PathWay #10 - Cover
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Page 2
PathWay Summer 2006 - Issue #10
Summer 2006
Issue #10
TASMANIA
TASMANIA
A HEALTHY PLACE TO BE
A HEALTHY PLACE TO BE
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PathWay #10 - Cover
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PathWay #10 - Text
14/11/06
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ADVISORY BOARD
Contents
Dr Debra Graves (Chairman)
Chief Executive, RCPA
Dr Bev Rowbotham
Vice President, RCPA
Associate Professor Jane Dahlstrom
Representative, Committee of Deans of
Australian Medical Schools
Dr Tamsin Waterhouse
Deputy CEO, RCPA
PATHWAY
Summer 2006
Issue #10
Wayne Tregaskis
S2i Communications
PUBLISHER
Wayne Tregaskis
EXECUTIVE EDITOR
Dr Debra Graves
COVER STORY
EDITOR
Justine Costigan
A Healthy Place To Be
ART DIRECTOR
Jodi Webster
8
Tasmania's pathologists enjoy a varied workload, high standards
and a lifestyle to dream of.
ADVERTISING SALES DIRECTOR
Bronwyn Sartori
HEALTH + MEDICINE
PUBLISHING CO-ORDINATOR
Andrea Plawutsky
Sexually Transmitted Diseases
12
How pathologists are dealing with rising rates of infection.
PathWay is published quarterly for the Royal College
of Pathologists of Australasia (ABN 52 000 173 231)
by S2i Communications, Suite 1201, Level 12,
Profile: Dr Chris Lawrence
16
Tasmania’s top Forensic Pathologist
4 O’Connell St Sydney 2000
Tel (02) 9235 2555 Fax (02) 9235 2455
Microbiology
PrintPOST approved PP60630100114
Finding the bugs that harm us
Passing the test
20
25
Why GPs need to use pathology testing wisely
Breast cancer
29
The Royal College of Pathologists of Australasia
Tel: (02) 8356 5858
Pathology on the front line of diagnosis
Email: rcpa@rcpa.edu.au
Stem Cell Research in Singapore: at the cutting edge
34
Email: wayne@s2i.com.au
Pathology Update 2007 – why you need to be there
38
PathWay
Jumping Jack Ant – new allergy research
40
S2i Communications Pty Ltd
Tel: (02) 9235 2555
Email: pathway@rcpa.edu.au
http://pathway.rcpa.edu.au
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
www.rcpa.edu.au
Cover
Dr David Challis, Dr Lawrie Bott, Professor James Vickers and
Professor Konrad Muller
PHOTO: TONY MCKENDRICK
PATHWAY_1
PathWay #10 - Text
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Page 2
INTRODUCING
VIRTUAL MICROSCOPE
TECHNOLOGY INTO THE PRACTICE OF PATHOLOGY
Virtual Microscopy
For RCPA Quality
Assurance Programs in
2005-2006
For continuing
education of pathology
personnel
For university teaching
material
The Royal College of Pathologists of Australasia and the RCPA
Quality Assurance Programs, with support from the Australian
Department of Health and Ageing, is introducing Virtual
Microscope technology into the practice of pathology. Aperio's
ScanScope姞 system represents the ultimate in high speed digital
slide creation, management and analysis for pathology.
Virtual microscopy is the practice of converting entire glass
microscope slides to high resolution digital slides. Digitalised
images of an entire slide can be remotely viewed on computer
monitors and distributed to other pathologists on DVD.
Digital slides have many applications in clinical, research and
educational arenas. Virtual Microscope technology offers seamless
true colour digital slides, integrated conferencing and annotation
sharing, archival and retrieval systems, education and quality
assurance, secondary consultation and more within the one
software package.
RCPA Quality Assurance Programs are able to offer the complete
digital slide system for pathology utilising the ScanScope姞 system.
For more information, visit http://rcpaqap.com.au
or contact: apqap@rcpaqap.com.au
PathWay #10 - Text
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Page 3
REGULAR FEATURES
FINDING THE BUGS
THAT HARM US
Letter from RCPA CEO,
Dr Debra Graves
4
PathWay News
6
GP Column
24
Dr Linda Calabresi debates the merits
of psychological testing for would-be
medical students
PATHWAY LIFESTYLE:
THE TASSIE ISSUE
Take out a subscription to PathWay
65
Conference Calendar
67
Backpage
68
Uncommon Complaints
Some diseases are just too strange to
be believed…
PAGE 20
ARTS + CULTURE
The Ferrari Safari
44
Behind the Scenes with The Tasmanian Symphony Orchestra
47
Days of Wonder
50
Tasmania spectacular arts festival
What’s on In Tasmania: Events Listing
66
TRAVEL
ANTS
- ALLERGY RESEARCH
PAGE 40
On The Water
53
Fishing, Sailing and Swimming in Tasmania
Cradle Mountain
57
Robert Eckstein shares memories of one of Tasmania’s most beautiful
National Parks
FOOD + WINE
Chef Profile
58
Tetsuya Wakuda
Tasmanian Wines
61
Ben Canadier explores Australia's most exciting wine region
RESTAURANT REVIEWS
PathWay makes the rounds at some of Australia's
most interesting and well-loved restaurants
62
PATHWAY_3
PathWay #10 - Text
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Welcome
to this special Tasmanian Edition of PathWay
I
t seems to be particularly appropriate to
be writing this editorial looking over
Constitution Dock in Hobart on a beautiful
spring day.
We also explore what some of our
pathologists and people associated with
the pathology profession do in their free
time in Tasmania.
We would like to give a very special
thanks to Tourism Tasmania for their
support of this edition of PathWay. We
thought there were wonderful similarities
between the College’s promotion of
Pathology as that very important part of
medicine not too many people are aware
of and Tourism Tasmania’s wish to
promote Tasmania as wonderful holiday
destination that not enough people know
about.
Tasmania has so much to offer as a
place to live and a travel destination – we
hope that the edition highlights this for
you.
I have just spent the last two days at
the Australian Association of Clinical
Biochemists/ Australian Institute of
Medical Sciences (AACB/AIMS)
Conference in Hobart, and have taken the
opportunity to meet with some of our
Pathologists at a meeting at Royal Hobart
Hospital.
Over the last few months, Tasmania
has been a particular focus for Pathology.
In addition to the AACB/AIMS conference,
Hobart has also hosted the Haematology
Society of Australia and New Zealand’s
(HSANZ) annual conference.
PathWay itself is a major plank in our
overall communications platform to
educate people about Pathology. This is a
special Tasmanian edition of PathWay.
In this edition we talk to pathologists
who work and live in this beautiful state
about the great career opportunities
available here from a diagnostic pathology
perspective but also a research point of
view.
4_PATHWAY
In our Lifestyle section, restaurants
such as Marque IV in Hobart are
highlighted, as is an amazing lineup for
the “Ten Days on the Island” extravaganza
being held in March next year.
A special mention must be given to
Breast Cancer Awareness month. This
edition’s article “Breast Cancer: Unlocking
the Secrets” details some great statistics
in relation to improved breast cancer
survival rates in Australia, however some
alarming ones also. The incidence of
breast cancer is now one in every eight
women, which translates into some
13,000 new diagnoses per year. When
one considers that Anatomical
Pathologists are the doctors who actually
diagnose these cancers, the crisis in
Pathology workforce and its implications
for the future for maintaining improved
survival rates has to be questioned.
Workforce crisis issues are also at the
forefront of concerns in New Zealand.
Concerns over the tendering
arrangements for Pathology and the
subsequent uncertainty for many
Pathologists in the country, with a
potential flow-on of worsening the
shortage, is highlighted in the news pages
of this edition.
Exciting new research opportunities
occurring in relation to Stem Cell
Research in Singapore is also discussed
in “Stem cell central”. This is an issue that
is very topical at present – we hope the
article provides some interesting
perspectives.
Finally it is on a sad note that I must
inform our readers that our editor for
PathWay, Justine Costigan, is leaving us
after 10 fantastic editions. On behalf of
the College and our publishers, S2i
Communications, I would like to sincerely
thank her for all her hard work and
creativity in producing PathWay for the
last two and a half years. I am sure you
will all join with me in thanking Justine for
her sterling efforts and wish her all the
best in the future.
On a positive note I would like to
announce that the College has been very
fortunate in securing Kellie Bisset, former
Editor of Medical Observer, as the new
Editor of PathWay from edition 11. We
look forward to working with Kellie in the
new year.
And on that note, I hope you enjoy
this special Tasmanian edition of
PathWay… and with the holiday season
rapidly approaching, I’m sure many of you
may get an opportunity to visit the real
thing – Tasmania itself.
Dr Debra Graves
CEO, RCPA
PathWay #10 - Text
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At Symbion Pathology we recognise
that our primary responsibility is to
the patients, medical practitioners and
communities we serve. Remaining
at the forefront of laboratory testing,
Symbion Pathology constantly strives
to innovate and improve accuracy and
efficiency within pathology practice.
With a national network of
distinguished pathology providers,
we remain committed to delivering a
service based on superior quality and
customer satisfaction.
A National Network of
Pathology Providers
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PathWay #10 - Text
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Page 6
Lymphoma Wizard May Increase Cancer
Survival Rates
project of the Australian Blood
Cancer Registry Working Group, the
Lymphoma Wizard, is a new medical
software program that may help to
increase the survival rates of people with
a lymphoma diagnosis, and help
researchers refine new treatments.
A
Developed by a consortium, including
software company Medical-Objects, the
new software will collect extensive data
about cancer patients. Until now, statebased cancer organisations have only
collected information about new cancer
cases and how many people have died
from the disease.
“The Blood Cancer Registry does not
know how many patients have been
diagnosed with a certain stage of the
disease, what sort of lymphoma they have
and the outcome,” said The Leukemia
Foundation general manager and
Lymphoma Wizard project leader Dr Anna
Williamson. “Researchers and patients are
frustrated as they don't know how
effective a current treatment is for their
type of cancer. They have to rely on data
from clinical trials of new treatments and
drugs, but there's no data to show
whether the treatment has achieved the
same success as the trial with the general
population.”
Leukemia and lymphoma is the fifth
most common cancer in Australia, with
about 4000 new patients diagnosed each
year. Currently, just over 50 per cent of
patients survive five years after a
lymphoma diagnosis. “Clinical trial data
show that survival rates have plenty of
scope to increase if clinicians follow the
best practice models,” she said.
The Wizard will help speed the
communication, reporting and collection
of data between oncologists and the
pathology service. The Wizard software
will also let patients access their
Study Shows Alzheimer’s
Present Without Impairment
ccording to a new study published in
the June 27, 2006, issue of
Neurology, the scientific journal of the
American Academy of Neurology,
Alzheimer's pathology can appear in the
brains of older men and women who
show no signs of dementia or cognitive
impairment.
A
The study evaluated 134 older men
and women who showed no impairment
at the time of their death. After they died,
their brains were examined at autopsy for
evidence of Alzheimer’s pathology.
At autopsy, more than a third of the
participants had brain tissue lesions
associated with Alzheimer's disease.
6_PATHWAY
“The results provide evidence in
support of the idea that some type of
neural reserve can allow a large number of
older persons to tolerate a significant
amount of Alzheimer’s pathology without
manifesting obvious dementia,” said study
author David A. Bennett, MD, of the Rush
Alzheimer’s Disease Center in Chicago.
Scores on the Mini Mental State
Examination, a mental status screening
electronic health reports, including
pathology reports, by way of a secure
online site, thereby allowing them to be
more involved in decision-making.
A four month trial of the software is
due to begin in Queensland before the
end of the year.
Broccoli
– the new weapon
against cancer
chemical in vegetables such as
broccoli, cauliflower and cabbage,
called I3C, can boost DNA repair in cells
and may stop them becoming cancerous,
new research published in the British
Journal of Cancer reports.
A
Although a link has already been
found between eating these foods and a
reduced cancer risk, this research shows
how that might happen. The repair
proteins, regulated by genes called
BRCA1 and BRCA2, are important for
preventing damaged genetic information
being passed on to the next generation
of cells. If people have a faulty BRCA
gene they are at a higher risk of
developing some forms of cancer,
including breast, ovarian and prostate
cancer. Low amounts of the BRCA
proteins are seen in cancer cells, so the
scientists propose higher levels might
prevent cancer developing.
Researchers suggest the ability of I3C
and genistein to boost the amount of
BRCA proteins could explain their
protective effects.
disease.
“It is now clear that the function of
crucial cancer genes can be influenced
by compounds in the things we eat,” said
Professor Eliot Rosen, from Georgetown
University, who led the research team.
(source www.brightsurf.com)
(source http://news.bbc.co.uk)
test of cognitive functions, were nearly
identical for participants with and without
a pathologic diagnosis of Alzheimer's
PathWay #10 - Text
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Concern About Changes
To Pathology Services In NZ
he RCPA has recently raised concerns
over the changes and restructuring of
pathology services in New Zealand, and
the impact this may have on the quality of
pathology services and the pathology
workforce in the years to come.
T
New Zealand District Health Boards
have supported the tendering out of
pathology services as if they were
“commodities” such as laundry or food
services, rather than the vital medical service
that they are. The District Health Boards
have stated that the tendering processes are
to ensure that they get value for money for
the Pathology services they buy.
However, the District Health Boards
have not undertaken adequate
consultation with the Pathology
profession or other medical experts to
define what the value or quality of the
services should be under these new
arrangements.
