has helped keep errors at
ACT Pathology in check.
“It keeps on reminding us that we are still
So in defence of Rudolph Virchow’s
catastrophic nineteenth-century
fallible and we make errors, so that makes
misdiagnosis, the biopsy sample may
There are also external and internal quality
us more vigilant as we do our work,” he
have been of poor quality, it may have
assurance programs, and the active
says.
been mislabelled, or Virchow may have
The audit allows him to take action in a
simply experienced a lapse in
participation in on-going professional
continuing education.
situation where a pathologist is making
concentration.
One approach to reducing error that is
more errors of knowledge. It also
Professor Davies also points out that
working well for ACT Pathology is the
encourages staff to sit down together and
laryngeal biopsies are notoriously difficult.
internal clinical audit, which is performed
review practices.
to varying degrees in hospitals across the
“It stops people being defensive about
country.
their diagnosis, and they are able to share
As part of its audit process, ACT
knowledge and problems with each
Pathology holds weekly histology quality
other,” he says. “It helps to standardise
Besides, had the laryngeal tumour been
assurance meetings with consultants and
processes in the laboratory.”
diagnosed in time, the surgery would just
registrars, conducts a weekly audit of all
Audits also help reduce the risk of what
as likely have killed Emperor Friedrich as
breast-screening cases, and performs
Professor Jain calls ‘slips’ – the errors that
the cancer. .
As he puts it: “Those of us who are more
self-critical say ‘there but for the grace of
God go I’.”
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the GP view
Eyes wide shut
KNOWING WHAT’S GOOD FOR YOU AND DOING SOMETHING ABOUT IT ARE TWO VERY
DIFFERENT THINGS, WRITES DR LINDA CALABRESI .
ecently I was chatting with a high
school teacher.
R
Research shows the most effective
treatment for the morbidly obese patient
is laparoscopic gastric banding. It
consistently achieves results that are
streets ahead of any of the alternatives
(and no I have no monetary interest in the
procedure just in case you were
wondering).
The conversation came around to the
increasing expectation that all of society’s
problems could be solved through
education about the relevant issues in the
classroom.
From sexually transmitted diseases to
suicide, all were now considered a result
of ignorance and as a consequence
became the responsibility of ‘chalkies’.
I empathised. In fact, I pointed out
(being a tad competitive by nature) that
the situation was probably worse in
general practice.
We were expected to screen for,
detect and educate about everything from
alcohol abuse to exercise levels, as well
as address the patient’s presenting
complaint – and all within a 15-minute
consultation.
While we both recognised the merits
of disseminating appropriate health
messages throughout the community, if
you look solely at return on investment, is
so much emphasis on education really
giving us bang for our buck?
Take the recent flurry of initiatives
developed to address the rise in
prevalence of obesity. Once again
education is the catchcry.
The principle appears to be that once
people are made aware of the problem
and given all the information about it then
they will take the appropriate action and
the problem will be solved.
It’s logical.
It should work.
The only fly in the ointment is that, in
many cases, it doesn’t – or at least not to
a sufficient degree.
Smoking is another good example.
These days, no-one could possibly
think smoking was anything but harmful to
your health. There is absolutely no
possible reason to smoke. Every man,
woman and child has been exposed to
the ‘smoking is a health hazard’ message.
36_PATHWAY
And yet, despite being educated to
the eyeballs, one in four adult Australians
continues to smoke.
Even worse, research shows that
those whose health is particularly at risk –
those with asthma – light up at a rate of
about one in four.
The reality is that awareness and
education can only go so far.
With regard to obesity, of course
prevention is better than cure. And of
course it would be better if everyone
could attain a healthy body mass index
(BMI) through diet and exercise. But for
many with the problem, this is just too
hard to manage. Whether it’s because of
habit, lack of motivation or psychological
issues, they are unable to help
themselves.
It’s not lack of awareness. And it’s not
lack of education. If my patient population
is any indication, they would like to
change and they’re not happy being
overweight but one has to recognise the
frailties of the human condition.
While governments are planning
obesity screening programs for schoolage children and underwriting more
awareness campaigns, there is a whole
population out there looking for solutions.
A population that is already suffering
from diabetes, heart disease and arthritis
because of their obesity – at considerable
cost to the health system, not to mention
their own quality of life.
So what does work?
But despite its proven success and
despite the known health advantages
that come with significant weight loss in
this cohort, does it attract a Medicare
rebate? No.
The only way a person can fund this
procedure is through the private system
having taken out top-cover private health
insurance, or pay upfront to the tune of at
least $15,000. Basically, if you’re going to
be big make sure you’re rich.
Making such a procedure more
accessible through Medicare wouldn’t be
without its problems.
One can imagine people eating up big
to reach the qualifying BMI.
And then there’s the question of the
very low calorie diets, and even the
weight-loss drugs orlistat and
sibutramine.
All have evidence to back their
effectiveness, and all are very expensive
for the average obese patient.
However, if the government is really
serious about addressing the obesity
issue, and if it truly backs evidenced
based medicine, it needs to seriously
consider funding some of these options
along with its promotion of healthy diet
and lifestyle, which is naturally the number
one priority.
They really must investigate what is
going to give them the best result.
Simply handing the problem back to
schoolteachers and GPs with instructions
to detect and educate will never be
enough.
Dr Calabresi is a practising GP and Editor of
Medical Observer.
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searching for answers
When death strikes
the young
AUTOPSY RATES ARE DECLINING NATIONALLY –
EXCEPT IN THE AREA OF PERINATAL MORTALITY.
CATHY SAUNDERS EXAMINES WHY.
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“The public perception that the autopsy is an intrusion after death
needs to be replaced by one that emphasises that it is an
investigative and diagnostic procedure” – Professor Yee Khong
hen parents lose a baby before or
soon after birth, often their first
question is “Why?”.
W
In many cases, an autopsy can
provide the answer but also, most
importantly, help with the management of
future pregnancies.
Perinatal pathology is integral to
unlocking this information, and involves
the synthesis of post-mortem tests that
may include anatomical pathology,
microbiology, virology, immunology,
biochemistry, haematology, chemical
pathology, molecular biology and
genetics.
“We put it all together and find the
most likely reason for the baby dying,”
says Professor Jane Dahlstrom, Professor
of Pathology at the Australian National
University and senior Anatomical
Pathologist at ACT Pathology and The
Canberra Hospital.
Getting answers and using them to
move forward is fundamental to many
parents’ sensitive decision to have an
autopsy in an era when adult autopsy
rates are declining.
Perinatal autopsy experts say only a
handful of parents regret having agreed to
an autopsy, while many rue the fact they
did not consent to one.
“The overall rate of perinatal mortality
in Australia now is less than 1% of all
births, so it is a relatively unusual
complication of pregnancy and I think we
are satisfying a natural need to know why
it happened,” says Professor David
Ellwood, Professor of Obstetrics and
Gynaecology at the Australian National
University and Director of the Fetal
Medicine Unit at The Canberra Hospital.
“It does give people some degree of
closure. I think it is different from adult
autopsy, where quite often the death is
expected and so perhaps there isn’t the
same level of uncertainty.”
Australian research shows that the
rate of adult autopsies decreased from
66% of all autopsies in 1992–93 to 39%
in 2002–03, while the rate of perinatal
autopsies climbed from 29% to 58% of all
38_PATHWAY
autopsies in the same period (MJA
2004;180:281–5).
changing the diagnosis or adding extra
information.
Perinatal autopsy rates are now
60–70%, compared with about 5% for
non-coronial hospital adult autopsy rates.
Professor Ellwood says it is important
that both an autopsy and placental
pathology are done.
A many-valued thing
“If families are resistant to having a
post-mortem, then as a minimum the
placenta should be looked at.”
rofessor Dahlstrom says the value of
an autopsy, which means “to look
within with one’s own eyes,” is manifold.
P
The primary aim is to establish the
cause of death, but it also serves to
confirm – or, in up to 20% of cases, refute
– the clinical diagnosis.
In addition, the autopsy can reassure
parents they did not do anything during
the pregnancy to jeopardise the baby’s
wellbeing, and it eliminates suspicion of
inappropriate or inadequate treatment.
Dr Diane Payton, Chair of the RCPA
Paediatric Pathology Advisory Committee
and senior staff pathologist at Royal
Brisbane and Women’s Hospital, says
there are also medico-legal benefits.
“If there has been a problem with the
pregnancy, delivery or early perinatal
course or any unexpected outcome, a full
post-mortem examination and an open
discussion of the post-mortem results,
clinical course and all other investigations
is very helpful in discussions with the
parents,” she says.
Studies confirm that a perinatal
autopsy provides useful information in a
large number of cases. Research by
Professors Dahlstrom and Ellwood and
Canberra neonatal specialist Dr Alison
Kent into perinatal deaths1 shows that in
the ACT and NSW over a five-year period
to 2005, an autopsy was carried out in
50% of perinatal deaths and placental
pathology in 95% of such deaths.
In about 40% of these examinations,
additional information was provided that
prompted further investigations
postnatally and/or changed management
of the next pregnancy.
Similarly, research in WA2 shows that
in half of perinatal autopsies in 2000–01,
the findings made a difference, either by
Professor Dahlstrom agrees.
“About one-third of the time, the
answer to why a baby has died is in the
placenta and the baby can be perfectly
normal,” she explains.
Causes include extensive placental
infarctions and villitis.
Another one-third of deaths are
caused by major congenital abnormalities
in a baby and the remaining third may be
related to maternal conditions such as
systemic lupus erythematosis, diabetes or
severe hypertension.
Guiding future care
By providing answers to the cause of
death, an autopsy paves the way for
future pregnancies to be managed
differently.
“Women who have experienced
stillbirth have a higher rate of stillbirth in
subsequent pregnancies,” says Professor
Ellwood.
“So, for example, if the problem was
to do with fetal growth or placental
function, you may well monitor the growth
of the fetus much more closely and
perhaps think about early delivery.”
Autopsies can also detect the
placental features of thrombophilias, which
can be treated, and this may improve the
outcome of the next pregnancy.
They can also identify genetic
abnormalities, which may have a
recurrence risk in subsequent pregnancies
and might also affect the future
pregnancies of siblings. The information
from autopsies can be very important in
genetic counselling and may have
implications for prenatal testing.
Dr Adrian Charles, of the Department
of Perinatal Pathology at Perth’s King
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Page 39
hen Karina Christensen and her partner Grant (pictured) lost their
first baby Ryan 26 hours after he was born three years ago, they
did not hesitate to agree to an autopsy.
W
Although two of Karina’s siblings had died shortly after birth from a
genetic disease – autosomal recessive polycystic kidney disease – she
always believed it would not affect her children because it requires both
parents to be carriers.
“I thought it could not be possible my husband would be a carrier,
that it was not going to happen to us,” she says.
But the 20-week ultrasound showed Ryan was affected. Karina says
they proceeded with the pregnancy in the hope that somehow he might
pull through.
Edward Memorial Hospital for Women,
says perinatal autopsies have sometimes
“After he died, we wanted to confirm what it was and in doing that,
we could then go forward,” she explains.
led to changes in clinical practice.
In the UK, autopsies on several
Although her parents had been told the cause of her siblings’
deaths, no autopsies had been done or blood tests taken, so Karina
and Grant found the autopsy removed any doubts. “It gave us closure
to know exactly what happened,” she says.
neonates who died suddenly showed the
cause was cardiac tamponade or fluid
around the heart. Further investigations
revealed they had all had a long-line
surrounded and compromised the heart.
The information from the autopsy also enabled them to make
decisions about their next pregnancy. As there is a one in four chance
of having an affected baby, they underwent IVF and had prenatal
genetic testing to ensure the implanted embryo was unaffected.
Opening up options
The couple now have a beautiful three-month-old boy, Daniel, and
are already planning their next baby.
catheter inserted into their right atrium,
which had led to fluid leaking. This
Karina says they are extremely grateful to Dr Alison Kent, neonatal
specialist at The Canberra Hospital, who came to see them at the 24week ultrasound of Ryan and prepared them for their options once he
was born.
“This finding materially altered practice,”
Dr Charles says.
Despite best efforts, some deaths
remain unexplained, but parents are often
“Alison and her staff were absolutely amazing and pulled out every
stop to help us,” Karina says.
relieved to learn from the investigations
that events during the pregnancy that
She also sings the praises of the perinatal pathologist,
haematologist and geneticist who were involved in the autopsy. To
show their gratitude to The Canberra Hospital, she and Grant regularly
donate items for the baby packs given to new parents.
may have worried them were unlikely to
have been of any significance.
When an autopsy is performed, the
incisions are minimal and the parents can
>
PATHWAY_39
PHOTO CREDIT: ANDREW CAMPBELL
Moving forward
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“About one-third of the time, the answer to
why a baby has died is in the placenta and
the baby can be perfectly normal”
PHOTO CREDIT: ANDREW CAMPBELL
– Professor Jane Dahlstrom
HOPE after
heartbreak
n 1998, Professor Dahlstrom (pictured) examined a baby who
had died in utero and decided to check the findings from an
autopsy conducted by another pathologist on a previous fetal
death in the same mother. She diagnosed neonatal
haemochromatosis which, at the time, was not treatable.
I
More recently, when treatment for the condition finally
became available, Professor Ellwood and immunopathologist
Professor Paul Gatenby instigated this treatment during the
pregnancy of the same woman, who by now had had five
stillbirths.
“She delivered a perfect baby at the end of last year,”
Professor Dahlstrom says.
“The doctors sent me a note saying ‘Well mother and baby,
beautiful placenta’. I went to see the mother. She was very
happy to see me.”
Such results make autopsies very worthwhile.
“If we had not done an autopsy, we would never have
known what was causing the pregnancy losses.”
40_PATHWAY
hold and even, in some cases, bathe the
baby afterwards.
If parents do not want a full autopsy,
an option is a limited autopsy. For
example, if an ultrasound during
pregnancy detected abnormalities in the
heart or kidneys, the parents might
consent to those organs being examined.
An even more acceptable choice to
some parents who refuse an autopsy are
simple, non-invasive investigations such
an external examination and photos, xray and ultrasound of the fetus.
There is also another initiative that
has made autopsies more acceptable to
many parents.
By law, the death of any fetus beyond
20 weeks’ gestation or with a birthweight
greater than or equal to 400gms is
deemed a perinatal death and the birth
and death must be registered and a burial
or cremation performed.
There was a time when a fetus below
that gestational age was disposed of with
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other surgical specimens, but things have
changed.
Dr Susan Arbuckle, head of
Histopathology and Chair of Diagnostic
Services at The Children's Hospital at
Westmead in NSW, says after a lot of
effort, she was successful in getting a
crematorium to agree two years ago to
cremate groups of fetuses. “I had to
obtain rulings on the law and permission
for the cremation of a group of fetuses
together as the law states you can only
cremate one person at a time,” she says.
She then had to find a crematorium –
which ended up being a private
crematorium - that was happy to comply.
“A number of other hospitals in the
last couple of years have now followed
suit using my letters and principles, which
is satisfying,” she says.
Now, many hospitals in most states
offer parents a private burial or cremation,
or a hospital mass cremation after which
the ashes are scattered in a remembrance
garden during a service for their baby.
Many hospitals also hold memorial
services in their chapel once or twice a
year for these parents.
But Dr Arbuckle says the autopsy
service in NSW is up against a lack of
funding from the state government to
enable all autopsies to be done by expert
perinatal pathologists.
“It would take some money – always
an issue – and willingness on their part to
actually put in place places of expertise
and support with structure and transport
systems,” she says.
Hurdles remain
There are other barriers to perinatal
autopsy in Australia. Parents may refuse
an autopsy if there are cultural and
religious taboos, while others may be
deterred by clinicians who don’t talk
positively about autopsies or if the
delicate matter is left to inexperienced
junior doctors.
Some clinicians fear if the autopsy
turns up something, parents may sue.
In rural Australia, the need to transport
the body long distances to the nearest
major city can deter parents who do not
want separation from their baby.
Professor Yee Khong, the RCPA South
Australian state councillor and paediatric
anatomical pathologist at the Women’s
and Children’s Hospital in Adelaide, says
public confidence rightly took a knocking
following the ‘organ retention’ controversy
in the UK in 2000, when several hospitals
were exposed as having retained
children’s organs and body parts following
post-mortem examinations, mostly
without the knowledge of the families of
the deceased children.
“It does give people some
“However, the root cause of the
problem has been the lack of public
information about the benefits of the
autopsy and of the process itself,” he
says.
perhaps there isn’t the same
“The public perception that the
autopsy is an intrusion after death needs
to be replaced by one that emphasises
that it is an investigative and diagnostic
procedure.”
Professor Khong says another barrier is
the fact that, following the organ retention
crisis, some consent forms are now so
cumbersome that clinicians may take the
easy route by not seeking consent, so
autopsies cannot be performed.
Workforce pressure
Workforce issues are also a factor, he
adds. Diagnostic workloads in anatomical
pathology have increased without a
commensurate increase in pathologists,
so surgical pathology and cytology are
often prioritised over the autopsy.
Experts agree that the perinatal
autopsy rates should be higher. In the UK,
the Royal College of Obstetricians and
Gynaecologists and the Royal College of
Pathologists recommend a minimum rate
of 75%, and here in Australia rates of
more than 90% were achieved in the late
1980s and early 1990s.
Most states are making concerted
efforts to increase their perinatal autopsy
rates, and most hospitals have special
teams who provide counselling support to
parents who lose their babies, and clinicopathology meetings to provide feedback
to the clinicians and nurses.
Professor Ellwood runs a perinatal
loss clinic at The Canberra Hospital where
he sees women in the ACT and
surrounding areas of NSW who have lost
babies.
At the King Edward Memorial Hospital
for Women, a midwife coordinates a
perinatal loss clinic where, once a
fortnight, a paediatric perinatal
pathologist, fetal medicine specialist,
neonatologist, paediatrician, chaplain,
midwife, social worker and psychologist
degree of closure.
I think it is different from adult
autopsy, where quite often the
death is expected and so
level of uncertainty”
– Professor David Ellwood
are available to talk to the parents. The
clinic is open to parents throughout the
state and occasionally a telemedicine
conference is held for families in the
country.
Also, the hospital’s perinatal pathology
department routinely takes photos and
hand and foot prints of stillborn babies as
a memento to hand to parents.
In Queensland, pathologists are trying
to get more colleagues with expertise in
perinatal autopsies to help reduce the
turnaround time.
In Victoria, the head of Pathology at
the University of Melbourne, Professor
Paul Monagle, says hospitals are working
with parent support groups to increase
community understanding, while a study
at the Royal Women’s Hospital is also
underway to discover parental views on
perinatal autopsy.
“The aim is not to increase the
numbers per se, but to ensure an
appropriate service is offered to all
families who suffer perinatal loss,”
Professor Monagle says.
In most states, pathologists talk to
clinicians, junior doctors, GPs training in
obstetrics, nurses and midwives about the
benefits of an autopsy.
“I think the most important thing is to
make sure the staff are all singing from
the same song book and that the
counselling for autopsy begins as soon as
possible,” Professor Ellwood says.
“In some cases, it may actually be
before the baby dies if you think that is
inevitable.”
References
1.
Poster presentation, Perinatal Society of
Australia and New Zealand, 11th annual
congress in Melbourne in April 2007
2.
11th Report of the Perinatal & Infant
Mortality Committee of Western Australia
2000-01 (WA Department of Health)
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spotlight on disease
A cereal offence
PATHOLOGY IS VITAL AT EACH STEP TOWARDS A DIAGNOSIS OF COELIAC DISEASE,
AS MATT JOHNSON DISCOVERS.
e are a civilisation built on a tiny
mutated protein. Nearly 7000 years
ago a group of Middle Eastern nomads
discovered a wild grass that, as a result of
an unusual molecular arrangement,
produced a grain so high in energy that it
encouraged them to give up their
wandering lifestyle and settle in one
place.
W
Anthropologists will suggest
everything that followed – buildings, cities,
churches, writing, art – resulted from the
discovery of wheat and the promise it
fulfilled of a regular food supply.
It is ironic, then, that 1% of modern
humans may now be sensitive to the very
thing that inspired this great cultural
expansion. For those suffering from
coeliac disease, gluten – the glycoprotein
present in wheat, and to a lesser extent
rye, barley and oats – is a no-go zone that
can cause highly unpleasant and lifechanging symptoms.
Under a microscope, the apparently
smooth lining of the small intestine is
actually thousands of tiny finger-like
projections, or villi, which protrude into
the gastrointestinal space. The purpose of
these villi is to increase the surface area
of the bowel, increasing its ability to
absorb nutrients and pass them into the
bloodstream.