CEO of the RCPA, Dr Debra Graves
says that the recent restructure of
Congratulations
pathology services is of paramount
concern.
NZ Award Recipients
“We believe the restructure has the
potential to have an immediate and long
term adverse effect on the foundations of
pathology, which is the cornerstone of
medicine.”
Congratulations are extended to Dr
“Pathology is a medical speciality that
takes some 12 - 13 years to obtain the
knowledge and the skills required to
practice effectively and safely. To equate it
with laundry or food services is a major
concern, to say the least.”
“The tendering process has caused
massive upheaval amongst pathologists
and scientists trying to provide high
quality services. There is an international
shortage of these professionals and this
uncertainty has led many to contemplate
leaving New Zealand for countries where
their professional services will be valued”.
New Zealand Pathologists have called
for the immediate cessation of further
tendering arrangements for the delivery of
Debra Graves and Dr Ian Beer who both
received awards at the NZ Annual
Scientific Meeting. Dr Graves’ Medal was
awarded for her distinguished service to
the advancement of pathology in New
Zealand. Dr Beers’ Medal was awarded
for his contribution to IANZ, College
activities and to pathology practice in
the Bay of Plenty region.
Pathology services in New Zealand; the
establishment of a high level National
Pathology Advisory Council to advise the
Minister and DHBs on pathology issues;
and The National Pathology Advisory
Council to work with government to
develop a National Framework for
Pathology Service delivery by Christmas
2006.
Ccentric
Healthcare Executive Search
Helping Further Your Career
in Pathology
Visit us at www.ccentricgroup.com
Phone: 1300 723 559
PATHWAY_7
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COVER STORY
A healthy place to be
THE STANDARDS ARE HIGH, THE WORK VARIED AND THE LIFESTYLE
HUGELY APPEALING – TASMANIA HAS MUCH TO OFFER ASPIRING
AND QUALIFIED PATHOLOGISTS, WRITES TONY JAMES.
PHOTOTGRAPHER: TONY MCKENDRICK
Enjoying all that Tasmania has to offer: Pathologists Dr David Challis,
Dr Lawrie Bott, Professor James Vickers and Professor Konrad Muller
8_PATHWAY
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Pathologists who spoke to PathWay were unanimous in their views: they
work in a collaborative and enthusiastic medical community, have
exposure to the full range of pathology for a population of half a million,
maintain high professional standards, contribute to excellent
undergraduate and postgraduate training programs and live in affordable
cities untroubled by traffic, pollution and other “big city” hazards.
nly one in every 40 Australians is
lucky enough to live in Tasmania.
Australia’s “south island” tends to be
dwarfed by the mainland, but the state
offers a valuable opportunity to balance
satisfying professional activity with a
quality lifestyle.
O
Pathologists who spoke to PathWay
were unanimous in their views: they work
in a collaborative and enthusiastic medical
community, have exposure to the full
range of pathology for a population of half
a million, maintain high professional
standards, contribute to excellent
undergraduate and postgraduate training
programs and live in affordable cities
untroubled by traffic, pollution and other
“big city” hazards.
Dr David Challis is a staff specialist in
anatomical pathology at the Royal Hobart
Hospital. He grew up in Tasmania,
completed his medical degree and
pathology training in Melbourne and then
returned to Hobart.
“The place where people grow up has
a big influence on where they decide to
live and work,” Dr Challis says. “It’s a
reality that we tend to ignore in efforts to
recruit doctors to areas of need. We need
to look more closely at how people make
decisions about their careers.”
“The Royal” is the tertiary referral
hospital for the state and manages a full
range of clinical problems. Staff
pathologists are also located at
Launceston General Hospital in the north,
and a single pathologist is based in the
North West Regional Hospital, which has
campuses in Burnie and Latrobe. But
there are significant difficulties in
recruiting specialists to smaller centres.
“The supply of pathologists has been
declining for many years,” Dr Challis says.
“Small country centres were the first to
lose them, and now regional centres are
struggling as well.”
Dr Challis’ unit has developed an
enviable reputation for training registrars
in anatomical pathology. Trainees have a
very high pass rate, and applications for
the three positions exceed the available
vacancies. “In fact we export people – our
undergraduate medical students become
enthusiastic about pathology, and once
they graduate they move on to training
positions in other parts of Australia,” he
says.
The range of pathology processed by
the hospital is an advantage, as is access
to autopsies, which can be difficult for
trainees in other states. Trainees assist
with 60 or 70 non-coronial autopsies a
year at the hospital, and they can also
observe 300 to 350 coronial autopsies a
year.
“In the bigger cities, coronial
autopsies are performed in specialist
forensic medicine institutes, which tend to
be stand-alone facilities isolated from
hospitals,” Dr Challis says.
Hospital specialists benefit from
working in a large hospital in a smaller
community. “There is a very good working
relationship between private and public
pathology services,” he says. “The good
working relationship also applies to other
disciplines within the hospital – for
example, colleagues in haematology,
cytogenetics and molecular genetics are
just down the corridor rather than in
another building.”
Like pathologists everywhere, Dr
Challis can refer problems to specialists in
other cities when needed. High-quality
digitised images make the process easier,
allowing collaboration around the world as
well as around the country. “Technology
has helped to reduce any sense of
isolation that we might have felt in the
past,” he says.
The local media and opposition
politicians regularly criticise access to
public health services in Tasmania but
rarely the quality or commitment of their
staff. Funding of health is a political issue
in every Australian state, and Tasmania is
little different. Dr Challis says there are
some significant infrastructure
deficiencies, particularly ageing and
inadequate public hospital buildings, but
the Government recently announced plans
to investigate total replacement of the
existing facilities.
Remuneration for hospital specialists
lagged that of mainland colleagues for
many years, but that has been at least
partly rectified in the past few years.
Dr Eileen Long has just passed her
final exams to qualify as an anatomical
pathologist. Born in Tasmania, she
obtained her undergraduate medical
PATHWAY_9
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Page 10
“The training program here is excellent,” says Dr Long. “Pathology
services are of a very high standard. Involvement in case meetings
with other specialties meant I could keep in touch with other
aspects of medicine, and I was actively involved in clinical decisions
across a range of disciplines.”
Dr David Challis, staff specialist in anatomical
pathology at the Royal Hobart Hospital
degree from the University of Tasmania,
has never considered herself a “big city”
person and feels Hobart provides an ideal
combination of lifestyle and professional
potential.
and private services, reflecting the
excellent co-operation between
pathologists in this small city. “There’s a
strong sense of camaraderie and shared
experience,” she says.
Dr Long decided to train in pathology
following some time working in Britain
after her internship.
Dr Lawrie Bott, a general pathologist,
is a new recruit to the Tasmanian
pathology community. As CEO of Sonic
Healthcare in the state, he will manage
three private practices - Hobart Pathology,
Launceston Pathology and North West
Pathology in Burnie. Previously working in
Wollongong, NSW, Dr Bott says he was
attracted by the lifestyle of Tasmania and
the challenge of managing a network of
practices serving a diverse state.
“I always found pathology exciting as
a student,” she says. “It’s about
understanding disease processes at the
most basic level and how disease affects
humans.”
Back in Australia and with a wide
range of options available, she
successfully applied for a registrar
position at Royal Hobart Hospital and
completed her first four years under the
supervision of Dr Challis.
“The training program here is
excellent,” she says. “Pathology services
are of a very high standard. Involvement
in case meetings with other specialties
meant I could keep in touch with other
aspects of medicine, and I was actively
involved in clinical decisions across a
range of disciplines. Pathology
departments in larger cities are tending to
develop subspecialties, which can limit
the experience of trainees aiming for wide
experience.”
Dr Long is finishing her fifth and final
year of training in the laboratories of
Hobart Pathology, a private service. “This
has given me the chance to work more
with skin pathology and cytology, which
tends to be limited in hospital-based
practice,” she says.
Next year she will move to half-time
consultant positions in both the public
10_PATHWAY
“The objective is to provide a high
quality service across diverse and
sometimes isolated areas, at an affordable
cost to the community,” he says. “All
centres in the state need pathology
services with a quick turn-around,
including emergency services. People
think Tasmania is small in terms of
distance, but travel times to more isolated
towns can be quite long. There is also a
mix of city and rural environments, and all
need substantial pathology services.”
Dr Bott says the public and private
pathology services in Tasmania can fulfil
99 per cent of the state’s needs, and the
standard is as high as anywhere in
Australia – and indeed the world. “We
have an excellent, committed team with a
high degree of expertise, many of them
trained in Tasmania,” he says. “When you
combine this with quality lifestyle at an
affordable cost, it’s a very attractive
proposition.”
Professor James Vickers, head of the discipline
of pathology at the University of Tasmania
Tasmania also performs well in
medical research. Its smaller size results
in some limits on expensive infrastructure,
but organisations such as the University
of Tasmania’s Menzies Research Institute
have shown that a focus on achievable
results can lead to internationally
significant outcomes.
Founded in 1988 as the Menzies
Centre for Population Health Research, it
quickly made its mark by defining the
links between sleeping position and the
risk of sudden infant death syndrome. The
findings, since replicated and widely
disseminated to parents and health
professionals around the world, have
saved countless lives. In Tasmania, the
reduction in cot deaths has been so
dramatic that there are now too few to
allow further epidemiological research.
PathWay #10 - Text
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Page 11
Dr Lawrie Bott, a general pathologist,
CEO of Sonic Healthcare for Tasmania
In Tasmania, the reduction in cot deaths has been so
dramatic that there are now too few to allow further
epidemiological research.
Other successes include
demonstrating the importance of vitamin
D to bone development in children and
adults, linking early-life sun exposure with
susceptibility to multiple sclerosis (a
disease that is more prevalent in higher
latitudes) and showing links between
infant bedding and asthma.
The epidemiological work is based on
Tasmanian attributes including a stable
and well-defined population, excellent
genealogical records and generous cooperation from the community.
The institute is growing rapidly, with
increased funding, closer links with
university and hospital-based biomedical
researchers and a new building. Major
research groups in the University of
Tasmania’s medical school will be
amalgamated into the institute’s structure.
The Menzies Institute is a World
Health Organisation Collaborating Centre
for Research and Training in NonCommunicable Diseases, such as
cardiovascular disease and cancer. Since
1990 it has had WHO responsibility for
assisting countries in the region to
implement programs for the prevention
and control of cardiovascular disease.
and expertise we have here,” Professor
Vickers says.
“Amalgamation of research under the
umbrella of the Menzies Institute will
strengthen that trend. The days of
individual researchers working in isolation
are long gone. Although we lack some
expensive pieces of equipment and we
receive little State Government funding
compared to the rest of Australia, it’s a
misconception that Tasmania is too small
for research.”
University-based research programs
have developed special expertise in
respiratory medicine, cancer immunology
and neurosciences. Professor Vickers’
own interest is in neurodegenerative
diseases and acquired brain injury. The
cross-discipline NeuroRepair group
combines the talents of pathologists, cell
biologists and biochemists to study the
cellular basis of degeneration and
regeneration in the nervous system.
“In Alzheimer’s disease we are looking
at the earliest pathology in nerve cells,”
Professor Vickers says. “This is a time
when there is some prospect for
intervention to stop or delay the
degenerative process. We are working
with cell culture models to follow changes
in the cytoskeletal proteins that give
neurons their structure and are damaged
in the disease process.”
A close and collaborative biomedical
community in Hobart facilitates teaching
as well as research in pathology, with
active involvement by private and public
clinical pathologists in undergraduate and
postgraduate programs.
“We have excellent relationships
between the university and local
pathologists,” Professor Vickers says.
“One or two lectures from a person at the
coal face during an undergraduate degree
can enthuse a person for life about a
discipline like pathology. We also have a
Professor James Vickers, head of the
discipline of pathology at the University of
Tasmania, is well aware of the pros and
cons of leading research in Australia’s
smallest state.
With funding sources including the
National Health and Medical Research
Council, the Tasmanian Masonic Medical
Research Foundation and the Royal
Hobart Hospital Research Foundation, the
group aims to understand the
mechanisms by which neurons grow, and
how to encourage their repair following a
traumatic injury, or during the onset of
Alzheimer’s disease, Parkinson’s disease,
motor neurone disease and other
conditions.
“The scale of investment in research is
different, but we have become skilled at
multidisciplinary co-operation, crossing
some of the traditional barriers between
disciplines to take advantage of the skills
The group works on experimental
models in cells and cultures and in
genetically engineered mice, as well as
human brain tissue acquired from
nationally co-ordinated “brain banks”.
covers the fundamentals of health and
number of “champions” who are working
to make sure pathology is given proper
emphasis as our medical degree is
redesigned into a five-year curriculum. We
have also been able to attract a stream of
really excellent postgraduate students to
pathology research.”
The University of Tasmania is now
offering a Bachelor of Medical Research,
the first such program in Australia. It
disease in human tissues, providing
options for specialisation, and allowing
students to complete their own research
projects in their final year.
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HEALTH + MEDICINE
STDs
on the rise
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WITH RATES OF SEXUALLY TRANSMITTED DISEASES INCREASING, PETER LAVELLE
LOOKS AT THE LAB TECHNIQUES USED TO TRACK THEM DOWN.