But expose these villi to gluten and, in
up to 1% of the population, an
inflammatory response will be provoked
that can leave the villi sparse and stunted.
The subsequent reduction in available
surface area can produce a bewildering
range of symptoms felt across nearly
42_PATHWAY
every system in the body. Abdominal pain,
bloating, diarrhoea and weight loss are
classic coeliac disease presentations.
In certain people, gluten causes the
release of cytokines in the intestinal wall.
Part of an immune response, the
cytokines not only damage the tissue but
they also activate other cells to produce
antibodies to gluten and the bowel wall
itself, further sensitising the intestine to
subsequent exposures.
Changing patterns
Coeliac disease was most commonly
diagnosed in babies when they started on
solid foods. But the pattern of the disease
is now changing, with many suffers
presenting later in life with symptoms
related to their inability to absorb
vitamins, minerals and nutrients.
And these symptoms can be easily
confused with other conditions such as
irritable bowel syndrome, lupus, anaemia
or just poor diet, leaving these ‘latent’
coeliacs to be treated for conditions they
don’t have while their doctors work to
slowly unravel the real cause of the
problem.
Equally puzzling are the ‘silent’
coeliacs: sufferers who have virtually no
symptoms.
But here is where pathology comes in.
With highly sensitive and specific
blood tests, combined with laboratory
analysis of biopsy tissue, a diagnosis of
coeliac disease can be confirmed.
Years of medical training meant
anatomical and cytopathologist Dr Peta
Fairweather knew all this in theory, but
she has since experienced the lot of the
‘silent’ coeliac first hand after it became
apparent the disease was in her family.
“I had the blood tests when it was
found my sister had coeliac disease and it
was suggested I should be tested,” says
Dr Fairweather, from Sullivan Nicolaides
Pathology in Queensland.
The results came back strongly
positive despite the lack of any obvious
symptoms.
Dr Fairweather was tested because
research has identified genes commonly
associated with coeliac disease. The
production of the HLA-DQ2 genotype is
found in approximately 90% of coeliac
disease cases, while the HLA-DQ8
genotype accounts for a further 5–10% of
cases.
Unfortunately, the two genotypes are
also common in nearly 30% of the normal
population, so there is speculation
another gene may be responsible for the
10% correlation of coeliac disease
between first-degree relatives.
Blood assays – the first step in
diagnosing coeliac disease – are simple,
relatively inexpensive and extremely
accurate. They usually include tests for
endomysial antibodies, anti-tissue
transglutaminase antibodies, and antigliadin antibodies. Anti-gliadin antibody is
an antibody produced against gluten,
while endomysial and anti-tissue
transglutaminase antibodies are
antibodies produced against the body’s
own tissues as a result of the immune
response to gluten.
>
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For those suffering from coeliac disease, gluten – the
glycoprotein present in wheat, and to a lesser extent rye, barley
and oats – is a no-go zone that can cause highly unpleasant
and life-changing symptoms
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“The tests are sensitive and
specific, an effective and
harmless treatment exists, and
there’s an increased
morbidity/mortality later in life if
the disease is undiagnosed”
PHOTO CREDIT: JODI WEBSTER
– Dr Glen Reeves
The endomysial and anti-tissue
transglutaminase antibody tests are highly
reliable, and an individual with abnormally
elevated levels has a greater than 95%
chance of having coeliac disease. Antigliadin antibodies are less reliable for
The Coeliac Society
Adult coeliacs and parents of coeliac
children have formed coeliac societies
in every state. These societies provide
information on the disease, glutenfree diets, gluten-free ingredients and
where to buy them, cooking and
recipes, gluten-free medicines,
overseas travel and education
material.
The Coeliac Society of Australia
First Floor, 306 Victoria Avenue
Chatswood NSW 2067
(PO Box 703, Chatswood NSW 2057)
Ph:
(02) 9411 4100
Web:
www.coeliac.org.au
Email: info@coeliacsociety.com.au
44_PATHWAY
diagnosis, but can be useful in monitoring
the response to treatment.
Although the tests are highly accurate,
a biopsy of the small bowel is needed to
confirm the diagnosis. This involves a thin
tube being passed down the mouth into
the small intestine, where a sample of
tissue is collected.
“Once the tissue is collected and
processed,” Dr Fairweather explains, “it is
carefully mounted, sectioned and stained
so we see a cross-section of as many
finger-like villous processes as possible.”
The sections are viewed by a
pathologist through a microscope.
“The typical microscopic appearance
of the small bowel of a coeliac patient is
blunt or flat villi with too many
inflammatory cells,” she says.
“In some cases the villi can appear
normal, but there might be too many
inflammatory cells present. If the
pathologist is suspicious, a special test
can be performed on the same piece of
tissue to check for the number of T cells
(the cells that cause damage in coeliac
disease) in the bowel lining.”
In Dr Fairweather’s case, her positive
blood tests did not correspond with her
normal biopsy result.
“The tissue was normal, but my
gastroenterologist wasn’t convinced and
scheduled me for regular reviews,” she
says.
Five years later her biopsy showed the
changes typical of coeliac disease. Yet Dr
Fairweather still had no overt symptoms.
Prevalence increasing
There is no cure for coeliac disease and
the only treatment is to follow a glutenfree diet. Provided the diet is followed, the
villi eventually recover and the symptoms
will subside. But the life-long diet has long
been considered to be complex,
expensive and socially disruptive, which is
why it must be preceded by histological
proof from a biopsy. It is also why some
have felt that ‘silent’ coeliacs – those with
biopsy changes but no symptoms – could
be spared the inconveniences of a glutenfree diet.
But that notion is changing as the
prevalence of coeliac disease and the
long-term effects are becoming more
apparent.
Once thought to affect fewer than one
in every 500 people with Northern
European ancestry, there are now studies
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COELIAC DISEASE FACTS
•
The symptoms of coeliac disease vary widely: some people have few
symptoms, but 43% complain of gastrointestinal symptoms, while 20%
present primarily with ‘tiredness’. Some of the more common symptoms
include tiredness, intermittent diarrhoea, abdominal pain, flatulence,
bloating, weight loss, fatigue, lethargy and anaemia.
•
Children with coeliac disease may also have slow growth, irritability, a
swollen abdomen and delayed development.
•
A gluten-free diet should never be started before an endoscopy or blood
tests, as it will interfere with establishing the correct diagnosis.
•
Research has confirmed that while coeliac disease has a genetic
component, it can also be triggered by various environmental factors,
possibly explaining the late onset of the condition in ‘latent’ coeliacs.
•
Australian doctors also routinely order tests to ensure the IgA deficiency
common in patients with coeliac disease doesn’t distort the results of
the other tests. Blood tests to check for nutritional deficiencies may also
be necessary, with iron, folate, vitamin B12, calcium and vitamin D levels
the most commonly affected.
suggesting one in every 100 Australians
has the condition.1 This is more than 10
times the figure quoted a decade ago,
and it’s now estimated only 10–20% of
coeliac sufferers are diagnosed, despite
others showing symptoms or
complications from the disease.
There has also been increased
awareness about the disease’s
complications, with links to diabetes, liver
disease, bowel cancer, epilepsy and
infertility all being investigated.
To screen or not to screen?
The increased prevalence and impact of
the disease has led some to call for mass
screening.
Dr Glenn Reeves, Senior Staff
Specialist in the Department of
Immunology and Immunopathology at
John Hunter Hospital in NSW, strongly
supports the proposal that children be
routinely screened.
He argues that coeliac disease meets
at least four of the five World Health
Organization criteria for mass screening.
“The tests are sensitive and specific,
an effective and harmless treatment
exists, and there’s an increased
morbidity/mortality later in life if the
disease is undiagnosed,” he says.
However, critics of mass screening
suggest that the social difficulties
imposed by a gluten-free diet are too
serious to be inflicted on those with
positive blood tests with normal biopsy
results, especially while studies suggest
blood tests alone are poor predictors of
whether the disease will ultimately cause
cell changes in the intestine.2
3
But other studies have disproved the
notion that screen-detected,
asymptomatic patients would be poorly
compliant with a gluten-free diet, with
Finnish research finding dietary
compliance comparable with symptomatic
coeliac patients.
The worldwide applicability of these
results has been questioned, since coeliac
disease in Finland is widely recognised
and gluten-free foodstuffs are readily
available.
However, Dr Fairweather has noticed
an enormous change in Australia since
she was diagnosed.
“There is definitely an increased
awareness of gluten intolerance and
coeliac disease amongst general
practitioners and alternative therapists
such as naturopaths,” she says. “The
restaurant industry is generally very
educated now with even fast food
restaurants carrying cards carefully
detailing allergens in their products, and
the range of prepared gluten-free
products now available in supermarkets is
amazing.”
She adds that provided a person with
coeliac disease uses principally fresh,
unprocessed food products, they can
easily maintain a varied and balanced
diet. Rice is naturally gluten free and
gluten-free pasta and bread are widely
available in health food stores and
supermarkets.
While universal screening for coeliac
disease may not be widely supported,
studies4,5 show that an increased
awareness of coeliac disease by GPs will
capture patients who were not previously
accurately diagnosed.
“The prevalence of coeliac disease
among the general population is
becoming more established,” Dr Reeves
says. “But the key is working with doctors
to make them think about coeliac disease
and to test for it even when there are
other legitimate explanations for the
symptoms their patients are presenting
with.
“The tests are just too simple and too
accurate, and the benefits too great for it
to be ignored.”
References
1.
Gastroenterology 2005;128:S57–S67.
2.
J Pediatr Gastroenterol Nutr 2005;41:44–8.
3.
Aliment Pharmacol Ther 2005;22:317–24.
4.
Dig Liver Dis 2005;37:928–33.
5.
Clinical Resource Efficiency Support Team
(CREST). Guidelines for the diagnosis and
management of coeliac disease in adults,
May 2006.
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
PATHWAY_45
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Medicine is Pathology
Pathology is the life blood of medicine, underpinning the diagnosis of all medical conditions.
As a specialist career choice, Pathology offers a wide range of possibilities through its various sub-disciplines.
Some offer direct patient contact and others, such as genetics and forensics have an investigative element.
Many major advances have been made in medical practice as a result of research carried out by pathologists immunisation against infectious diseases, organ transplantation and safe blood transfusion, just to name a few.