O
ne of the great Australian success
stories in public health was the safe
sex campaign initiated in the 1980s when
HIV first appeared. It was intended to
prevent the spread of the virus, but it
also promised to lower the incidence of
other sexually transmitted diseases
(STDs).
There was always a little bit of crossover
but only a few per cent. But now,
depending on the age you are when
infected, there are huge differences. For
example, in a 50-year-old with genital
herpes it's still nearly always HSV 2, but if
you get it in your 20s, it's far more likely to
be HSV 1.”
Alas, the fall-off in the incidence of
STDs has not been sustained. There was
a drop in the late 1990s, but since 2000
there has been a general increase in
STDs, particularly in the case of male-tomale sex, says Dr David Leslie, a medical
microbiologist at the Victorian Infectious
Diseases Reference Laboratory.
The good news is that the incidence of
HSV 2 is diminishing.
Reported rates of HIV, syphilis,
gonorrhoea and chlamydia in particular are
rising, Dr Leslie says.
Part of the reason is the success of
anti-retroviral therapy for HIV giving some
people a false sense of security that HIV is
no longer a terminal illness, leading in turn
to unsafe sex practices.
Last year, there were almost 40,000
cases of chlamydia reported to Australia’s
National Notifiable Diseases Surveillance
System, 8 per cent more than in 2004 and
30 per cent up on 2003 cases. In the past
five years, HIV diagnoses have risen 41
per cent, according to the National Centre
in HIV Epidemiology and Clinical
Research.
Dr Robert Baird, an infectious diseases
physician and microbiologist at Melbourne
Pathology, says one of the most dramatic
developments is the worldwide increase in
syphilis cases, which in the past year or
two has reached Australia.
“Some of it's coming in from East
Timor, some from mainland Asia, but it's
basically a worldwide phenomenon and
not just in gay men, but the general
heterosexual population," Dr Baird says.
A disease that had become almost
non-existent has come back with a
vengeance, he says.
“Our lab has seen 10 times more
cases of primary syphilis in the last year
than we’ve seen in the previous 10 years.”
GPs are not used to seeing a lot of
primary syphilis cases and can mistake
them for other types of genital ulcer.
Often the disease occurs vaginally,
anally or even inside the mouth or urethra
and isn’t recognised. A month or two later
it is followed by secondary syphilis, a
whole body rash that classically involves
the palms and the feet as well.
Time was when every third-year
medical student could pick the rash of
secondary syphilis. But it came to be so
infrequently seen that doctors don’t think
of syphilis and miss it, Dr Baird says.
Often the doctor will take a biopsy of
the rash and send it to a pathologist and
the pathologist too is so unused to seeing
secondary syphilis that he or she mistakes
it for something else.
There needs to be an education
campaign aimed at GPs and pathologists
about the resurgence of syphilis, Dr Baird
argues.
Genital herpes, the most common
sexually transmitted disease, has changed
its epidemiology over the past 20 years,
he says.
“Most genital herpes used to be
caused by (the herpes simplex virus 2) and
mouth herpes was caused by HSV 1.
"There's less and less HSV 2 in the
young, to the point where it could
potentially disappear in a generation or
two,” Dr Baird says. “This phenomenon
isn’t confined to Australia; it’s been noted
in other Western countries too. We don’t
exactly know why it's happening – it could
be one area where safe sex campaigns are
having an effect.”
But gonorrhoea remains a major public
health problem. New strains from Thailand
and other sex tourism destinations in Asia
are appearing in Australia and are highly
resistant to many of the usual antibiotics.
Says Dr Leslie: “Most strains show
some resistance to penicillin. We’re seeing
increasing resistance to second line drugs
like ciprofloxacin, though fortunately they
appear to have remained sensitive to
ceftriaxone, so there is still effective
treatment available.”
As for chlamydia, its prevalence is
increasing in gay men and the general
heterosexual population, he says. This is
worrying because chlamydia often doesn’t
produce symptoms and can lead to silent
pelvic inflammatory disease and infertility
in women.
Lab diagnostic techniques are critical
in the management of STDs. Many of the
conditions present a similar picture. There
are many other causes of genital ulcers
besides primary syphilis, for example – it
might be candida, herpes or a local
trauma lesion that gets infected.
Chlamydia and gonorrhoea may
produce a urethral discharge and pain on
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urinating, but they are caused by different
organisms and require different antibiotic
treatments. The good news in all this is
that the diagnostics have improved
considerably in the past five years.
Nucleic acid amplification
technologies, including polymerase chain
reaction techniques, have revolutionised
STD diagnosis. Rather than culturing the
micro-organisms or viruses causing
disease or detecting antibodies that the
body has made to them, these tests look
for the DNA (or RNA) they contain. They
work in the same way as forensic DNA
testing.
"You look for the specific DNA of the
particular pathogen you suspect from the
clinical picture, using primers that fix only
to those particular sequences of DNA
bases that are found in that pathogen, to
identify it," Dr Baird says.
PCR technology has advantages over
traditional technologies in that it is more
sensitive and can be more specific. One of
the problems of traditional diagnostic tests
is sensitivity – whether they pick up the
organism or not and avoid false negatives.
Another is specificity – whether they pick
up the right organism and not another one,
so that they avoid the problem of false
positives.
With immunoassay tests, for example,
there are often false positives and false
negatives. The immunoassay is looking for
proteins – antibodies made against the
bacteria or viruses – in a blood sample.
But people’s immunological responses
vary. There may not even be antibodies to
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the infecting agent, even though the
person has been exposed and has the
clinical picture.
Then there are timing issues – the
assay may not be done when antibody
levels in the blood are high enough.
Both these situations will produce false
negatives. The immunoassay may also
cross-react with other proteins that are not
linked to the pathogen, giving false
positives.
Nucleic acid techniques are highly
sensitive and highly specific, because they
are looking directly at the DNA or RNA of
the organism, not the antibodies produced
by the patient’s immune response.
Part of the reason they are very
sensitive is they can pick up the DNA even
if the virus or bacteria is degraded.
"The organisms you’re looking for
don’t have to be viable or alive; you can
actually detect DNA in dead chlamydia or
dead viruses, so viruses that have been
shed and are not viable still may have
nucleic acid that can be detected," Dr
Baird says.
He says most of the laboratories that
have changed to nucleic acid techniques
have noticed their positivity rate go up by
50 to 70 per cent and this may be the
reason behind what appears to be a
marked increase in the incidence of
chlamydia. Yes, there's more chlamydia
being detected, but it could be due to
more sensitive diagnostic techniques than
was the case 10 years ago.
Dr Leslie says chlamydia is a difficult
organism to culture and fluorescent
microscopy tended to miss it, especially
from anorectal and oral sites.
“With PCR we can pick up chlamydia
from any site with ease,” he says.
PCR testing can be manual or
automated and faster than other methods.
Being highly sensitive and specific means
it can be used to make the initial
diagnosis, not just to confirm an initial less
specific test. Another plus is that PCR has
less stringent specimen transport
requirements than the traditional
technologies.
"In the old days, to do dark ground
microscopy for syphilis for example, we
had to bring the patients into the lab
where the microscope was, because we
needed to look at the specimens within 30
minutes of taking them. But with PCR,
timing is less of an issue because the DNA
can be detected even in dead bacteria,"
he says.
PCR testing is widely available for
chlamydia, and generally for gonorrhoea
and herpes, though for syphilis it is only
available at a handful of labs in Australia
and is more of a research and
development tool at this stage. There are
some specificity problems with
gonorrhoea, but the situation is gradually
improving.
For trichomonas, a parasite that
causes vaginal inflammation or infects the
urethra, and human papilloma viruses
(which can lead to genital warts and in
some cases cervical cancer) PCR is less
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widely available, but that will change. In a
few years it will be widely available for all
STDs, Dr Leslie predicts.
Has PCR made traditional pathology
techniques such as light microscopy and
BEATING
cervical cancer
immunoassay redundant? In some cases it
does replace the traditional techniques. In
herpes and chlamydia, the nucleic acid
technologies are far better than the old
culture methods.
But there is still an important role for
the traditional methods. With gonorrhoea,
light microscopy and culturing can
determine bacterial susceptibilities. Also,
ne job pathologists are likely be doing less of in years to come is looking
O
at cervical cancer smears, thanks to the new human papillomavirus
vaccine, Gardasil, which came on to the Australian market in September.
The vaccine is based on virus-like particle (VLP) technology developed at
the University of Queensland, which produces virus-shaped particles that
mimic the real virus to create an immune response.
as new strains appear, they may not be
recognised by the PCR kits, which can
only pick up DNA in existing strains.
"Some of the commercial gonorrhoea
nucleic acid assays have recently been
missing some of the gonorrhoea strains
that are now coming into the Northern
Territory,” Dr Leslie says.
There is also a role for traditional
The vaccine has four VLP components covering the HPV types 16, 18, 6
and 11, which are the most common strains affecting women and responsible
for 70 per cent of cervical cancer and 90 per cent of genital wart cases.
It is administered as three injections over a six-month period and available
from GPs on a private prescription at a cost of about $150 a dose.
CSL, which markets the vaccine in Australia, has applied for it to be
listed on the Pharmaceutical Benefits Scheme, and the Federal Government
is also considering whether to have it administered to girls throughout
testing methods in monitoring the effects
Australian schools in a similar way to the existing rubella vaccination program
of treatment. With treatment, antibody
– possibly by 2008.
concentrations may fall, and this can be
PAP smears will still be needed to detect cancers caused by other HPV
confirmed by immunoassay.
strains – but the welcome news is there will be fewer invasive cervical cancer
Immunoassays are also useful for
slides turning up in pathology labs. There could be an additional role for
antenatal screening, screening of partners
pathologists though in the screening of those who are already sexually active.
and contacts, and of blood and tissue
If they are found not to have been exposed to HPV types 16, 18, 6 and 11,
donors.
then they could still be suitable for the vaccine.
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
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PROFILE
Dr Chris Lawrence was one of three
pathologists who conducted autopsies
on the victims of Tasmania’s Port
Arthur massacre in 1996.
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Sleuth with a scalpel
FORENSIC PATHOLOGY HAS A HIGH PUBLIC PROFILE THANKS TO CRIME NOVELS AND TV SHOWS.
IN THE REAL WORLD, THE SPECIALTY HAS TAKEN DR CHRIS LAWRENCE FROM ROUTINE
AUTOPSIES TO HELPING GATHER EVIDENCE OF WAR CRIMES, WRITES PAM RACHOOTIN.
PHOTOGRAPHER: TONY MCKENDRICK
r Chris Lawrence has been caught up
in the aftermath of some of the most
dramatic national and international events
of recent years. It isn’t an interest in
touring trouble spots that has brought this
about, but his knowledge and skills as a
forensic pathologist.
D
While working in the US, Dr Lawrence,
now the director of forensic medical
services in Tasmania, developed expertise
in forensic anthropology and gained
extensive experience in autopsies
involving gunshot wounds. This
knowledge has been put to good use.
He was one of three pathologists who
conducted autopsies on the victims of
Tasmania’s Port Arthur massacre in 1996.
In 1998 he worked as chief pathologist for
the International Criminal Tribunal for the
former Yugoslavia in Bosnia, where he
exhumed and examined 900 of the 7500
victims of the Srebrenica massacre.
He later gave evidence at the
International War Crimes Tribunal in The
Hague in the trial of General Radislav
Krstic, who was convicted of genocide
and sentenced to 46 years in prison. Dr
Lawrence found this legal work
particularly rewarding.
Where hostilities have descended into
the barbarity of a massacre, the way to
approach the evidence is “one body at a
time”, he says.
“You have to prove every single one. If
they are in a mass grave, it’s easy, but in
places like Kosovo, where they are all
buried in single graves, you have to look
at each one and determine whether there
is enough evidence.
“If you don’t get a good nexus
between your investigation and your
exhumation and autopsy process, then
the exhumation is useless. So it’s got to
be done very thoroughly, and it’s an
incredibly expensive process.”
Ironically, it is the more routine and
predictable elements of the job that
helped lead Dr Lawrence into pathology.
He decided to specialise in the field as it
is often more family friendly than other
disciplines. Having said that, the 48-yearold married father of three laughs at how
he has ended up in forensic pathology,
the area with the most after-hours work.
“My job is a little bit unusual in that I
am the only forensic pathologist in
Tasmania, so I am on call 24/7, which can
be a bit of a burden,” he says. “Routinely,
I start about 8.30. Traditionally the
autopsies have been done in the morning,
so the first thing I do is go down to the
mortuary.”
He might have no autopsies or up to
four a day. “Four is quite a lot. The
straightforward autopsies take about an
hour. The more complicated ones can
take up to four hours, so things can vary
from being pretty quiet to being full on for
most of the day.”
Keeping fit helps in coping with the
rigours of what is a stressful job, he says.
“You do a lot of courtroom work.
People always want answers immediately.
You get called out at all sorts of odd and
irregular intervals. Most of your homicides
are going to occur on weekends and at
night, so there can be a period where you
don’t have a lot of control over your life.”
According to his colleague, Dr Jo
Duflou, who worked with him and knows
his family, “He is very much a family man
with outside interests, which include his
farm. I think the secret is to have a life
outside work, a supportive family, and an
ability to switch off when you get home.”
Dr Lawrence’s approach to
investigating a possible homicide is “just
like any other form of medical
examination. You take a history (from
others) and then you perform an
examination. I basically try to prove or
disprove the story that I am being told (by
the police). Does the objective evidence in
front of me match what I am being told?
Do I need to get further information, or is,
indeed, the history wrong?
“In cases of a homicide, I would be
called out to the scene to do some
preliminary assessment … With a bit of
experience you can tell the police whether
or not it’s suspicious, what might be the
cause of death, or, at the very least, what
they need to do to sort it out.”
Teamwork is vital. “You are only as
good as the detectives, the crime scene
investigators, the coroner’s officers, and
the doctors involved. The autopsy is really
good for checking facts, but in terms of
trying to work out exactly what
happened… if you don’t have enough
information, you can’t make an
assessment.
“We recently had a double murder up
in the north of Tasmania where there was
an unknown assailant.What eventually
turned out is that we were able to identify
traces of the weapon in the two (victims),
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It’s not just the murders; he has also dealt with media frenzies, such as the one
surrounding the autopsy on Michael Hutchence, the lead singer of INXS.
“The high-profile cases can be quite dangerous, because there is a huge amount of
speculation. If you are not careful with those cases, they can go badly wrong on you.”
and then find the weapon and pull the
case together.”
It’s not just the murders; he has also
dealt with media frenzies, such as the one
surrounding the autopsy on Michael
Hutchence, the lead singer of INXS.
“The high-profile cases can be quite
dangerous, because there is a huge
amount of speculation. If you are not
careful with those cases, they can go
badly wrong on you.
“The work in Bosnia sticks in my mind
as really special. Things like the Port
Arthur Massacre, too. Disasters stand out
because they are moments of such high
drama.”
In 2001, Dr Lawrence’s work took him
to East Timor, where he examined the
remains of victims of the civil unrest that
followed the elections there.
Oddly enough, it is not the massacres
and disasters that he finds most
psychologically demanding. “The stressful
periods are often far more mundane,
where you are just trying to cope with
ordinary work days, and not ever being
able to complete anything to your
satisfaction — where there are constant
demands for your attention from multiple
different sources.”
He has had difficulty finding another
forensic pathologist to assist him but has
just been successful in recruiting one from
the US.
He says the homicide rate in Australia
has been steady for the past 100 years.
However, there has been an increase in
detection of child homicide. “Child abuse
cases are really tragic, and they are really
very hard to do and to take through
court… but they are enormously
important.”
Dr Lawrence’s work has also
impacted on consumer safety, for
instance in the case of all-terrain vehicles
(four-wheel motorbikes), which were
involved in seven deaths in Tasmania in
18 months.
“When I started doing forensics, the
three-wheeled motorbikes were common,
and there was a big court case in America
where they agreed to withdraw them from
the market because they tended to roll
over. What is interesting is that now the
four-wheeled vehicles are doing the same
thing.”
He has alerted farmers and farmers’
organisations to this danger and is
making manufacturers aware of the safety
issue.
While he is not out directly saving
individual lives, Dr Lawrence says a lot of
what forensic pathologists do is geared to
preventing further deaths, and that is a
source of satisfaction.
He says it is sad to see how many
deaths are caused by what he calls
“criminal stupidity” — especially young
people doing things where they just didn’t
anticipate the consequences of their
action. “They say of the forensic
pathologist, that he knows everything one
day too late.”
Dr Lawrence studied law after
becoming a forensic pathologist, but
doesn’t think that is a requirement. “You
tend to learn about the areas of your own
expertise. As one lawyer said to me once,
‘You’ve been in court about murders far
more times than I have been, so you tend
to know what you are talking about, and I
don’t.’ ”
Ultimately, he had to decide which
discipline he wanted to pursue. “Forensic
pathology is far more interesting than the
law,” he says.
Dr Lawrence has a special interest in
diving-related deaths. “They are very
difficult to investigate … It is an odd
environment, under water using
compressed air. It produces odd results,
and you have to be involved in diving to
understand what is going on.” He has
been a diver since 1977.
He also is intrigued by sudden deaths
during sport, many of which are due to
cardiac arrhythmias inherited as a
dominant trait.
“In forensics, weird things tend to
happen slightly more commonly than
you’d expect… Coronial cases tend to be
strange and unusual. The older I get, the
more careful I am never to say ‘never’,
and never to say ‘always’. I have been
surprised in the past. Someone who has
accidentally fallen on a spike that has
gone through their brain, a man driving a
car where the gear stick has gone through
his heart, very, very strange occurrences
that you wouldn’t anticipate happening,
but occasionally do occur.
“On a regular basis, from the history
I’m given, I try to guess what the cause of
death is, and then do the autopsy. The
only problem is it is only possible to get
60 to 70 per cent accuracy. I am nearly
always surprised by what I find at
autopsy. You can’t even anticipate which
case you are likely to get wrong.”
He warns that “in a period where you
do have more objections to autopsy, it is
one of those difficult balancing acts. It
could be the family who is objecting to
the autopsy, or it could also be a
perpetrator.”
He and his colleagues run the only
short forensic pathology course in
Australia. He confesses he is a tad
didactic. He likes teaching, but there are
times when he finds some of the modern
teaching philosophies frustrating.
Dr Allan Cala, a forensic pathologist
who is also involved in teaching the
course, rates Dr Lawrence as one of the
top three or four forensic pathologists in
the country. “I would reject one of his
opinions at my peril. He is very
knowledgeable, and a really nice bloke.”
Dr Lawrence says forensics has gone
through a down period but things are
looking up. “There are trainees coming
through, and I’m very glad, but we still
need to keep up the hard work and
support the people in this profession.”
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HEALTH + MEDICINE
Germ Warfare
MICROBES CAN BE TOUGH LITTLE CRITTERS, BUT THE
HARMFUL ONES HAVE SMART ADVERSARIES IN THE
MICROBIOLOGISTS SEEKING TO SAFEGUARD AND
IMPROVE HUMAN HEALTH, WRITES LOUISA DEASEY .
t is sad to think that the most important
discovery in treating infectious diseases
is at the heart of one of the gravest issues
facing microbiologists in the 21st century.
back. Germs are tough little critters. As
antibiotic class of last resort, which makes
we create ways to kills them, they are
them all the more threatening.
Antibiotics have saved millions of lives
and eased untold suffering, but growing
bacterial resistance to them is a major
problem for microbiologists, those dealing
with the bacteria, viruses, parasites and
other microbes that can harm health.
The evolutionary process is natural
I
Standard aspects of Western
medicine such as sterilisation, antiseptics,
penicillin and vaccinations were pioneered
by microbiologists. But just as great gains
have been made over the past two
centuries in our knowledge of infection,
microbes have had their ways of fighting
20_PATHWAY
capable of mutating into new versions
that can withstand our onslaught.
“We’re now seeing strains of
resistance to carbapenems, which are
basically the antibiotics you use in dire
enough, but human practices such as
situations at the top of the pinnacle,”
overuse of antibiotics can speed up the
Professor Iredel says.
spread of resistant bacterial strains, which
This particular antibiotic resistance
are the ones left to multiply when drugs
was not seen much before 2000, he says.
have killed off non-resistant germs.
“(The problem is) related to the ready
Associate Professor John Iredel, a
microbiologist in the infectious diseases
and microbiology department at Sydney’s
availability of antibiotics, and a lack of
control of antibiotic prescription.”
In Tasmania, Infectious Diseases
Westmead Hospital and an academic at
Physician and Microbiologist at the Royal
the University of Sydney, says the latest
Hobart Hospital, Alistair McGregor, is
strains of resistant bacteria relate to an
thankful the island’s relative isolation has
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“Pathology is about good surveillance and diagnosis which allows the opportunity for early
intervention and, ideally, prevention. If we can prevent patients becoming infected with
antibiotic resistant bugs then we will save lives, avoidable complications and money.”
helped to prevent the widespread
dissemination of antibiotic resistant bugs.
matter of days not weeks, thanks to
automation and molecular technology.
“Tasmania has been lucky so far, but it
is inevitable that we will start to see the
same sort of antibiotic resistance issues
that are now appearing on the mainland.
We now have a brief window of
opportunity to take preventative measures
and I believe that if we are able to
increase our infection control procedures
and better monitor and control antibiotic
prescribing now we may be able to
reduce the impact of these bugs over
time.”
Dr Arthur Morris, a clinical
microbiologist with Diagnostic Medlab in
Auckland, New Zealand, says using
automation to try to detect the DNA of the
pathogen suits some diagnoses but not
others.
“Pathology is about good surveillance
and diagnosis which allows the
opportunity for early intervention and,
ideally, prevention. If we can prevent
patients becoming infected with antibiotic
resistant bugs then we will save lives,
avoidable complications and money.”
Despite the difficulties, antibiotics are
still a vital part of health care and for most
microbiologists working on the “front
line”, a huge part of the job is consulting
on antibiotic use, a task all the tougher in
intensive care, where Professor Iredel
works, “because you’re ‘flying blind’ due
to the time constraints”.
This creates one of the biggest
challenges for microbiologists working in
clinical pathology – keeping a patient alive
can often mean killing off everything with
the strongest antibiotic that can be used.
This means they can’t grow certain
organisms separately and thus lose
valuable scientific research. It has also
contributed to new forms of antibiotic
resistant bacteria appearing in hospitals.
Professor Iredel says the latest
partnerships with bio-tech companies
have meant the development of some
essential rapid-diagnostic tools. Where
most microbiology is “hands on” – i.e.
patient swab samples are sent to a lab
where the microbiologist grows certain
organisms and identifies the pathogen –
molecular advances have sped up
disease diagnosis in some cases.
Most recently and successfully,
chlamydia can now be diagnosed in a
“Molecular testing can be quicker,
which is always good in terms of
diagnosis,” he says. “For example,
tuberculosis can take up to six weeks to
grow in a lab, but with molecular testing it
can be found in just a few days.
Chlamydia is also difficult to grow, so the
vast majority of chlamydia tests are
molecular.”
The new technology is a long way
from taking over though, and the
microbiologist’s skills of careful
investigation and assessment are
still very much required.
and extends to getting an accurate
patient history, which may involve
questioning relatives or friends.
“Certain key information can mean the
difference between studying one of
millions of organisms. You can never have
too much information in a clinical sense.
“A patient presenting to her GP
complaining of sweating, fever and
headache could have one of thousands of
bacteria. The first challenge is educating
the clinician on how to get a good
specimen to send to the lab.
“If the patient reveals they have
recently travelled to a certain country, that
can narrow down the hunt even further.
It’s important to ask plenty of questions,
because the patient will often not realise
Dr Morris says he was
captivated by microbiology when he
studied it as a fill-in subject as part
of a medical degree.
“It’s a living science. The story of
an organism evolves over several
days and you have to coax and
create the right environment for
growth. It’s like a mysterious
detective story where you need to
look for certain signs and clues …
many don’t become apparent until
you’re further down the line.”
Communication skills are an
important element of the job, he
says.
“As a microbiologist, you can
spend your days speaking with
everyone from the patient to the lab
staff to the doctors, midwives and
community specialists.”
With an emphasis on
investigation, good microbiologists
spend a lot of time asking questions
and also educating others on what
to look for.
Dr Morris says the process
begins by educating the clinician on how
to take a valid specimen from the patient
Associate Professor John Iredel, a microbiologist
in the infectious diseases and microbiology
department at Sydney’s Westmead Hospital
PHOTO: JAMES ALCOCK
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THE
MICROBIOLOGY
PATHWAY
There are a number of different
career paths available for those
interested in Microbiology.
MEDICAL MICROBIOLOGIST
the relevance of something to their
diagnosis.”
Dr Joan Faoagali, a clinical
microbiologist at Royal Brisbane Hospital,
says the excitement of working with living
organisms that can alter rapidly is what
led her into the field. “You never know
what you’re going to find. Every day is
different, as the organism changes from
one day to the next.”
Dr Faoagali says surveillance is the
cornerstone of microbiology.
Fluid swabs – from a patient’s tissue,
the spine or an ulcer – are monitored and
studied, much like the evidence in a legal
trial, to form the threads of the most likely
story. Dr Faoagali says there can often be
disagreement in the lab about what an
organism appears to be, but it is in this
grey area that the ‘‘art’’ of microbiology
applies.
She says it is often a case of
searching for that vital piece of
information that could change the
diagnosis.
Though you might not relate a
microbiologist to the emergency
department of a hospital, the passion, as
Dr Faoagali says, for knowing “which
germs and parasites to put in jail”, means
the difference between life and death for
many patients with infections.
Dr Faoagali says this is one of the
most satisfying parts of her job – through
MICROBIOLOGY SCIENTISTS AND
LABORATORY TECHNICIANS
Microbiology Scientists undertake a 3 to
4 year undergraduate degree in science
through various Universities. Many
scientists undertake further training such
Masters and PHD degrees after their
basic degree. Laboratory Technicians
require to undertake at least a Diploma
in Applied Science,
For information for training as a medical
laboratory scientist visit www.aims.org.au
microbiologist, the clinician can have a
Research assistants support
researchers by providing technical
assistance in the collection, processing,
and co-ordination of data, samples, and
specimens. Your work will involve
conducting routine tests, experiments
and procedures relevant to the field of
study. You’ll need at least a Bachelor of
Science.
“I feel embarrassed to say it, but I feel
really enjoy and that is so interesting,” she
says.