Whatever your interest, there is something for you in Anatomical Pathology, Chemical Pathology, Clinical Pathology,
Forensic Pathology, General Pathology, Genetics, Haematology, Immunology or Microbiology.
www.rcpa.edu.au
The Royal College of Pathologists of Australasia
207 Albion Street
Surry Hills NSW 2010
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lP ia t hfWe
s
t
y
l
e
ay lifestyle
travel
48
50
private passions
53
54
travel doc
56
recipe for success
58
dining out
61
the good grape
64
conference calendar 65
rearview
66
postscript
68
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travel
Shanghai
surprise
IT MIGHT BE HARD TO SLOW DOWN IN
BUSTLING SHANGHAI, BUT ANDREA
PLAWUTSKY PUT THE BRAKES ON LONG
ENOUGH TO SAMPLE THE CITY’S OTHER
PHOTO CREDIT: SHUI ON
GREAT ATTRACTION: FOOD.
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PHOTO CREDIT: SHUI ON
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Xin Tian Di - inside and out
hanghai’s re-emergence as a vital and
vibrant global financial capital is
undisputed. What is less well recognised
is its emergence as a major international
culinary icon.
S
Shanghai boasts some of Asia’s
foremost restaurants and entertainment
venues – from the renowned ‘M on the
Bund’ and the sensationally restored Xin
Tian Di district, to the dazzling heights of
the Grand Hyatt’s lounge, set on the 87th
floor, with floor-to-ceiling views
overlooking the Huang Pu River and the
city from the centre of Pudong.
‘M on the Bund’ is a classic Shanghai
treasure. Set next to the well-known
Peace Hotel, on the historic waterfront, it
was opened in January 1999 by Australian
chef, Michelle Garnaut, in what was then
considered a culinary desert.
Housed on the seventh floor of the
Nissin Shipping Building (built in 1921),
M’s roof terrace provides the perfect
vantage point from which to overlook the
surreal Pudong skyline. The view is
equalled, if not surpassed, by the
sophisticated and contemporary dining
experience on offer at M, featuring a
mélange of Middle Eastern and
Mediterranean influenced dishes. M would
be at home in any of the world’s major
dining hot spots.
Within that Pudong skyline, many
major hotel chains have taken their place,
including the Grand Hyatt. The lobby is on
the 55th floor, while the lounge and bar
are on the 87th and 88th floors. It was not
too long ago when 15 or 20 storeys were
considered impressive in China, and
clearly this is not your average hotel.
Those who journey to the top are
rewarded with a breathtaking view of the
Pudong and city centre from a trendy
nightspot, although it’s a very smoky one
– smoking laws in China are yet to catch
up with the West.
History on a plate
The Xin Tian Di district, in the city centre,
offers a quintessential Chinese dining
experience within spectacularly restored
traditional ‘shikumen’ (‘stone gate’)
houses.
Located in a central two-square block
setting and reminiscent of a Zhang Yimou
film set, the three-storey stone-gate
houses evoke images of mid-19th century
tea houses, with ornate lattice woodwork
and dark fixtures contrasted with
contemporary glass and lighting.
Shikumen houses were the architectural
symbols of Shanghai in the 20th century –
as they seem to be again today.
Literally translated as ‘New Heaven
Earth’, Xin Tian Di has further historic
importance. In 1921, meetings held inside
one of the shikumen were chaired by the
original Chairman, Mao Zedong, leading
to the formation of the Communist Party.
Now a wide range of culinary delights
are enjoyed by affluent locals and tourists
alike within the Xin Tian Di district at
places such as the opulent Va Bene
Shanghai, Ye Shanghai, Cuban club and
restaurant Che and my favourite, the
sensational Tou Ming Si Kao (TMSK).
The decor is uniquely individual and
outright sensual – and in some cases,
highly extravagant — throughout the
various restaurants. The washbasins in
TMSK are painted ornate porcelain lotus
flowers in a dimly lit, fully mirrored room.
Equally memorable at TMSK is the
hauntingly seductive traditional Chinese
music played discreetly behind a sheer
screen on the upper-floor dining room.
PATHWAY_49
>
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Shanghai shikumen
he Shanghai ‘shikumen’ – literally ‘stone gate’ houses –
were once the housing style of most of the city’s residents.
T
The Taiping uprising in the mid-19th century forced a large
number of residents from the city and neighbouring Jiangsu
and Zhejiang provinces into Shanghai’s ‘foreign concessions’.
To meet the housing needs of the rapidly expanding
population, shikumen sprang up quickly across the
concessions. Most were built by foreign companies, and
married Eastern and Western architectural styles.
Typically built along narrow alleys, they featured a stone
gate framing a black wooden front door, and were based
around a central courtyard. The terraced houses were smaller
than their rural counterparts, but the traditional courtyards still
provided an inner sanctum from the hustle and bustle outside,
and a space for gardening.
In recent years, these historic relics were deteriorating due
to lack of maintenance. Xin Tian Di’s shikumen were recently
restored by the Hong Kong developers, Shui On. The
reconstruction was based on old design drawings and much
effort was invested in preserving the historical architectural
features of the buildings, such as the old bricks and tiles.
The developer’s motto, “Yesterday meets tomorrow in
Shanghai today”, truly sums up the district, whose renovation
efforts have been recognised with a number of awards,
including the national Innovation China 2001 – Architecture
Award, AIA Hong Kong Citation 2002, and the 2003 Award for
Excellence from the US-based Urban Land Institute.
50_PATHWAY
PHOTO CREDIT: SHUI ON
The beautifully restored buildings in Xin Tian Di now house
some of the city’s finest restaurants and retail outlets and
feature ‘state of the art’ facilities.
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PHOTO CREDIT: WORLDNOMADS.COM
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The Bund as seen from ‘M on the Bund’
The Xin Tian Di district is a
study in ‘fusion’ cuisine, with
the majority of restaurants
The Xin Tian Di district is a study in
‘fusion’ cuisine, with the majority of
restaurants featuring a blend of Eastern
and Western techniques and tastes.
There’s the understatedly elegant T8,
fabulous old residences which have been
restored to glory.
Set in the Ruijin Guest House
compound, Face features a bar, lounge
and two restaurants within a gorgeous
featuring a blend of Eastern
offering European fare with Asian accents,
and Western techniques and
whose trademark dishes include tataki of
tastes
caramelised salmon with green mango
houses the highly popular Face Bar on
and longans, slow-cooked lamb and
the first floor, Hazara’s Indian and Lan Na
Sichuan high pie.
Thai restaurants on the second, and Face
sesame-crusted tuna with daikon radish,
Le Platane, featuring renowned chef
English-style manor. The richly decorated
meeting place for locals and tourists alike
Lounge on the third. The upper-floor
Justin Quek, who is widely regarded as
Lounge is a quieter, calmer experience
one of Singapore’s most important French
than the busy Face Bar downstairs, and
chefs, marries French and Asian cuisine
specialises in older whiskies, fine
with stunning success. Quek also runs
brandies, Champagnes and wine.
Villa du Lac, which has a commanding
view of Taipingqiao Lake and Park,
It is well worth the effort to venture
serving Huaiyang cuisine in a decidedly
out of Shanghai’s major hotels and into its
French atmosphere.
world-class restaurants. Whether you’re
The other restaurant districts worth
on the Bund, in Xin Tian Di or the old
considering are located in the former
foreign concession districts, a world of
French and English Concessions, within
delights awaits.
PATHWAY_51
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PHOTO CREDIT: WORLDNOMADS.COM
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Traditional Shanghai fare
hanghai’s cuisine offers enormous variety, but few traditional dishes of its own. Not generally considered one of the eight
celebrated styles of Chinese cooking (Beijing, Guangdong, Sichuan, Jiangsu, Zhejiang, Hunan, Anhui and Fujian), Shanghai’s
cuisine, known locally as ‘hu cai’, is essentially a refinement of those from the adjacent areas, including Jiangsu and Zhejiang
provinces.
S
Shanghai fare often features highly flavoured sauces and a more liberal use of
sugar than is normally associated with Chinese cooking, hence many tangy sweet and
sour combinations.
Key dishes to look out for include:
beggars chicken – a seasoned chicken,
wrapped in lotus leaves and baked in a
dough pastry
drunken chicken – chicken, fish, eel,
shrimp or crab soaked in Shaoxing wine
overnight, and served cold. Not for the
faint of heart, one alternative is ‘drunken
shrimp’, which are traditionally placed
live into the boiling wine at the table
red cooking – a slow-cooking
technique frequently used with beef,
featuring highly fragrant star anise, black
cardamom, five-spice powder and soy
sauce
ba bao fan (‘eight precious pudding’) –
a traditional Shanghainese banquet dish,
made with eight different types of fruit to
represent eight precious stones
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smelly or stinky tofu (chou dofu) –
fermented tofu, usually fried to a golden
colour
thousand year eggs – preserved eggs,
usually prepared through traditional
methods for 100 days, and served when
they reach a dark green or black
translucent stage
guo tie (fried jiaozi, or Chinese
dumplings) – not to be missed, these
dumplings are generally filled with pork,
but are also available with a range of
fillings.
Shanghainese cuisine frequently starts
with cold appetisers, such as wineflavoured jellyfish, braised sliced beef or
marinated vegetables, and unlike many
Chinese cuisines ends with dessert –
small delicate sweet and savoury pastries.
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private passions
Some like it hot
DR NIRMALA PATHMANATHAN IS JUST AS EXACTING IN THE KITCHEN AS SHE IS IN THE
PHOTO CREDIT: IAN BARNES
PATHOLOGY LAB, AS KATRINA LOBLEY DISCOVERS.
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PHOTO CREDIT: IAN BARNES
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“I think pathologists are, by nature, very
control-freakish people. They have to have
everything just so”
B
y day, Dr Nirmala Pathmanathan is a
busy anatomical pathologist who
specialises in breast cancer at Sydney’s
Westmead Hospital. But at night and on
weekends, she swaps her lab coat for an
apron and conjures up the most
extraordinary feasts for family and friends.
she cooks at home are re-creations of
restaurant meals she and her husband
have enjoyed over the years. She also has
a repertoire of favourite Sri Lankan dishes,
including a fish curry from the country’s
north-eastern provinces where her mother
grew up.
Lucky them. The 37-year-old’s culinary
passion runs so deep that she insists on
doing most of the work herself, including
shopping for fresh ingredients for her
exotic recipes. Couldn’t her husband, IT
specialist Shankar Moorthy, run to the
shops for her?
“I make everything from scratch,” she
says. “You have to make tamarind water
and the curry powder used in it is made
from raw ingredients like cumin seeds that
are heated up and ground down by hand,
so it takes a little bit of time.”