22_PATHWAY
For more information visit the RCPA website
at www.rcpa.edu.au
RESEARCH ASSISTANT
so lucky to come in every day to a job I
PHOTO: PORFYRI PHOTOGRAPHY
To become a medical microbiologist
you must first complete a medical
degree and then undertake further
training with the Royal College of
Pathologists of Australasia. The College
accepts applications from registered
medical practitioners with a minimum of
one year's post-graduate experience.
pathologist. Applicants must be
employed in an accredited laboratory
before seeking registration with the
College. Pathology training takes a
minimum of five years and includes a
series of examinations.
successful lab research by the
swift and accurate diagnosis.
Dr Joan Faoagali, a clinical microbiologist at Royal
Brisbane Hospital
Medical microbiologists are specialist
pathologists who supervise specimens
coming into the lab for infection
diagnosis. They ensure appropriate
methods are followed and that the
answers are correct and meaningful.
Ultimately they give direct advice on the
management of the disease. They are
also involved in public health issues
such as infection control, immunisation
and how to make food and water safer.
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
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Smallpox:
ne of the proudest moments for
microbiologists – and the world –
was a sunny May day in 1980 when the
eradication of smallpox was formally
declared. This followed an intensified
vaccination program, begun in 1967 and
led by the World Health Organisation, to
wipe out the viral disease.
O
Smallpox, believed to have originated
more than 3000 years ago, was one of the
most devastating diseases mankind had
faced, sweeping death around the world.
Of its two main forms, the deadlier had a
fatality rate of about 30 per cent. Up to 80
per cent of survivors were left
permanently pockmarked. There is even
some evidence that Egyptian mummies
show signs of the dreaded ‘‘pox’’, which
literally means “pustules”.
It is little known that the distinguished
microbiologist who made the historic
eradication announcement to the World
Health Assembly in Geneva was an
Australian.
Emeritus Professor Frank Fenner was
chairman of the Global Commission for
the Certification of Smallpox Eradication
and had been an adviser to the
eradication project as an expert in pox
viruses. The announcement followed
years of careful surveillance and
vaccination across 23 countries, and
Professor Fenner says there has not been
a known case of smallpox since.
A former director of the Australian
National University’s John Curtain School
of Medical Research, who graduated in
medicine in 1938 and became an ANU
professor in 1949, he puts the eradication
of smallpox down to simple factors
methodically executed.
gone, but not forgotten
“We were very lucky because we had
a strong American leader of the group,
Donald Henderson, who instituted very
careful surveillance. It was a massive
project, we went to over 100,000 villages
in 23 countries, and vaccination was
successful because it only took around 30
minutes to teach the doctors in those
villages how to use the bifurcated
vaccination needle, which had no
syringe.”
Vaccination and strict quarantine
rules in Western countries in the early
20th century did something to eradicate
smallpox in the US, Europe and Australia,
but it was still rife in Asia and Africa.
There was, and still is, no effective
treatment.
The disease mainly spread via infected
air droplets transmitted in face-to-face
contact with a sufferer after fever had
begun, but there were also instances
where ventilation systems played an
unfortunate role.
One extraordinary case that illustrates
how rapidly the airborne virus could
spread was in West Germany in 1970.
Donald Hopkins writes of the case, in
Smallpox in History (University of Chicago
Press, 1983): “A patient with undiagnosed
smallpox infected 17 other persons in the
hospital without having had direct contact
with any of them.”
The cause was traced to air vents.
Sufferers developed pustules over their
body and face. Pox in the mouth could
make eating impossible and in the eyes
could lead to blindness. A person with
smallpox would commonly lie in bed
sweating feverishly and aching for three to
four weeks. Those who survived had the
comfort of knowing they were immune for
life.
It is unknown where smallpox
originated, but the most common theory
is that it was related to the much milder
cowpox and began in villages where
humans lived closely with cows.
The smallpox vaccine was based on
the discoveries of Edward Jenner, who
noticed more than 200 years ago that
milkmaids with small lesions on their
hands due to cowpox were immune to
smallpox. The first vaccine was developed
based on the theory of giving a dose of
cowpox to build up resistance. In the
initial stages of vaccination research, in
the 19th century, some physicians took
infected cows directly to people’s doors
where they would rub the infected
pustules for ‘‘immunisation’’.
In 1992, when Boris Yeltsin
announced that the USSR had been
researching biological warfare with a store
of 20 tonnes of the smallpox virus, the
World Health Organisation set up a
committee that produced a 100-page
booklet on what to do if a smallpox case
ever appeared again. Vaccine stocks and
the booklet were distributed to every
country across the world.
Professor Fenner isn’t worried about
smallpox being used in bio-terrorism
tactics in the current day.
“Because of Yeltsin’s announcement in
1992, plans were put in place just in case
we do see it again. But for now we need
to focus on working to find solutions to
the current-day plagues such as AIDS,
malaria and tuberculosis, which still exist
in epidemic proportions in some parts of
the world.”
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GP COLUMN
A matter of personality
TESTS PROFILING POTENTIAL MEDICAL STUDENTS MAY RULE OUT PEOPLE WITH THE TALENT TO
BE TOMORROW’S BRIGHT STARS, WRITES LINDA CALABRESI.
ave you ever had the experience of
suddenly questioning something you
have always taken for granted?
H
suitable to study medicine? In theory, of
course we need problem solvers and
pattern recognisers, but surely we also
need routine followers and people who
have the ability to think outside the
square.
I recently had reason to consider how
universities these days select which of our
high school students are to be allowed to
study medicine.
Medicine is such a diverse profession.
You cannot tell me that the sort of person
who makes a good general practitioner is
the same sort of person that makes a
good orthopaedic surgeon, or a good
radiologist or a good researcher.
A friend’s daughter in her final year of
high school has, since she was a little girl,
wanted to be a doctor, just like her mother
and her grandmother. It has been her
experience with the undergraduate entry
process that really put the spotlight on the
Undergraduate Medicine and Health
Sciences Admission Test (UMAT) for me.
It’s been a long time since I faced the
hurdle of getting into medicine, which at
the time was only undergraduate. The
requirements were simple – get the marks
and you’re in!
Of course this system was far from
ideal. You could have been a complete
psychopath and you would have been
allowed to study medicine provided you
were in the top few per cent of the state
in your final exam.
In fact I remember one student in my
original year who was decidedly odd in
looks, behaviour and communication
ability but who was brilliant at book-based
learning. He sailed through the first couple
of years, which were all lectures and
tutorials. It wasn’t until he was let loose
on patients in the third year that the alarm
bells sounded and the examiners then
proceeded to fail him at every clinical
exam until he left the course. It seemed
such a cruel waste of effort really.
But is the new system that much
better? Now we are asking 17-year-olds
to sit an exam that supposedly profiles
them and determines their suitability for a
number of the “caring” professions.
On the basis of tests that include
pattern recognition and how they would
deal with an airport full of people whose
flight had been delayed, these high school
students will be told whether they are
24_PATHWAY
Dr Calabresi is a practising GP and
Editor of the Medical Observer
made of the right stuff to wield a
stethoscope or write a prescription.
And they will be told this just weeks
before they have to sit one of the most
important series of exams they will ever
face!
I have heard it said, usually by
academics, that it doesn’t really matter if
these teenagers don’t pass the UMAT.
They can try for the graduate medicine
programs further down the line. But if you
were 17 and told you don’t have the right
psychological profile to become a doctor,
why would you bother?
And then there are “experts” who say
you can do well at the UMAT if you study
for it – attend the often-expensive
courses, do IQ exams, read the
appropriate websites. But is that the
point? Are they then really testing the
nature of the person or simply their ability
to play the game?
My other major concern here is, who
decided on the profile considered most
Are we losing some of our brightest
young things on the basis of some ivory
tower ideal? If they gave these tests to
some of the stars of our profession – the
Ian Frazers or the Robin Warrens – how
would they go? I suspect our loss at this
key stage of a smart young person’s life
will be faculties such as law and
engineering’s gain.
Of course, one shouldn’t attack a
system unless one has a more effective
alternative to offer - which I don’t.
Perhaps the answer is to let these
high schoolers sit their final exam and
only then decide who should be tested for
entry into medicine. Perhaps all medical
courses should be graduate programs.
Whatever the solution it should be
better than telling a hard-working 17-yearold that no matter what their performance
in their final year of secondary school they
don’t have a place in medicine, as has
been the case with my friend’s daughter.
We all know this profession
accommodates a wide diversity of
personalities and no doubt will continue to
do so as the numbers of overseas
graduates, who never underwent a UMAT,
continue to swell our ranks.
We need to ensure that our selection
process considers personalities that will
be suited to the full array of medical
disciplines and not to a too narrow
stereotype.
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HEALTH + MEDICINE
Passing the test
ENCOURAGING DOCTORS TO USE PATHOLOGY TESTS WISELY IS NOT ONLY ABOUT COST
CONTROL – IT IS CENTRAL TO QUALITY MEDICAL PRACTICE, WRITES TONY JAMES .
J
udy, 54, complains to her GP of
tiredness, headaches, mild nausea and
bloating. It is suggested that some blood
tests might help sort out the problem.
is only then that thought should be given
to appropriate investigations, such as
pathology and diagnostic imaging that
need to be requested.”
The list of possible diagnoses could
run into the hundreds, but it is a scenario
faced by GPs every day in their routine
practice. If a significant illness exists, the
possibilities could range from depression
to ovarian cancer.
A recent study has shown that in at
least 70% of diagnoses, pathology tests
are involved in making that diagnosis. It is
important though to request the right test
at the right time. For example, if a GP
orders a profile of 20 different tests in a
healthy individual, most of these results
will be normal. There is however a two in
three chance that at least one result will
be ‘abnormal’ but usually these are of no
clinical significance.
Ordering “some tests”, funded from
Australia’s Medicare budget of $1.6
billion, might ultimately be appropriate,
but in keeping with good medical practice
it should not be the first step in making a
diagnosis. Medical practitioners should
always start with taking thorough and
skilled history of the problem the patent
presents with,” according to Dr Matthew
Meerkin, a Sydney-based chemical
pathologist. “Next a thorough physical
examination of the patient should occur. It
Dr Meerkin is editor of Common
Sense Pathology, a bi-monthly series
published on behalf of the Royal College
of Pathologists of Australasia (RCPA). It is
one of several initiatives aimed at
improving the quality use of pathology
services, which has emerged as a major
issue for both Federal and State
governments, the RCPA, the medical
profession and consumers.
It is tempting to attribute concerns
about pathology tests to a narrow focus
on cost control, but the concept is also
central to quality medical practice. Dr
Debra Graves, CEO of the RCPA and
herself a Doctor, says appropriate use of
pathology tests might require an increase
in the use of some tests but less use of
others. For example, some diseases
remain under-diagnosed in Australia, and
increased testing of people at risk would
facilitate earlier treatment and better
outcomes.
Pathology tests can be used for a
number of purposes – to assist with the
initial diagnosis of a disease, to monitor
the progress of the condition or its
treatment, or in preventive medicine to
identify people at high risk (for example,
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“Appropriate pathology testing requires a very sound understanding of the pathological
basis of disease,” Dr Graves says. “I have some concerns that an emphasis on
problem-based learning in undergraduate medical courses is neglecting the systematic
study of pathology and the best way to take advantage of pathology services. Medical
students need to acquire that core knowledge so they can practise effectively.”
with elevated cholesterol levels in the
presence of other cardiovascular risk
factors). GPs order about 70 per cent of
Medicare-funded tests. Investigations
ordered by hospital-based specialists and
doctors in training are funded by statebased hospital budgets and amount to
about another $1 billion a year.
“Appropriate pathology testing
requires a very sound understanding of
the pathological basis of disease,” Dr
Graves says. “I have some concerns that
an emphasis on problem-based learning
in undergraduate medical courses is
neglecting the systematic study of
pathology and the best way to take
advantage of pathology services. Medical
students need to acquire that core
knowledge so they can practise
effectively.”
Continuing education throughout
doctors’ professional lives is the key to
quality use of pathology services, she
says.
Common Sense Pathology is now in
its 20th year, although it has had some
“rests” during that time because of
funding difficulties. It is now published as
a joint initiative between the RCPA and
the weekly medical newspaper Australian
Doctor, supported by funding from the
Commonwealth Government.
Dr Meerkin says Common Sense
Pathology has been extremely well
received by its primary target audience,
GPs.
“It is based very strongly on practical
case studies that are relevant to GPs,” he
says. “We concentrate on conditions that
are difficult to diagnose, require
complicated thought processes and rely
at least partly on investigations.”
Topics covered this year include
recent advances in the diagnosis and
management of viral hepatitis,
malabsorption (for example coeliac
disease and inflammatory bowel disease),
genital tract infection, and lipids and
cardiovascular disease.
A recent issue discussed the
diagnosis of urinary tract infection in
adults. It challenged the traditional
practice of ordering urine microscopy,
bacterial culture and susceptibility testing
for this common problem. Instead, it
proposed that uncomplicated cases can
be diagnosed on the basis of history and
simple urine dipstick tests in the surgery
and then treated immediately.
As well as Common Sense Pathology,
College educational initiatives include the
comprehensive Manual of Use and
Interpretation of Pathology Tests,
developed by a committee chaired by
New Zealand anatomical pathologist
Professor Brett Delahunt. The Manual is
freely available online
(http://www.rcpamanual.edu.au), including
a version downloadable to PDAs.
It provides useful and accessible
guidelines on selecting pathology tests
and interpreting the results. Its first
section lists specific clinical problems and
the tests that might be appropriate.
“Consideration must always be given to
the individual clinical situation,” the
Manual notes. “Tests should never be
ordered as a ‘routine’ or ‘screen’. An
important principle is to request tests only
when the results will contribute to
diagnosis and/or management.”
The second section lists the details of
individual tests, including the specimens
needed, the clinical application and their
interpretation. A regular fact file called
“From the lab” published in Medical
Observer and a similar regular feature in
New Zealand Doctor complement these
educational initiatives.
Brisbane pathologist Dr Michael
Harrison chairs the Quality Use of
Pathology Committee which oversees the
Quality Use of Pathology Program within
the Department of Health and Ageing. The
program aims to promote education of
referrers, providers and consumers to
support best practice in requesting,
interpreting and following up pathology
tests. The committee has produced a
series of reports on the topics ranging
26_PATHWAY
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The fundamental principles of quality use of pathology are to use the right test in the right patient with
the right indication, at the right time, at the right cost and with the right results and the right outcome.
from the feasibility of developing clinical
practice guidelines for test ordering in
common clinical presentations such as
tiredness, the potential of IT based
decision support systems to facilitate
better use of tests, and how results can
best be reported to and used by referring
doctors. The committee includes
representatives of the AMA, GPs, medical
faculties, medical colleges, consumers,
health informatics specialists, pathologists
and the RCPA.
“We have some evidence on how
pathology tests are used in Australia, but
we need more,” Dr Harrison says.
Information from the Health Insurance
Commission on Medicare-funded tests
provides broad patterns but has a number
of deficiencies, including lack of
information on the reason for the test and
grouping multiple items under a single
Medicare Benefits Schedule item.
The past BEACH (Bettering the
Evaluation of Care of Health) surveys
provide more detailed information from
representative samples of GPs. Each year
about 1,000 GPs complete reports on 100
consecutive consultations. Information
collected from 1998 to 2001 was
summarised in a report on pathology
testing published in 2003. Covering about
300,000 consultations and 80,000
pathology requests, it revealed a marked
20% increase in investigations even
during that short time, resulting mainly
from more tests being ordered for each
clinical problem. The greatest increase
was in chemical pathology, with smaller
but significant increases in haematology
and histopathology. There were increases
in investigations for patients presenting
with these five commonly-managed
problems: hypertension, diabetes,
menopausal symptoms, ischaemic heart
disease and cardiovascular check-ups.
Just sixteen tests accounted for 75 per
cent of all requests, emphasising the fact
that high-volume, low-cost tests account
for the majority of expenditure.
GPs who were younger, female, and
worked part-time, in larger practices and
in rural or remote locations ordered more
tests.
“It’s not possible to say whether more
tests are appropriate or inappropriate,
without knowing the full details for each
request,” Dr Harrison says. “Doctors who
ordered more pathology tended to
prescribe less medication, indicating that
GPs are not a uniform group and have
significantly different styles of practice.”
Possible external influences on
request rates include new MBS item
numbers (for example, for care plans
detailing the comprehensive care of
chronic illnesses) and system changes
such as computerisation.
Although increased fear of litigation
might be a ‘driver’ in encouraging more
tests as a defensive strategy, it is not
generally regarded as a major factor, Dr
Harrison says. For example, a study in the
Hunter region of New South Wales found
the vast majority of requests by GPs were
based on clinical indications, rather than
patient demand or medicolegal concerns.
The fundamental principles of quality
use of pathology are to use the right test
in the right patient with the right
indication, at the right time, at the right
cost and with the right results and the
right outcome. However, translating this
mantra into practice remains a challenge.
“The diagnostic process is a
complicated one, and it is difficult to
study how individual doctors’ approach
the complex, undifferentiated problems
they see in general practice,” Dr Harrison
says. “But the more knowledge that
doctors have about pathology, the more
appropriately they can use the tests.”
Some basic rules can be applied to all
types of testing. There is generally good
consensus about first-line and secondline investigations. For example, if thyroid
disease is suspected then the initial test
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“With the introduction of capped
funding, there is now a
recognition that pathologists
should have a central role in
working with referrers to improve
the appropriate use of tests.”
should be for blood levels of thyroid
stimulating hormone (TSH). Subsequent
tests such as T3 and T4 levels are only
needed in most cases if TSH is abnormal.
The exceptions to this (the infertile patient
or those on thyroxine replacement) are
well defined.
Re-test intervals are another area
where clear rules can be applied. There is
no point repeating HbA1c tests in patients
with diabetes in less than about two
months, as it reflects long-term blood
glucose levels and relate to the average
survival time of red blood cells (110 days).
INR tests are used to monitor
anticoagulation with warfarin. It takes four
to seven days for INR to reflect changes
in warfarin dose, so conducting the test
more often could lead to premature dose
adjustments and the possibility of
dangerous over- or underdosing. Some
information systems in hospitals now have
automatic blocking of re-testing within a
certain interval, which is especially useful
in an environment where many doctors
can see a single patient and each order
their own set of tests .
Dr Harrison says the Quality Use of
Pathology Committee has three main
aims. The first is to increase the
knowledge and role of patients in their
own pathology testing. They should be
aware of the nature and purpose of tests,
and particularly the implications and need
for follow-up. They should become
sufficiently informed to make informed
decisions regarding their own testing and
management.
Second, the Committee wants the
development of support for the referral
practices of doctors in selecting those
patients who need tests and which ones,
and then implement this in routine
practice, for example as part of e-health
systems. These practices should be
informed by evidence and facilitated by
best practice professional relationships
and protocols between referrers and
pathologists and maximise health benefit.
Interactions between pathologists and
referring doctors include the interpretation
of abnormal results, the usefulness of
reports to referrers, follow-up of abnormal
results, and feedback on the
appropriateness of tests.
“Regulations in the past tried to put
pathologists at arm’s length from
requesters, mainly because of concerns
about over-servicing,” Dr Harrison says.
“With the introduction of capped funding,
there is now a recognition that
pathologists should have a central role in
working with referrers to improve the
appropriate use of tests. It is in their best
interest to encourage quality use.”
Finally the Committee is considering
the area of laboratory practice – what
further improvements can be made to the
process of specimen collection, testing
and result reporting.
Drs Meerkin, Graves and Harrison all
agree that requesting doctors must
balance the desire to do everything
possible for their patients with an
acknowledgment that the health system
has finite resources. “I don’t think this is a
major issue”, Dr Graves says. “In any
system, we have to work in a framework
that the community can afford. It’s widely
accepted that everyone has a responsibility
to make the system work.”
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
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HEALTH + MEDICINE
Breast cancer:
unlocking the secrets
PATHOLOGISTS’ ROLE IN THE DETECTION AND
TREATMENT OF THIS COMMON ILLNESS HAS
INCREASED DRAMATICALLY IN THE PAST
15 YEARS, WRITES MATT JOHNSON .
t is brutally short and cruelly
definitive but offers almost no
information. Just two lines stating,
“adenocarcinoma of breast is present”.
It is a diagnosis more than 13,000
Australian women will receive this year,
but unlike this 70-year-old pathology report
from the archives of St Vincent’s Hospital in
Sydney, the report women now receive can
run to as many as five pages, and what it
contains will have a profound effect on their
treatment and prognosis.
I
If all Australian women lived to the age of 85,
one in 8 would develop breast cancer. The risk in
men is one in 763. The average age of women
when diagnosed is 60, but one-third will be under
50 and more likely to suffer larger and aggressive
cancers. Although the survival rate is improving,
(a one in 56 risk in 2004 compared to a one in
43 risk in 1983), breast cancer remains the
most common cancer-related cause of death in
women in Australia, claiming 2594 lives in
2001.
What has been discovered over the past
15 years is that breast cancer is not a single
disease but a group of diseases linked to
different genetic mutations, each of which may
behave differently and respond unpredictably to
various treatments. Pathologists working in
breast cancer research have been central to this
discovery. And a consequence of their findings
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“We’re now asked to
provide information that
will guide the oncologist
and the surgeon to
accurately treat the
cancer.”
has been an increased role for
pathologists in breast cancer detection
and treatment.
Clinical Associate Professor Michael
Bilous, an Anatomical Pathologist at the
Institute of Clinical Pathology and Medical
Research at Westmead Hospital in
Sydney, has not only witnessed much of
this evolution but has also played a role in
researching and assessing the data that
has driven it
“The basic change that has occurred
is that once the pathologist was simply
asked to assess the tissue they had been
sent, to see if cancer was present,” he
says. “Now the pathologist is expected to
provide information about the likely
behaviour of a particular breast cancer:
whether it’s likely to spread, to recur,
respond to a particular therapy or need
extra therapy.
“We’re now asked to provide
information that will guide the oncologist
and the surgeon to accurately treat the
cancer.”
Breast cancer is usually slow growing,
so it can be several years before it
becomes large enough to detect. It
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usually starts in the lobules where milk is
made or in the ducts that carry milk. In
the worst cases it can spread into the
lungs, other organs and bones. Chances
of survival are related to how early the
cancer is detected and how far it has
spread.
Australia’s National Breast Cancer
Centre program to provide women with
free mammograms has been a remarkable
success, but most investigations rely on
women going to their doctor after they
have noticed something unusual.
The doctor will conduct the first stage
of what is known as the “triple test”. After
gaining a family history, he or she will
conduct a clinical examination. If there is
concern about the findings, patients will
be advised to undergo two further tests.
Taken alone, none of the tests in the
“triple test” can reliably detect breast
cancer, but used together they will find
more than 99 per cent of cases.
The second test involves
mammography or ultrasound imaging of
the breast. A mammogram is a low-dose
X-ray that can find changes too small to
be felt through physical examination. In
women under 35 (or who are pregnant or
breastfeeding) breast tissue is too dense
for changes to be obvious using
mammography, and an ultrasound may be
required. For some women both tests may
be needed.
If an area of concern is found, a
sample of cells can be extracted from the
lump with a needle. This is known as a
Fine Needle Aspirate or FNA. It is here,
once the sample is collected, that the
pathologist’s work starts.
“Despite all the changes of the past
decade, most of the work is still done
looking down a microscope,” Professor
Bilous says. “The samples are taken,
processed, prepared onto glass slides
and then assessed by the pathologist
looking into a microscope.”
The cells are graded and the stage of
the cancer is assessed, but the sample is
also prepared for more tests.
“Once we’ve looked at the cells, we
then want to test the properties of the
cancer cell, to see what stimulates its
growth. This information is very important
to determine which patients are eligible
for hormone therapy or the newer
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“Forty years ago cancer of the breast meant a mastectomy. By being a part of the
multi-disciplinary team and using new information, we’ve moved to give women a
choice of chemotherapy, endocrine therapy, or if surgery is appropriate, the information
to decide between radical or conservative techniques. The pathologist is vital in
determining which therapy is most appropriate for their cancer.”
treatments such as Herceptin,” Professor
Bilous says.
“All this information – all the
observations and measurements – is put
into a report for the surgeon and
oncologist. We then meet weekly with the
team and discuss each patient to
formulate an approach for their treatment.
“It’s a multi-disciplinary team that will
include people from all aspects of
medicine: the surgeon, the oncologist, the
pathologist, the breast care nurse, the
geneticists, and we discuss the findings in
context of the patient’s needs, wishes and
circumstances. At end of the meeting, one
person from the team will speak to the
patient and discuss ongoing
management.”
The aim of treatment for early breast
cancer is to remove the cancer from the
breast and nearby tissue by surgery, and
then to destroy any individual cancer cells
that may be left behind, usually with
radiotherapy and/or chemotherapy.
A crucial part of Professor Bilous’ role
is providing the patient with information to
make a choice about what type of
treatment they have.
“Forty years ago cancer of the breast
meant a mastectomy. By being a part of
the multi-disciplinary team and using new
information, we’ve moved to give women
a choice of chemotherapy, endocrine
therapy, or if surgery is appropriate, the
information to decide between radical or
conservative techniques. The pathologist
is vital in determining which therapy is
most appropriate for their cancer.”
Even once the cancer has been
diagnosed and the surgical phase of
treatment has begun the pathologist
remains part of the team, firstly to assess
the surgical margin. When surgeons
remove the cancer they also try to take
some of the healthy breast tissue around
it: this healthy tissue is called the surgical
margin. It’s the pathologist’s role to
assess the tissue in the margin to see if all
the cancer has been removed. If not,
more surgery may be required.
The second role for the pathologist is
to assess if the cancer has spread to the
lymph nodes. Lymph vessels drain excess
fluid from the breast and run into lymph
nodes in the armpit. The nodes are the
most common sites that invasive cancer
cells will be found and in the past they
were routinely removed. Painful at the
time, the surgery also affected the limb’s
ability to drain lymph fluid, and some
patients had to permanently wear
pressure dressings on their arm to reduce
swelling or lymphoedema.
Dr Adrienne Morey, an associate
professor at the University of NSW and
director of anatomical pathology at St
Vincent's Hospital in Sydney, explains the
role of the pathologist in reducing the
number of unnecessary axillary lymph
node dissections.
“We call it a ‘sentinel node biopsy’.
The lymph nodes are the first place where
cancer cells will metastasise to, the first
port of call, but different parts of the
breast will drain to different nodes, so
before the operation the patient’s breast is
injected with a radioactive colloid. The
colloid gets into the first draining node
and then during the surgery the surgeon
will pass a Geiger counter over the area.