“Never, never – I couldn’t possibly
trust him,” laughs Dr Pathmanathan.
“If it’s something very basic like a loaf
of bread or milk, yes, but if it’s anything
else I wouldn’t trust anyone. I have to go
and select the ingredients myself.”
She is also renowned for her take on a
Sri Lankan dish – fried coconut-milk lamb.
“You use a lot of spices and you put
layers of coconut milk on it and you
slowly, slowly cook it until it’s completely
dry.
“You have to be very, very patient so
you don’t burn it. It takes a couple of
hours. No-one in my family can replicate it
– even my mum gets me to make it. I
make it a few times a month because I
get lots of requests.”
While she frequently caters for
elaborate dinner parties at home – a
typical menu might include three or four
different entrees, four vegetable mains
and two meat-based mains as well as
dessert – she recently took on the huge
task of catering for her sister’s
engagement party.
“We had 120 people at my mum’s
place and I cooked for the whole lot,” Dr
Pathmanathan says.
“I had assistants to help me chop up
stuff, but basically I did all the cooking. I
can multi-task – that’s another thing you
learn from being a pathologist, because
you have to do 50 things at once as a
pathologist and you can multi-task with
your cooking as well. But it was a pretty
complex task – I won’t be doing it again
quickly.”
Dr Pathmanathan says she is very
focused on hygiene in the kitchen,
probably due to her pathology training.
Dr Pathmanathan credits her mother
with fostering her love of cooking.
Her hygiene rules also extend to
cleaning up afterwards. Her husband is
allowed to load the dishwasher but Dr
Pathmanathan insists on doing the rest
herself, “otherwise it’s not done properly”.
once”
“I’ve always enjoyed cooking from a
very early age – I’d always be in the
kitchen with my mum and I’d always want
to take over.”
“My husband always says he’s
cleaned the kitchen, but it’s not ‘Nirmala
clean’ so basically I have to do it again,”
she says.
So online grocery shopping is not an
option?
She’s hoping to pass on her passion
for cooking to her own children, who at
age four and two already help to prepare
meals.
“I think pathologists are, by nature,
very control-freakish people. They have to
have everything just so.”
“I can multi-task – that’s
another thing you learn from
being a pathologist, because
you have to do 50 things at
“No way,” she says firmly. “I have to
see it, touch it, smell it. I’m very handson. There’s a good greengrocer in
Chatswood and I only go there. I always
know the ingredients are fresh and they
have good-quality stuff.”
“I want them to have the same sort of
interest in food and be conscious of what
they eat and always want to eat fresh and
healthy things.”
Dr Pathmanathan has such a
discerning palate that many of the dishes
“I have a huge family here in Sydney.
We’re a very, very close-knit family and
we see each other every weekend for
some function or some gathering. I’m
always asked to cook for these – and I do
it with pleasure.”
Sarita, 4, and Nikesh, 2, are willing helpers
in Dr Pathmanathan’s kitchen
She also cooks frequently for her
extended family.
All this hard work, she admits, takes
up a lot of her time.
“With my research and other work, I
often have to get up at 3 or 4 o’clock in
the morning to prepare a lecture or write
up a paper,” she says.
“I do that very frequently. It is tiring –
you wish the days were longer so you
could fit everything in.”
However, she never regrets time spent
cooking.
“It’s lovely to see people enjoy your
food. I find that very gratifying.”
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travel doc
DARWIN’S PLAYGROUND
DR STEPHEN ADELSTEIN GOT UP CLOSE AND PERSONAL WITH SOME
AMAZING ANIMALS DURING HIS TRIP TO THE GALAPAGOS ISLANDS.
Marine iguana,
isla santa cruz, galapagos islands
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t’s one thing to admire photographs of
the incredible wildlife of the Galapagos
Islands, but it’s something altogether
different to be tripping over them in their
natural environment.
I
I suppose I expected this wildlife
sanctuary to be more like a game reserve,
where tourists admire the animals, but
from a respectable distance.
How wrong I was.
Just an arm’s reach away were sea
lions, ancient tortoises, sharks, flamingos
and penguins. And what really amazed me
was how unfazed these creatures were at
encountering humans.
While we respected their space and
did not touch them, it almost seemed like
they wouldn’t have minded if we had. They
have never been threatened and have not
learned to fear us, unlike their cousins in
more brutal parts of the world.
Travelling to the Galapagos Islands
wasn’t a short trip – a 14-hour flight to
Santiago, and another couple of flights to
the island of Baltra, the gateway to the
Galapagos National Park. But it satisfied
my long-held fascination with Darwin and
his theory of evolution.
When you’re there, you really can see
this theory at work for yourself.
Each island is its own unique
environment and vegetation ranges from
tropical forest to barren rock. And the
animals have adapted in response.
The finches, for example, have evolved
in different ways and it was fascinating to
see how the shape and size of their beaks
varied depending on which island they
inhabited.
On arriving in Baltra, we boarded
dinghies called pangas to reach our 16berth boat, which was extremely
comfortable, with showers and air-con in
each room. We soon learned to appreciate
these creature comforts at the end of each
exciting but exhausting day.
“On Santa Cruz Island, we met Lonesome George, a tortoise
believed to be about a hundred years old and who steadfastly
refuses to reproduce. While he might simply be dismissed as
cantankerous and picky, there’s a theory behind his disinterest”
We managed to visit seven islands
(there are 13 main islands and a host of
smaller ones), and each day’s itinerary was
packed with activities. We did plenty of
snorkelling and the naturalist guides
travelling with us were a mine of
information. Each night we debriefed with
them about what we had seen and
discussed what lay ahead for tomorrow.
really have picked George out of a line-up
but I did notice that different species of
tortoise appeared to have differently
shaped shells.
At the Charles Darwin Research
Centre, on Santa Cruz Island, we met
Lonesome George, a tortoise believed to
be about a hundred years old and who
steadfastly refuses to reproduce. While he
might simply be dismissed as
cantankerous and picky, there’s a theory
behind his disinterest: it’s believed he
might be a separate species to the other
tortoises on the island. And while there
could be some long-lost mate swimming
around in a distant part of the world, I
have to say I’m not totally convinced.
Everyone on the boat agreed the
Galapagos Islands were a great way to
end our holiday. The tours were well-timed
– I never felt I was part of a swarm of
tourists descending on the unfortunate
animals.
So what does a tortoise of a hundred
years look like? Well I don’t think I could
For me, the week-long trip came at the
end of several weeks in South America,
visiting places such as Argentina, Peru’s
ancient Inca ruins at Machu Picchu, and
Lake Titicaca.
I appreciated that things were well
regulated so you didn’t lose that sense of
idyllic isolation.
And of course, this can only benefit the
spectacular wildlife too.
Dr Stephen Adelstein is an immunopathologist and
head of the Department of Clinical Immunology at
Sydney’s Royal Prince Alfred Hospital.
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recipe for success
LEADING BRISBANE CHEF PHILIP JOHNSON PROVES DINING OUT NEEDN’T BE A CULINARY MINEFIELD
FOR FOOD ALLERGY SUFFERERS. BRONWYN MCNULTY FINDS OUT MORE.
hilip Johnson believes cooking good
food is all about caring – and the loyal
patrons of his award-winning Brisbane
bistro, e’cco, would happily agree.
P
But the chef’s caring is not just about
ensuring his customers get a great meal:
for some of them, dining out is a matter of
life and death.
So Johnson provides specially
marked menus, ensuring any patron with
a serious food allergy (such as to eggs or
nuts) can relax and enjoy their meal, safe
in the knowledge that it won’t be their
last supper.
The consideration doesn’t end there.
It’s not just people with serious allergies
who appreciate the discreet pointers.
Vegetarians and diners with an intolerance
(or simple aversion) to wheat, dairy and
garlic can avoid these ingredients too.
Surely such attention to detail must
reveal a chef personally familiar with the
challenges and frustrations associated
with a food allergy or intolerance?
Surprisingly, no.
“It started a year or two ago,” 48-yearold Johnson says. “We were just getting a
lot of people giving us a card saying
‘coeliac disease’ or some other food
allergy on it. We don’t set out to create a
balanced dietary menu. We write a normal
menu, and then look at what’s suitable for
what sort of diet. Usually something falls
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into each category, or we can take a
sauce out, or change it, and so on.
girl said ‘ag-lio?’, and I thought, I’m not
going to put up with that.”
“So now, if someone says ‘what can
you do for me?’, we can give them a menu
that basically says it’s vegan, vegetarian,
has nuts in it, or dairy or wheat…”
Because he knew he’d be cooking
Mediterranean-style food, Johnson
wanted something Italian. Flicking through
an Italian dictionary he found “e’cco”,
which means “here I am”, “there I am”,
“here is” or “there is”.
Johnson’s acclaimed restaurant of 12
years received the Remy Martin
Cognac/Australian Gourmet Traveller
Restaurant of the Year award in 1997 and
he still cooks there two or three nights a
week.
Much of the rest of his time is devoted
to consultancies (formerly to Air New
Zealand, now to Aromas Noosa,
Consolidated Properties and Domain
Resorts), demonstrations, cooking
classes, guest appearances and writing
cookbooks. His fifth cookbook,
Decadence (Murdoch Books), is due out
on Mother’s Day next year.
Johnson and his wife Shirley opened
e’cco in a refurbished tea warehouse on
the edge of Brisbane’s CBD in 1995 after
a two-year stint in England, during which
time Johnson worked in London at Antony
Worrall Thompson’s bistro dell’Ugo.
And the English meaning of the word
fitted well with the cavernous old
warehouse housing his new restaurant.
More than 10 years on, e’cco is still
getting rave reviews praising Johnson’s
simple, generous and unpretentious food.
Simple starter
The second of three boys and a girl,
Johnson started cooking as a child in
Christchurch, New Zealand, helping in the
kitchen when his mum wasn’t well.
“She had an ongoing illness and I had
a grandmother who was a pretty good
cook,” Johnson says. “I started off making
things like pavlova or self-saucing
puddings.”
The restaurant was very nearly named
Aglio (pronounced A-lio), until the girl
registering the name stumbled over its
pronunciation.
After leaving school he became an
apprentice chef at a chain of New Zealand
pubs. Then a move to Australia saw him
working in Sydney, Perth and Brisbane.
And although he enjoyed his job, Johnson
says in those days he was lacking the
passion he now credits with his success.
“Aglio means garlic in Italian,” Johnson
says. “But when I went to register it, the
“It was pretty much just a job to me
back then,” he confesses – until a trip to
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“We don’t set out to create a balanced dietary menu.
We write a normal menu, and then look at what’s
PHOTO CREDIT: JAMES ROBERTSON
suitable for what sort of diet”
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PHOTO CREDIT: JAMES ROBERTSON
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e’cco’s roast pumpkin, Persian fetta
rocket salad, with pinenuts removed
Here are some of Philip Johnson’s tips
for food allergy sufferers who want to
England in 1985 ignited a newfound
fascination with creating good food.
“I worked in a London restaurant
called Menage à Trois, which specialised
in starters and desserts. On my first day I
saw 15 different types of mushrooms and
20 types of lettuce. In all that time
working in Australia I had only worked
with field and button mushrooms and
iceberg and cos lettuces.”
Suddenly Johnson couldn’t get
enough experience in the kitchen. When
he wasn’t working shifts at Menage à
Trois, he hung out at Le Gavroche to pick
up tips from the famous Roux brothers.
Frenchmen Albert and Michel Roux
ran the Mayfair restaurant, and Gordon
Ramsay and Marco Pierre White, among
others, learned their trade there.
It was this steep learning curve that
inspired Johnson and his new English
bride Shirley to open their own restaurant
when they returned to Australia. The pair
first bought Le Bronx, in Brisbane’s New
Farm, in 1988. Seven years later they
opened e’cco.
Today Johnson still sees Le Bronx
diners at e’cco. So what, apart from
caring, is the secret to his success?
Johnson raves about his staff.
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“A lot of the guys who work for me are
really passionate about what they do. It’s
not a job to them – they are very driven
people. It’s really nice to see that sort of
drive in the kitchen.”
The produce gets a good rap too:
“Here, it’s pretty much ‘what you see is
what you get’… it’s a matter of using
good oil, good vinegar… we’re not silly in
our obsession to use the best. It’s a
combination of quality and what we can
afford.”
Undoubtedly, the 1997 Remy Martin
Cognac/Australian Gourmet Traveller
award has helped: “That just gave us a
profile you couldn’t buy,” he says. “But it
was up to us to maintain the quality.”
Whenever he travels, Johnson eats
out. “It’s the only way to keep abreast of
things. It also gives you a benchmark of
where you sit in the state of things.”
Work commitments require that
Johnson travels often, but he also makes
personal trips to far-flung kitchens in a bid
to pick up new techniques and styles.
And while fantastic things often happen in
commercial kitchens in cities bigger than
Brisbane or Sydney, Johnson reckons it’s
here in Australia that diners get the best
bang for their bistro buck.
dine out.
•
When you are making your booking,
make the restaurant aware of your
particular food intolerance. If you
tell them ahead of time, in the vast
majority of cases it will work out
fine.
•
Don’t just say, “I’m a coeliac, what
can you do for me?”. Many chefs or
waiters may not understand what
that means, and may offer you
something inappropriate.
•
Look at the menu and, using that as
a framework, ask if certain
ingredients can be omitted from
specific dishes.
“I think, for what people pay, the
quality of produce and cooking they get in
the top places in Australia is really high,
and $35 is not expensive for a main
course. In England you would be paying
£35 [about $82]. There are a lot of really
inventive people in this country.”
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diningout
Clean sweep
HAVING A FOOD ALLERGY OR INTOLERANCE NEEDN’T MEAN AN END TO FINE DINING
HERE ARE JUST A FEW RESTAURANTS THAT WILL LAVISH YOU WITH CHOICE.
The Peasants Feast
The Peasants Feast Organic Restaurant owner, Sydney clinical
immunopathologist Dr Robert Warlow, believes that “What you
put in your mouth determines whether you stay healthy or
become ill and how long you live.”
And putting something in your mouth at The Peasants Feast is
not a hard ask.
Housed in an intimate, rustic, quasi-Moroccan setting on the
bustling Newtown restaurant strip, its European-flavoured menu
caters to any food requirements, from organic, vegetarian,
meat, poultry and fish to vegan and gluten-free. Most allergies
can be catered for with 24 hours notice.
It was with some initial trepidation that we scanned the menu –
but that quickly gave way to delight when we saw the range of
vegetarian, vegan and gluten-free fare on offer.
From an ‘embarrassment of choices’, we chose the duck, chive
and ginger crepe ($15) and Turkish dips ($12) as starters to
share.
The duck was an interesting combination of flavours, with
tender meat ensconced in a smooth crepe. The dips included
beetroot, tzatziki and hummus.
For mains, we selected the syrian chicken ($26), hot pot beef
stifado ($27) and the Tunisian-style vegan spinach parcel ($19).
The Syrian chicken was surprisingly spicy – a hearty winter
meal with a good blend of flavours including lemon and cumin.
The meat was very tender in the dishes we tried, as Dr Warlow
only permits slow roasting of the meats on the premises to
ensure their nutritional value and integrity are retained.
The beef hot pot was just that – exceptionally hot – when it
arrived at our table. Upon cooling, we found the sauce a
melange of cinnamon and red wine flavours, covered with
country-style mashed potatoes.
Surprisingly, neither of the meat dishes were accompanied by
vegetables – something we had not anticipated in such a
‘health-focused’ restaurant.
The generously sized vegan spinach parcel had a deliciously
nutty flavour, and sat atop a smooth chick pea purée.
We were unable to pass up sampling the enticingly described
dessert menu, particularly when we learned they were all
created without using sugar.
Dr Warlow has introduced the use of xylitol – a natural
sweetener derived from a Canadian tree bark – which he
believes is toxic in the large amounts consumed by most
people in Western society. A diabetic substitute, xylitol has a
glycaemic index of only seven.
Following much debate, we selected the dark chocolate tart
with chantilly cream ($12) and the apple, date and orange
crumble with ice cream ($12). Another option for our
consideration was organic cheese.
We were intrigued to learn that the dark chocolate tart was
created with no fats, and with a base of cocoa, which would
explain the incredibly smooth texture and true bittersweet taste.
The crumble was divine, with a strong hint of orange.
Overall, we were very impressed with the genuinely healthy
meals on offer. Dr Warlow sees his kitchen as a laboratory and
is an advocate of preventive health – eating organic, healthy
dishes using medically safe cooking methods – because after
all, “you truly are what you eat”.
–Andrea Plawutsky
The Peasants Feast
121a King Street, Newtown, Sydney
Ph: (02) 9516 5998
Web: www.peasantsfeast.com.au
Open for dinner Tues–Sat, Sunday brunch 9am–1pm
BYO
About $120 for two, plus drinks
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diningout
Estia
They don’t chuck the crockery into the fireplace, which may not
endear Estia to more traditional Greek diners, but everything
else about the place is vibrantly Greek.
It is also prominent among the Adelaide restaurants that are
more sympathetic to those with dietary constraints, perhaps
made easier by the very nature of Greek cuisine.
Adelaide seems to be well provided with restaurants that take
special care to provide coeliacs, vegetarians and vegans – as
well as those with certain food allergies – with suitable and
interesting menus.
Many designate dishes that are GF (gluten-free), and in Estia’s
case, the restaurant has produced a dedicated GF menu which,
to be truthful, is very similar to the main menu but with some of
the choices removed.
When Estia was opened by the Mavridis family 15 years ago,
many patrons hailed it as the best Greek food in Adelaide.
Despite increased competition, many still do, and with chef
Arthur Lotsos in charge of the stoves for most of that period,
Estia has built a reputation for reliable, good-quality cooking.
Located on a prominent corner with big fold-back doors leading
to Henley Square, just an oyster-shell’s throw from the beach, it
has ample outdoor seating in summer and an indoor open fire in
winter. Although popular with a local clientele, it also draws
customers from suburbs nearer the city centre, about a 15minute drive away.
The menu focus is on mezedakia dishes and platters, which
means there’s something new appearing on the table
throughout the meal. It’s sociable and fun, and Estia is a place
that’s not afraid of noisy diners – in fact it can get quite rowdy
as the night wears on.
Coeliacs will have no difficulty with most of the mezedakia
choices, which range from feta and fresh tomato baked in olive
oil and oregano, or octopus pickled or marinated in various
ways, to home-made chevapchichi sausages in cumin-spiced
tomato salsa, various dishes based on eggplant, or chargrilled
fish or meat dishes such as quail marinated in olive oil, garlic
and fresh rosemary.
Desserts will prove more of a problem as most use pastry in
some form or another, so it might have to be just their very
good loukoumi (Turkish delight).
Estia’s main wine list is very good, but the Mavridis family
clearly love their wine, so the separate vintage wine list is even
better.
- Nigel Hopkins
Estia
255 Seaview Road, Henley Beach Square, Adelaide
Ph: (08) 8353 2875
Web: www.estia.com.au
Open for lunch and dinner Tue–Sun
Licensed & BYO
Mezedakia from $8.50 to $18.50
About $80 for two, plus drinks
Bookings recommended Fri–Sat
B.coz Organic Dining
B.coz is not just Melbourne’s only certified organic fine dining
restaurant, it is also one of a handful of eateries in the city that
offers specific vegetarian, lactose-free and gluten-free menus.
And we’re not just talking about one or two dishes.
B.coz’s special menus offer a full range of entrees, main
courses and desserts. Here’s a sample from the lactose-free
menu: an entree of wok-tossed Queensland bug meat, salad
leaves, macadamias, Spanish onion, chilli and organic
passionfruit, followed by chargrilled biodynamic Gippsland eye
fillet, potato and salad leaves with a Worcestershire jus. Order a
warm caramelised pineapple and quince tartlet with sultana
nutmeg ice cream to finish, and you’ll understand why B.coz
attracts a broad range of customers, not just those interested in
organic food or with specific allergies.
Chef and owner Rod Barbey’s cooking style could be lazily
characterised as modern Australian but there’s a bit more to it
than that. Barbey uses plenty of ingredients that would be at
home in a health food store (think quinoa, brown rice, sunflower
seeds), and while some dishes wouldn’t be out of place in a
wholefood restaurant, there’s an inventiveness with ingredients,
combined with good cooking and beautiful presentation, that
deserves the title ‘fine dining’.
The wine list is about the size of a small telephone book,
offering a range of Australian reds and whites as well as wines
from New Zealand, California, France, Spain and Italy – and it
would be very easy to get carried away with the choice
available and do some real damage to your credit card (I
glimpsed a bottle of 1985 Chateau Lafite Rothschild at $1050
before hurriedly turning the page).