“If they find a ‘hot’ node, they take it
out and send it to pathology for
assessment. We prepare a frozen section
to see if cancer cells are present in this
‘sentinel node’, and if they are, the
surgeon will remove additional nodes. If
the sentinel node is negative, it saves an
unnecessary axillary dissection, but it
relies on the pathologist to look for
microscopic deposits of cancer.”
With the surgical phase completed,
the management team will look at
preventing the cancer from recurring. For
this they will return to the pathologist’s
original report about what influences the
growth of the patient’s particular type of
cancer cells.
Firstly, they will consult the report for
the cancer’s hormone receptor status.
Two hormones produced by the ovaries,
oestrogen and progesterone, can
stimulate the growth of abnormal breast
cells. Cancer cells stimulated by
hormones can be identified by testing
them for a receptor: a protein found on
the surface of cells that hormones attach
to to cause growth and repair.
Breast cells can be positive or
negative for either hormone, but knowing
a breast cancer contains receptors helps
direct treatment as cancers positive for
receptors are more likely to respond to
hormone therapy. The other receptor the
pathologist is searching for is the HER-2
receptor. HER-2 is a gene that helps
control how cells grow, divide and repair
themselves, and about one in four breast
cancers have too many copies of the
HER-2 gene and produce excess HER-2
protein on the outside of the cancer cells.
Cancers with too many copies of the
HER-2 gene tend to grow fast and have
an increased risk of spreading, but
Herceptin (trastuzumab), one of the first
generation of targeted cancer therapies,
binds to the HER-2 protein and reduces
the effect.
Herceptin does not cure breast cancer
but does reduce the risk of recurrence by
about 30 per cent in patients with an
early-stage breast cancer who are HER-2
positive. It is, however, extremely
expensive, so before it can be prescribed
patients must be tested for the gene.
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“At the moment breast cancers are so different that treating two patients the same may
only work for one. If we can target therapy to that type of cell, tailor the therapy to the
patient’s genes to knock out the cancer cells by knocking out the genes that make them
grow, then we might be able to control the disease.”
Until recently there were two main
tests for HER-2: the IHC
(ImmunoHistoChemistry) test and the
FISH test (Fluorescence In Situ
Hybridisation). The IHC test looks for the
protein on the cell’s surface while the
FISH test uses fluorescent gene probes to
look for the gene itself to see if it is
present in high numbers (“amplified”).
On October 1 this year the Federal
Government accepted a recommendation
from the Pharmaceutical Benefits
Advisory Committee to list Herceptin on
the Pharmaceutical Benefits Scheme for
the treatment of patients with HER-2
positive early stage breast cancer
following surgery, provided they tested
positive for gene amplification. The
advisory committee estimates this will be
about 2100 patients each year.
The committee rejected the IHC test
as the standard test for determining
treatment eligibility despite it being
cheaper and more widely available, after
data from Australia and overseas
indicated there were serious problems
with its accuracy.
The use of fluorescent dyes, however,
restricts the FISH test to laboratories with
fluorescence microscopes and doesn’t
allow the results to be preserved for future
reference (the fluorescent signal quickly
decays).
“There are a number of problems with
the FISH test: it is certainly a timeconsuming, labour intensive and
expensive technique, but there is a new
alternative that satisfies the (committee’s)
requirement,” says Dr Morey, who is
referring to the CISH test.
Using peroxidase enzyme to detect
HER-2 gene amplification under a normal
light microscope, the Chromogenic In Situ
Hybridisation (CISH) test allows slides to
be stored at room temperature without
loss of signal. It correlated well when
tested in five Australian laboratories
against breast cancers where the HER-2
status was already known.
Roche, the maker of Herceptin, is
funding the establishment of several CISH
testing laboratories over the next four
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years, and pathologists will continue to
assess and research new tests and
treatments.
cancer and know what type it is, but
“The discovery of the importance of
hormone receptors and, now, the HER-2
gene have made it very apparent that
breast cancer is not just one disease,” Dr
Morey says. “Recent research suggests
there are at least five or six subtypes
based on molecular profiles, and in the
future we will need additional molecular
assays to sub-classify breast cancer and
be able to provide more accurate
prognostic information.”
reliable way to diagnose the disease is to
For Professor Bilous the hope is to
one day develop a test that will detect
cancer without requiring the pathologist to
examine cells.
only work for one. If we can target therapy
“A lot of people want to look at a
breast from the outside and detect the
that make them grow, then we might be
we’re not even close to that,” he says.
“Unfortunately, at this stage the only
get a sample of the cells and then try to
quickly and accurately prepare the report
and, hopefully present it the same day.
“The cutting-edge research is really
focussed on what makes breast cancer
cells act the way they do: looking at the
genes that control their growth. At the
moment breast cancers are so different
that treating two patients the same may
to that type of cell, tailor the therapy to
the patient’s genes to knock out the
cancer cells by knocking out the genes
able to control the disease.”
BREAST CHANGES
– WHAT TO LOOK FOR
• A lump or lumpiness.
• Any change in the shape or appearance of the breast
such as dimpling or redness.
• An area that feels different to the rest.
• Discharge from the nipple.
• Change in the shape or appearance of the nipple:
pulling in or scaliness.
• Pain.
The vast majority of women who undergo the triple test
are negative for breast cancer but it is vital that all breast
changes are carefully investigated. If it is cancer, early
detection will drastically improve the chances of effective
treatment.
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From doctor to patient
and back again
ANATOMICAL PATHOLOGISTS DIAGNOSE BREAST CANCER
EVERY DAY, BUT AS PATHOLOGIST JANE DAHLSTROM WRITES
- SHE NEVER THOUGHT IT WOULD HAPPEN TO HER.
am a wife and mother but I am also a
doctor, teacher, researcher, and breast
cancer survivor.
I
I essentially diagnosed my own breast
cancer. The cancer first presented as
Paget’s disease. This is an uncommon
type of breast cancer where the cancer
cells spread from the breast into the skin
of the nipple and surrounding skin. It often
presents as an itchy nipple that may bleed
easily or lose colour. A biopsy was
performed followed by a left mastectomy
and sentinel node sampling. A lesion was
later detected in the right breast on MRI.
My treatment included bilateral breast
reconstruction following a right
mastectomy.
Having gone through the process of
diagnosis and treatment myself and as a
doctor diagnosing patients with this
disease I am acutely aware of how even
with good knowledge the very basics of
comprehending the diagnosis and
treatment can be difficult. I firmly believe
understanding what is going on can help
maintain a positive attitude to so
important in recovery.
Most breast cancer patients will
undergo a biopsy prior to definitive
treatment. Anatomical Pathologists are
responsible for making this important
tissue diagnosis. One type of biopsy that
may be performed is fine needle
aspiration – where a thin needle is used to
draw cells often out of a lump. The cells
are then placed onto a slide which is then
stained so the pathologist can look at the
cells. The second type of test is a core or
mammotome biopsy. This is often used
when a lesion is detected on
mammography. This type of biopsy not
only allows the pathologist to look at
individual cells but also the relationship of
cells to each other. This is very important
if you are trying to decide if a cancer is
invasive or not. Fine needle aspiration and
core biopsy aim to tell you what the
lesion is but they usually do not remove
the lesion. Lumpectomies and
mastectomies are used to remove
breast lesions. The lumpectomies we
receive are often blue. That is because
it is now common for surgeons to
perform sentinel node biopsies which
require dye to be injected into the tumour
site to show where the first lymph node
related to the tumour is. My students are
often surprised at how blue the breast is
but as anyone who has had this test done
will know when you have the dye injected
into your body you cry blue and wee blue
so it is not surprising the breast tissue is
blue too!
As a pathologist it is my job to provide
information which will determine further
treatment and to some extent the
prognosis for a patient. In a breast cancer
report, the pathologist describes the size
and type of cancer and gives the doctors
the information they need to decide on
further treatment. If lymph nodes have
been sampled we say whether there is
any breast cancer in those as this may
result in the doctor recommending
chemotherapy.
In the ANU medical course where I
teach, medical students learn about
breast disease in all 4 years of the
graduate course. In 2003 I began a
surgical specimen teaching museum as I
realised that many medical students had
no idea what normal tissues looked liked
let alone diseases such as emphysema,
hyatid disease and cancer. Seeing
pictures only gives a two dimensional
view. I believe if doctors do not
understand what a disease looks like they
are not in a strong position to explain
things to a patient.
When a tissue comes in
for pathological assessment it is
usually photographed and the
pathologist then examines the tissue and
takes samples. According to government
guidelines, the remaining tissue not
required for diagnosis in all pathology
laboratories is usually discarded about 6
weeks after examination. If after a full
pathological assessment the tissue still
has some features that could be used for
teaching we send a letter to the patient
asking whether we can keep their tissues
for teaching medical students and allied
health professionals. We have had an
overwhelming response. Some patients
have even asked to see their tissues and I
am more than happy to arrange this. Our
students have voted this museum as one
of their best learning experiences 3 years
in a row.
Throughout my journey as a patient I
have had wonderful care and amazing
support from my family, friends and
colleagues. At times it has been quite
overwhelming.
My son Peter was aged just 7 after my
first mastectomy. I was 41. At that time he
was in the habit of coming into my
bedroom and sitting on my bed and
chatting as I got dressed. One day as I
was putting my breast prothesis in my bra
he looked as me, smiled and said “ as
good as new”.
Dr Jane Dahlstrom is an Anatomical
Pathologist and Associate Professor at the
Australian National University Medical School.
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HEALTH + MEDICINE
Stem cell central
AS CONTROVERSY RAGES IN COUNTRIES SUCH AS
AUSTRALIA AND THE US OVER THE USE OF EMBRYONIC
STEM CELLS, SINGAPORE HAS EMERGED AS A HAVEN
FOR BIOMEDICAL RESEARCH, WRITES DAVE HOSKIN .
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Ironically, given its reputation for conservatism,
Singapore has a history of being an early adopter of
progressive medical techniques.
t was the veto heard round the world.
Faced with the Stem Cell Research
Enhancement Act, legislation that would
have overturned America's restrictions on
human embryonic stem cell research,
George Bush, exercised in July the first
veto of his presidency.
I
In August 2001, Bush had been the
first president to allow federal funds to be
used for such research, but with the
caveat that scientists were restricted to
stem cell lines already in existence. His
decision did not affect private
laboratories, but with the vast majority of
the country's basic science research
funded by the federal government, it still
left US researchers at a disadvantage.
There was wide public support for lifting
these restrictions, and indeed the bill
presented to Bush was the result of
bipartisan co-operation in Congress.
But the legislation's advocates could
not muster the two-thirds majority
required to override Bush's veto, and
while states such as California have
attempted to fund their own research,
California’s proposed $US3 billion ($A4
billion) program is mired in legal battles.
Consequently, with the world's largest
economic power unwilling to throw its full
weight behind the field, places such as
Singapore have emerged as a haven for
biomedical research. Aware that key areas
of its economy, such as low-cost
manufacturing and electronics, were
contracting, the Singapore Government
launched a biomedical science initiative,
the first step in establishing biotechnology
as the city-state’s economic "fourth pillar".
The timing of the initiative was well
chosen, and local stem cell research,
already given a head start by the
pioneering work of Professor Ariff Bongso,
managed to catch the wave of progress.
these cells have no specialised function
and, if cultured correctly, will produce
billions of offspring.
Ironically, given its reputation for
conservatism, Singapore has a history of
being an early adopter of progressive
medical techniques. Professor Bongso
initially came to prominence serving as a
fertility specialist for the team responsible
for many of Asia’s test tube baby
breakthroughs. In vitro fertilisation was still
a controversial treatment at the time, and
other countries were slow to embrace it.
The potential applications of the
research were astounding. Professor
Bongso hoped that his cultures could
eventually create a gallery of cells for
regenerative medicine and tissue
replacement. Furthermore, observing stem
cells promised to provide basic insight
into disease processes, and this
knowledge would hopefully one day
translate into new drug therapies.
As a consequence, Singapore took
the lead, and in 1987 Professor Bongso
joined the staff of the National University
Hospital to help establish a state-of-theart IVF program.
When he carried out his original
research, he and his team were the only
people in Singapore working on human
embryonic stem cells. Today there are
about 30 stem cell research groups in
Singapore, a notable example being that
of Professor Lee Eng Hin and Associate
Professor James Goh and its focus on
developing technologies in bone, cartilage
and ligament regeneration.
It was during his work in IVF that he
became fascinated by the potential of
embryonic stem cells. In 1993, under
strict guidelines imposed by the National
University Hospital's ethics committee, he
obtained spare embryos from the IVF
program and began attempting to multiply
stem cells without allowing them to
differentiate.
His success was initially limited, and
despite managing to isolate bona fide
stem cells, they spontaneously
differentiated into mature fibroblasts, cells
found in connective tissue, after two
generations. By keeping the stem cells
dividing in a petri dish for any time at all
though, he had achieved something that
had never been done before.
Professor Bongso's fascination with
embryonic stem cells was driven by the
fact that they are pluripotent, i.e. capable
of generating almost any cell type found
in the adult body. In their early stages
In 2005 the team announced that it
had successfully used mesenchymal stem
cells derived from bone marrow to repair
damaged cartilage in the knees of five
people.
Another success story is that of ES
Cell International, a company that recently
moved from Melbourne to Singapore.