Fortunately there’s a good choice of wines by the glass – and
there’s also the option of choosing the degustation menu which
comes with specific recommendations for what to drink, if you
find it hard to make decisions.
Located in upmarket Hawthorn, B.coz looks very swish. A wall
of mirrors visually widens the narrow dining space, and plush
chocolate carpet, tables laid with heavy silver cutlery, thick
white table linen and stylish blond wood chairs create a sedate
but welcoming environment.
Service can be a little slow on busy nights, but the staff are
keen to make sure you have a pleasant evening and will keep
you topped up with wine, water and bread if you have to wait.
– Justine Costigan
B.coz Organic Dining
403 Riversdale Road, Hawthorn East, Vic
Ph: (03) 9882 7889
Web: www.bcoz.com.au
Open for lunch Wed–Fri, dinner Wed–Sat
About $200 for two, including drinks
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Sensations
Sensations
When you walk into Sensations gourmet cafe in Perth you feel
you’ve entered a welcoming country kitchen, complete with
pantry brimming with good home-cooked food.
The rustic touch comes from the wooden floorboards, tables and
chairs, colourful ceramics on the walls, and shelves lined with
pretty crockery and stacked with produce.
But the eye-catcher is the large display cabinet stocked with
frittatas, salads, curries and quiches and an enticing array of
cakes, pastries, biscuits and puddings – all with yellow or white
flags.
The number of yellow flags must gladden the hearts of people
with coeliac disease, for yellow is a colour code for gluten-free.
Eating out can be a tough call for coeliac sufferers. While they
may sit down to what appears to be an innocuous steak and
salad, they may be in trouble if the salad is dressed with a
balsamic vinaigrette, as balsamic vinegar can be coloured with
wheat malt.
So a cafe like Sensations that caters so widely to people with
coeliac disease (about 70% of meals and 50% of the cakes are
gluten-free) must be quite a find.
Owner-chef Suzanne Evans says she was inspired to venture into
gluten-free fare seven years ago when a regular customer was
diagnosed with coeliac disease and was distraught she could no
longer indulge in her favourite chocolate cake. Suzanne took up
the challenge and the result is a kitchen with a working area
dedicated to gluten-free cooking.
Even non-coeliacs can be grateful to that chocolate cake
customer. On the night we dined there, we finished our meal with
the gluten-free chocolate date almond meringue cake ($6.50) and
it was a delight – very moist and full of chunky almonds.
Having started with warm gluten-free bread, we bypassed the
grazing plate of marinated seafood, warm wild onion cheese
pâté, olives and bagel and went for the mains.
The aromatic vegetarian hotpot with spiced chicken ($23) was a
delicious combination of pumpkin, chickpeas and chicken in a
creamy coconut milk on brown rice. This Gold Plate awardwinning cafe uses only free-range chicken and eggs.
The gluten-free risotto with prawns, green peas, mint and
parmesan cheese ($24) was a simple but tasty dish. Those who
fear that gluten-free food must be bland can rest assured that’s
far from the truth.
The meals are not large and lack garnish, but the upside is that
they leave space for one of those desserts.
– Cathy Saunders
Sensations en Ardross
43a Ardross St, Applecross, Perth
Ph: (08) 9364 8806
Open for breakfast and lunch 7.30am–5.30pm 7 days, dinner Wed–Fri
BYO, corkage $3
About $65 for two, plus drinks
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the good grape
Great white pointers
PACK AWAY THE WINTER REDS
Vivacity
AND PULL OUT SOME ZIPPY
Some wines come across as a little
WHITES FOR A GREAT START
TO SPRING, WRITES BEN
CANAIDER .
reshness, purity, vivacity and life are
the elements vital to wines consumed
come spring. These are wines that can
kick-start your interest in drinking again,
following on from a waning winter of big
reds and heavily worked chardonnays.
F
So with spring upon us, put away the
stodgy wines and turn to lighter and
brighter beverages – and here are the
qualities to look for in them.
Freshness
‘dumb’. Freshness or purity might not be
A bargain Clare Valley riesling full of the
lacking, but an essential core of vivacious
variety’s lemon, lime, minerals and delicate
acidity can be missing. Acid makes for
wines with line and length, with a long
after-taste, and with real refreshment. Acid
also helps such wine cut through fish oil,
Pink, crown-sealed, semi-fizzy moscato
Wines from cooler climates with
weighing in at a mere 5.5% alcohol by
greater levels of natural acidity do this
volume is the ideal choice for a vernal
better – or at least more effortlessly.
equinox celebratory breakfast (23
Australian winemakers for the greater part
September this year, by the way). Black
have to add acid to their wines, which
and Gordo Muscat grapes were picked at
isn’t the most evil thing in the world, but is
night, chilled, crushed and given six hours
still an addition…
skin contact. Fermented until some
Of course the combined effect of
‘alive’. Good aromatics leading to vibrant
Certain Australian regions excel at
this sort of expression, like the Clare
Valley. Here, mineral characters and
citrus come together in wonderfully
invigorating rieslings.
64_PATHWAY
shellfish, or the last oysters of the season.
and prosciutto, for example.
Some early-release 2007 wines, such
as riesling and rosé, for instance, can be
enjoyed now, but given that so many of
these wines are now sealed under
screwcap, the wines inside can often
seem a little bit tight, or premature.
I heard a winemaker once say that he
loved riesling the most, as it was such a
pure wine. He meant it was simple –
beautifully simple. Riesling is picked,
crushed, fermented, settled and bottled.
There’s not a lot of winemaker artefact
going on. What is in the grape is what you
get in the wine: a pure expression of the
vineyard and the vine.
burn here, too. Serve it now with some
INNOCENT BYSTANDER
MOSCATO 2007, $13.50/375 ML
these three qualities – freshness, purity
Purity
floral edges. There is uplifting acidity to
olive oil and the fats one finds in salami
The recent vintage, or the one just before
that – so 2007 and 2006.
Clever winemakers anticipate such
youthful awkwardness and compensate
for it when finishing the wines; but do be
aware of the fact that many 2007 wines
will – at this moment – be a little bit
undercooked. Just like newborn babies,
they come good pretty quickly, however.
LEASINGHAM MAGNUS
RIESLING 2006, $14
natural carbonation occurred, the wine
was chill filtered and cold bottled. Fruity,
grapey, but balanced.
and vivacity – make for a wine that is
but not-too-loud fruit flavours suit the
burgeoning spring.
Here are a half a dozen wines –
whites, rosés and a semi-sparkler – that
suit the job perfectly.
PRIMO ESTATE
LA BIONDINA 2007, $17
DE BORTOLI YARA VALLEY PINOT
NOIR ROSÉ 2006, $22
When rosé looks like this one looks – a
pale, bronze, ‘partridge eye’ sort of hue –
you know you are getting a rosé for
grown-ups. There’s nothing sweet or juicy
about it: dry, savoury strawberry flavours
roll out in a subtle way. Serve it with
absolutely anything when out of doors.
lively and yet not ungenerous white that
CHARLES MELTON ROSÉ
OF VIRGINIA 2007, $20
says so much about clever winemaking.
This rosé is more of a crowd pleaser. It’s
Picked a little early, its colombard and
got fresh, berried, generous fruit flavours,
sauvignon blanc grapes hang on to their
and yet there is good balance and it
zippy acidity, and that drives a very
finishes clean, without the cloying
succulent and refreshing mouthful of wine.
elements so often found in garishly
Serve heavily chilled and tackle any hot
coloured rosés.
This wine has set trends. It is a fresh,
and spicy food you care for.
TAHBILK MARSANNE 2006, $17
Such fresh spring wines are as close
to a wine diet detox as you can get, so
chill them lightly, sit outside in the sun,
If you don’t know of this wine, do yourself
and as you push a few pieces of home-
a favour… Marsanne is a Rhône white
made antipasto around the plate, be
varietal that has flourished in central
thankful for quiet luncheons at home and
Victoria, at Tahbilk, for yonks. It has citric,
a glass or two of revivifying wine.
honeysuckle smells and tastes, with clean
In winter we thought we had seen the
and wonderfully determined acidity. The
best of our times; in spring we see
2006 is an outstanding recent example.
everything anew.
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2007
Conference Calendar
SEPTEMBER 2007
OCTOBER 2007
14
10
Australasian Dermatopathology
Society Meeting 2007
14-16 September
Perth
www.sapmea.asn.au/derm07
5th Annual Pathology Refresher
Course
10-12 October
Budapest
www.ryalsmeet.com/meetings/ISSP101007/
main.htm
15
The Greek Conference KOS 2007
15-21 September
Dodekanese, Greece
www.greekconference.com.au
23
14
HSANZ Annual Scientific Meeting
14-17 October
Brisbane
www.fcconventions.com.au/HAA2007
International Clinical Trials Symposium
23-26 September
Sydney
www.clinicaltraials2007.com
24
AACB Annual Scientific Conference
24-27 September
Melbourne
17
Medical Technology and Innovation
2007
17-18 October
Sydney
www.miaa.org.au
19
www.aacb.asn.au
27
XXth Scientific Meeting - Australian
Society for Colposcopy and Cervical
Pathology
27-30 September
Gold Coast
Enhancing Pacific Partnerships for
Health
19-21 October
Guam
www.asccp.com.au
NOVEMBER 2007
2
Short Course in Forensic Pathology
2-4 November
Hobart
evep@rcpa.edu.au
MARCH 2008
14
Pathology Update
14-16 March
Sydney
www.rcpa.edu.au/pathologyupdate
OCTOBER 2008
6
19th International Symposium on the
Forensic Sciences
6-9 October
Melbourne
www.anzfss2008.org.au
MARCH 2009
13
XXV WASPaLM and Pathology Update
13-15 March 2009
Sydney
www.rcpa.edu.au/pathologyupdate
Pathology Update 2009
in conjunction with XXV WASPaLM
XXV World Congress
of Pathology and Laboratory Medicine
13 - 15 March 2009
Sydney Convention and Exhibition Centre
- Darling Harbour, Sydney, Australia
hosted in association;
Conference Secretariat: Ms Eve Propper • email. evep@rcpa.edu.au • www.rcpa.edu.au
PATHWAY_65
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rearview
SCOURGE
OF THE
HIGH SEAS
THE CURE FOR SCURVY WAS FOUND, LOST AND FOUND AGAIN, WITH HISTORICALLY
SIGNIFICANT RESULTS, WRITES DR GEORGE BIRO .
hile the term ‘scurvy’ might conjure
W
was prone to spoilage, often inedible, and
lacked vitamin C.
creaking tall ships, this isn’t a disease that
Folk cures included purging, bleeding,
drinking vinegar or even sulphuric acid.
up images of poorly fed sailors on
has been completely relegated to the
history books.
Nowadays, food faddists, heavy drinkers
and elderly men living alone are at special
risk.
Why?
Unlike most animals, we humans
cannot synthesise ascorbic acid (vitamin
C). We must get it from fresh fruit,
potatoes, tomatoes and green vegetables,
and so a diet without these essential
ingredients can give rise to this nasty
disease.
There’s no escaping it: the word ‘scurvy’
has bad vibes.
The adjective scurvy is defined as ‘mean’
or ‘contemptible’. And the noun, which
refers to the disease, is just as unsavoury.
Think swollen bleeding gums, loose teeth,
halitosis, weakness, fever, ulcers of the
legs and feet, gangrene, agonising pains
and a lingering death.
At sea, scurvy used to kill more men than
all other illnesses combined with piracy
and shipwrecks.
On one of Columbus’s voyages, legend
has it, some of his scurvied men wanted to
be dropped off to die on a nearby island.
Here they ate fresh fruit and when
Columbus later passed by, he was amazed
to see the now-healthy men waving.
He named the island ‘Curacao’, meaning
cure. But over the next three centuries,
scurvy still claimed over two million lives.
The sailors’ diet (salted beef, pork, fish,
dried peas, hardtack biscuits, beer or rum)
66_PATHWAY
But during the 18th century, three men –
though they may never have met – finally
cracked the riddle.
Born in Edinburgh in 1716, James Lind
started as a lowly surgeon’s apprentice,
but rose to be ship’s surgeon on HMS
Salisbury. He decided to take the more
scientific view.
In 1747, he set up a trial for which he
chose sailors with advanced scurvy: they
all had “putrid gums, the spots and
lassitude with weakness of their knees”.
For 14 days, Lind separated the treatment
group of 12 into six pairs and added
various foods and medicines to the
common diet of each pair. The controls
ate the usual diet.
The first treatment pair drank a quart of
cider per day; the next drank an acidic
elixir; the third got lots of vinegar; the
fourth just plain sea water; the fifth a
medicinal paste (garlic, mustard seed,
radish root, balsam of Peru and gum
myrrh).
The lucky last pair each got two oranges
and one lemon daily until the supply ran
out on day seven. After only six days
these men were nearly cured and looked
after the others.
While most authorities offered dogma or
speculation, Lind offered evidence. But it
took him six years to publish his findings,
and even then, the naval brass did not
change sailors’ diets.
Two more men were to take up the
challenge of scurvy: James Cook
(1728–1779) and then Gilbert Blane
(1749–1834).
In 1768, Cook sailed to the South Pacific
to discover new lands, to record the
transit of Venus at Tahiti and to test
several possible anti-scorbutics to cure
scurvy. On the Endeavour, he landed
wherever he could for fresh vegetables
and water. He also got the ship’s
naturalists (including Joseph Banks) to
identify edible plants on foreign coasts.
On board, he had fermented barley malt
(called ‘wort of malt’), sauerkraut,
mustard, distilled water, a little
concentrated extract of lemon and orange
juice, and marmalade of carrots. In a
voyage of almost three years, Cook had
no deaths from scurvy – a remarkable feat
at the time. But the Admiralty was not
interested.
Within two years, Cook set forth again to
search the South Seas and map Polynesia
and New Zealand. By the time he
returned, he had spent nearly seven
consecutive years at sea without losing a
single sailor to scurvy. He was the toast of
Europe. But even so, no-one knew just
which of his measures was effective.
A further chapter in navy history saw both
France and Spain help the Americans in
the War of American Independence in a
bid to oppose British expansion.
The Royal Navy had burgeoned from
about 100 ships to over 400, and to man
them, it co-opted untrained men in poor
health.
Disease claimed one-seventh of them, but
the Admiralty still favoured wort of malt
over lemons and oranges.
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“Think swollen bleeding gums, loose teeth, halitosis, weakness, fever, ulcers of the legs and feet,
gangrene, agonising pains and a lingering death”
Our third hero, young Gilbert Blane, rose
to become personal physician to Admiral
Sir George Rodney. Blane published at his
own expense a pamphlet based on Lind’s
and Cook’s ideas: ‘A Short Account of the
Most Effectual Means of Preserving the
Health of Seamen’.
Soon the Navy was mobilising again to
By the end of the war in 1783, the death
rate in the ships under Blane’s medical
supervision had plummeted from one in
seven, to one in 20.
kept the fleet healthy.
However, once the war ended, the
Admiralty lost interest in scurvy.
fleet of 33 warships off Cape Trafalgar on
Near the end of the 18th century, though,
Blane finally achieved his goal: the daily
issue of fresh lemon juice on all Royal
Navy ships.
himself nearly died of scurvy way back in
counter the rise of Napoleon.
For years on end, it kept the various fleets
of the French and their Spanish allies
blockaded in their ports. How could the
British stay at sea so long? Their transport
ships kept topping up the lemon juice that
On 21 October 1805, 27 ships,
commanded by Horatio Nelson on the
Victory, closed on the French and Spanish
the coast of Spain. Here Nelson, having
1780, fell to the bullet of a sniper. But
Napoleon’s great plan to invade Britain
was foiled and according to author
Stephen R. Bown, this was in no small
part due to vitamin C.
“At Trafalgar the British tore the heart out
of Napoleon’s navy, and the defeat of
scurvy had played a significant role in
their supreme victory,” he writes.1
Blane’s breakthrough on scurvy came 48
years after Lind’s experiment on the
Salisbury – a tragically long gap between
discovery and implementation.
It was only in the early 20th century that
vitamin C was isolated and its link with
scurvy confirmed.
1. Scurvy: How a Surgeon, a Mariner and a
Gentleman Solved the Greatest Medical
Mystery of the Age of Sail. Camberwell,
Victoria: Viking, 2003. ISBN 70041203.
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postscript
Noah’s lark
DR PAM RACHOOTIN HAS UNCOVERED A GREAT
SECRET: THE PREVIOUSLY UNKNOWN CONNECTION
BETWEEN NOAH AND PATHOLOGY.
oah was in a predicament, bobbing
aimlessly around in the Flood, taking
on water, and running out of food for man
and beast. Along with his family and the
animals, he had squeezed onboard
medical specialists of all types. These had
come two by two, in breeding pairs.
N
Desperate for some guidance, Noah
began consulting each specialist group in
turn. The first group he asked was the
critical care mob, but they were completely
useless. Yes, they could drain the hull, but
only if Noah could provide them with a
proper pigtail catheter. This plan was
promptly squealed out of order by the
passengers of porcine persuasion, who
figured that they had the most to lose.
The cardiologists were approached
next. Ever keen to intervene, and
concerned about fluid overload, they
prescribed a global dose of diuretics.
The psychiatrists, questioning the true
extent of the Flood, diagnosed the
problem as being merely bipolar, and
suggested that Noah should set sail for
the Equator.
So, Noah next approached the
gastroenterologists with his revised
course for the Ark. Alas, they could only
assist if Noah allowed them some oldfashioned entrails to examine. But
wouldn’t sacrificing the animals diminish
the appeal of the whole eco tour? So
what to do?
Noah knew better than to ask for a
neurological opinion, with its inevitable
knee-jerk reaction.
So he became more and more
nervous. He wondered whether his
mission had any hope of succeeding,
given the difficult circumstances. He
approached the ship’s public health
physicians, and asked them whether they
could work out the odds of survival. They
were unable to help him because by then
they were completely broken down by age
and sex.
68_PATHWAY
The despondent Noah
finally consulted the two GPs
on board. Perhaps their
breadth of knowledge would
save the precious Ark. Alas,
Mr GP was only interested in
examining the moles on
board. Ms GP admitted that
she could not provide any
relevant service herself. Due
to government policy she
was restricted to writing referrals to allied
health professionals. Perhaps instead of
navigation advice Noah could make due
with a mental health care plan?
Suddenly, onto the deck stepped Ms
and Mr Pathologist.
“Don’t despair Captain Noah. Why not
arrange a test?”
And that is how the very first
pathology test was born, known forever
after as the LFT or Land-Flood Test. A
dove is sent forth and returns exhausted –
land flooded, negative test result.
Question: could this be a
possible lab artefact?
Repeat test: dove sent forth, returns with
olive leaf – flood has subsided; positive
test result. High sensitivity and
specificity; cheap, non-invasive
screening test; doves survive to multiply
and despoil all the Earth’s windscreens
and piazzas; new government invents the
Medical Benefits Scheme; political
prejudice persists through the ages;
pathologists declared heroes.
Of course much of this rich historical
detail ended up on the cutting-room floor
in the translation of the Bible from
Aramaic to Hebrew. What we are left with
today, as the so-called Old Testament, is
just an executive summary. But modern
science has helped biblical scholars to fill
in a lot of the blanks. For example, we
now know that Noah nearly barred the
pathologists, who were on stand-by, from
joining the expedition. It came down to a
choice between them and a pair of giant
pelicans. Due to a computer glitch leading
to a botched reservation, this species
missed the boat, a fate that could just as
easily have befallen pathology if the cruise
director’s decision had gone the other
way. In recognition of the martyrdom of
the oversized pelicans, we retain to this
day the medical term bulk bill.
In Noah’s defence, early pathologists
did not have the status and prestige that
they now enjoy among their professional
colleagues. Whereas other medical
specialists had the good sense to poke
and prod in order to diagnose disease
and make prognoses, early pathologists
utilised mysterious technology, including a
musical instrument consisting of taut
strings on a curved wooden frame. This
crude implement, which was plucked,
became derisively known as a
pathological lyre, a concept that today still
connotes the disgustingly unreliable.
Over time, plucking gave way
increasingly to cutting as the preferred
technique, and prognostic accuracy was
observed to improve. Pathology
demonstrated irrefutably its value to society.
But of course the woes of pathology
did not end with the Flood.
There came a new generation that
knew not the pathologist heroes, so that
the prophets declared: “Let us deal wisely
with the pathologists living amongst us,
lest they fail to be fruitful and multiply and
replenish the Earth’s laboratories”.
a
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Page 1
PathWay Spring 2007 - Issue #13
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