Headed by Dr Alan Colman (one of the
researchers involved in the cloning of
Dolly the sheep), ES Cell International
recently announced the production and
banking of clinically compliant human
embryonic stem cell lines, and is offering
to sell them to researchers worldwide.
Singapore is not the only country to
nurture stem cell research, but unlike
other notable hubs such as Britain and
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Professor John Rasko
biomedical giants such as
Novartis, GlaxoSmithKline and Eli
Lilly into the city-state.
Companies such as these are
housed in the massive BioPolis, a
seven-building research centre.
South Korea, Singapore's Government
displays an unabashed enthusiasm for the
field. Where other countries speak of
governmental funding in terms of tens of
millions, Singapore speaks in billions. In
2005 it committed $S12 billion ($A10
billion) over the next five years to further
strengthen research and development,
more than doubling the commitment
made in the previous five-year period.
Unsurprisingly therefore, Singapore’s
biomedical industry has rapidly expanded
in the past six years, with the Government
going out of its way to attract research.
There is a strong emphasis on the
protection of intellectual property rights,
and tax incentives have already enticed
36_PATHWAY
Singapore has also
aggressively recruited top
scientists from overseas,
investing heavily in their research
as well as harnessing their
expertise to train local scientists.
The latter element of the initiative
has progressed more slowly (and
indeed Singapore's Agency for
Science Technology and Research pulled
the plug on the local division of Johns
Hopkins University, claiming it had failed
to meet requirements in training students),
but it is hoped that eventually Singapore's
next generation of scientists will be able
to take the reins.
The most compelling attraction for
overseas researchers is the fact that
Singapore's biotechnology industry is here
to stay. The willingness to allow research
to develop over longer periods than usual
helps create an atmosphere of stability,
and for scientists all too used to working
in a controversial field, this is refreshing.
The Government has a strong
commitment to research that translates
into benefits for patients, but as Professor
Bongso puts it, "I think the approach is
cautiously optimistic, evidence based,
with no immediate hurry to run to the
clinic.”
Pathologists in Australia note that one
of the most fundamental differences
between Down Under and Singapore is
the latter’s liberal attitude towards stem
cell research, in particular the practice of
therapeutic cloning.
Therapeutic cloning is defined as the
application of cloning technology to
produce tissue for therapeutic purposes,
without the creation of a complete animal
or human being. For instance, in the case
of a researcher attempting to develop a
therapy for diabetes, a doctor would take
a sample of skin cells from the patient and
isolate their DNA. Next, a donor egg cell
would be hollowed of its own genetic
contents and injected with the patient's
DNA.
The resultant embryo would be
nurtured to grow and divide into a
blastocyst. Some blastocyst cells are
harvested and then coaxed with growth
factors to mature into insulin producing
cells. Finally, millions of these insulinproducing cells would be injected back
into the patient. In an ideal world, the
patient's diabetes could then be
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Opinions were canvassed regarding the use of stem cells in
medicine, and whether IVF embryos were an appropriate source
for material. Once the dialogue was concluded, a strong,
transparent framework was established, with the use of embryos
from IVF and therapeutic cloning being allowed under
Singaporean law.
"Stem cell scientists know what they can
do and what they cannot do. We know
where our boundaries are."
Professor Ariff Bongso
temporarily “reversed” with no side effects
such as tissue rejection.
Like Australia, many countries have
banned this practice as part of a general
moratorium on human cloning, but there
is a compelling case for therapeutic
cloning to be allowed under strict ethical
and legal guidelines. Certainly the ethical
framework developed by Singapore was
not arrived at lightly, and it is interesting to
contrast its review of the subject with that
of Australia's.
Formed in December 2000,
Singapore's Bioethics Advisory
Committee sought guidance on human
stem cell research and cloning both
internationally and locally. In November
2001, a consultation paper containing
interim recommendations was released to
39 of Singapore's professional groups
(such as teachers, lawyers and engineers),
as well as its numerous religious groups.
Opinions were canvassed regarding
the use of stem cells in medicine, and
whether IVF embryos were an appropriate
source for material. Once the dialogue
was concluded, a strong, transparent
framework was established, with the use
of embryos from IVF and therapeutic
cloning being allowed under Singaporean
law.
"The framework has very fair checks
and balances," says Professor Bongso.
Despite reaching similar conclusions,
the review commissioned by the
Australian Government has not been so
readily accepted. The Lockhart review
comprised a six-member committee
tasked with examining the Prohibition of
Human Cloning Act 2002 and the
Research Involving Human Embryos Act
2002. In passing this legislation, the
Australian Government had agreed to
fund stem cell research, but it banned
human cloning.
However, after a six-month review of
the legislation, one of the many
recommendations of the Lockhart
committee was that the ban on
therapeutic cloning be lifted. The fact that
the review has received little enthusiasm
from the Government concerns Australian
researchers, and they feel that a cogent,
thoughtful report is being needlessly
ignored.
"There has not been a great deal of
leadership in terms of deciding what the
path should be for the country," says
Professor John Rasko, a haematologist
involved in research on adult stem cells at
Royal Prince Alfred Hospital and the
Centenary Institute.
"In Singapore there really does seem
to be an immediate familiarity among
senior politicians about the issues.
Whereas to hear someone like (Australian
Treasurer Peter Costello) recently say (nine
months after the report was delivered) that
he wanted to learn what the issues were,
and was going to read the Lockhart
review, was a bit disappointing."
It is clear that local researchers admire
the work being done in Singapore, but
they also warn that failing to learn by their
example could leave us in a similar
situation to the Americans. Associate
Professor Chris O'Neill, a researcher
studying the genetic predisposition of
embryos that form stem cell lines, is
careful to point out that the current
discussion about therapeutic cloning does
not detract from the real contributions the
Australian Government has made to stem
cell research.
But he also feels that the situation is
not ideal. "I think that when you look at
the amount of money that is going into
stem cell research around the world and
the amount that's going in here in
Australia, there's a very obvious
discrepancy, such that there is a bit of a
brain drain," he says.
"As soon as you have to do things
offshore then you lose a certain amount of
the intellectual capital associated with
that. I think we are losing intellectual
capital as well as intellectuals."
At the time of writing, there did appear
to be some movement on the issue, with
Prime Minister John Howard agreeing to
allow a conscience vote on any Lockhartstyle legislation introduced to Parliament.
The ensuing debate would doubtless
be highly politicised, but as Singapore has
managed to demonstrate, ethics and
economic benefits need not be mutually
exclusive. It is the balance that is
important, and for Ariff Bongso it is his
Government's careful attempts to find that
balance that he identifies as the bottom
line.
"(We have) good infrastructure,
discipline, a good and transparent
regulatory framework, ample funding,
encouragement and support from the
higher echelons of Government," he says.
"What more can one ask?"
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
PATHWAY_37
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HEALTH + MEDICINE
Pathology Update 2007
2- 4 March
Sydney Convention and Exhibition Centre
Darling Harbour, Sydney
athology Update is regularly praised
as one of the most important events
on the pathology calendar and Pathology
Update 2007 promises to be no different.
Offering exceptional opportunities to
exchange expertise and knowledge,
Pathology Update 2007 has an impressive
list of distinguished national and
international speakers, an expanded
program for Trainees, forums and
discussions. Professional Day, on Friday 2
March, will expand on the 2006 forum’s
theme of “Forum of the Future with
Innovations”, with an impressive array of
speakers, including international guest
speakers Dr Larry Kricka and Lord Patrick
Carter of Coles.
P
As well as an important professional
event, Pathology Update 2007 has a fun
and relaxing social program that will
provide a chance to meet other
pathologists and international speakers in
a relaxed and informal environment. The
Update will kick-off with the Welcome
Cocktail Party, ‘A Bash of Jazz and a
Splash of Wine’ at the Trade Exhibition on
Friday 2 March with a special cocktail and
jazz ensemble Smooth Grooves. The
Pathology Update dinner on Saturday 3
March is a chance to celebrate the
achievements of the past year with fellow
pathologists. Held at the stunning
Summit restaurant at historic Australia
Square, enjoy extraordinary views of the
city, while seated 47 levels up enjoying a
sumptuous three course meal.
This year, the College has simplified
the registration form, offering delegates
the choice of day or full registration.
Fellows and Trainees with full registration
will be able to attend the entire
conference, including the Cocktail Party
and Conference Dinner. Day registration is
available to delegates who wish to attend
for one day only in line with current
practice at other medical conferences.
38_PATHWAY
Special Events
he Inaugural David Rothfield Memorial
Oration will be presented on
Professional Day - Friday 2 March by Dr
David Burnett.
T
A Chemical Pathologist trained in
Sydney and London, David Rothfield was
Director of Biochemistry at St Vincent’s
Hospital Sydney for 22 years. Upon
retirement he became staff pathologist at
NATA, reducing to part-time in 1993, a
position retained until his death. Dearly
loved and respected by so many, David is
fondly remembered for fostering a culture
of excellence in many fields and for his
hands-on dedication to training and
tutorials for Trainees. His enthusiasm (into
his 80’s) for the QA Programs he was
instrumental in establishing and
championing was unbounded.
Dr David Burnett was Consultant
Biochemist to the St Albans and Hemel
Hempstead NHS Trust, UK until 1995 and
awarded the OBE for services to Clinical
Biochemistry in 1996. He became a
Fellow of the Royal College of
Pathologists in 1998 and Emeritus
Member of the Association of Clinical
Biochemists in 1999. He continues to act
as a consultant in quality and
accreditation systems and is the author of
A Practical Guide to Accreditation in
Laboratory Medicine published in 2002.
Published papers include: Standards for
the Medical Laboratory - harmonisation
and subsidiarity; Accreditation and pointof-care testing; and Clinical Pathology
Accreditation - Standards for the Medical
Laboratory.
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Special Guests
Lord
ver 100 distinguished speakers will
participate in Pathology Update 2007.
Among them include;
O
Professor Ian Frazer
- 2006 Australian of the Year.
Professor Ian Frazer, Director of the Centre
for Immunology and Cancer Research,
University of Queensland, will present the
Eva Raik lecture and participate in the
Microbiology program.
Above: Pathology Update Dinner to be held at
Sydney's famous revolving restaurant - The Summit.
Left: Lord Carter of Coles
Dr David Huntsman
Dr David Huntsman, Genetic Pathology
Evaluation Centre, Jack Bell Research
Centre, Canada will participate in the
Anatomical Pathology and Genetics
program.
Patrick Carter of Coles
(pictured above)
of New Fellows and
Highlights
T
Dr Larry Kricka
Dr Larry Kricka, Professor of Pathology
and Laboratory Medicine, University of
Pennsylvania, USA will participate in the
Professional Day Program.
Dr Arnold Monto
Dr Arnold Monto, Professor of Epidemiology,
University of Michigan, USA. Dr Monto, a
bird flu and bioterror expert, will
participate in the Microbiology program.
Dr Robert Petras
Dr Robert Petras, National Director of
Gastrointestinal Pathology Services,
AmeriPath Institute of Gastrointestinal
Pathology and Digestive Disease, USA will
participate in the Anatomical Pathology
program.
Dr Sunil Sethi
Dr Sunil Sethi, Chief and Senior
Consultant, Department of Laboratory
Medicine, National University Hospital,
Singapore will participate in the Chemical
Pathology program.
Annual Admission
Lord Patrick Carter of Coles chaired the
Report of the Review of NHS Pathology
Services in England.
rofessional Day is proud to have a
parallel trainees’ program on the
Friday morning including a High
Performance Microscopy Workshop
presented by Olympus.
P
The scientific program has five
combined sessions: Genetics and
Haematology, Anatomical and Genetics,
Forensics and Paediatrics, Haematology
and Microbiology, Genetics and
Immunopathology.
Pathology Update continues its social
events program with a Wine and Cheese
closing on Sunday afternoon from 3.004.00pm in the Trade Exhibition Hall with
wines from the Margaret River from Lenton
Brae Winery.
For more information about Pathology Update
2007 visit www.rcpa.edu.au/pathologyupdate
for a full update calendar or to register online.
Awards Ceremony
he Annual Admission of New
Fellows and Awards Ceremony
is the formal highlight of the College
year, when new Fellows, Honorary
Fellows and Associates are
admitted to the College. Special
awards and prizes are also
presented at this time, including the
Distinguished Fellow Award, the
Meritorious Service Award, the
RCPA Honour Roll, the Kanematsu
Award and Trainee prizes. The
President of the College, Dr Stewart
Bryant, will deliver the Edgar
Thomson Oration as part of the
proceedings.
Saturday 3 March 2007,
6.00 – 7.00pm, Bayside Terrace.
All Pathology Update attendees are
invited to attend this special event.
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Jumping jack flash
THE JACK JUMPER ANT POSES A SERIOUS, SOMETIMES DEADLY, RISK TO THOSE
ALLERGIC TO ITS STING. BUT IT MAY ALSO HAVE SOMETHING MEDICINE CAN GAIN
FROM, WRITES JUSTINE COSTIGAN .
PHOTOGRAPHER: BRETT HARTWIG
hen Robert Heddle first encountered
jack jumper ants more than 30
years ago, the then little boy wasn’t
exactly sure what they were, but he knew
straight away they might be dangerous.
W
On a family picnic near Mt Lofty in the
Adelaide Hills, the primary school student
was fascinated by the sudden appearance
of the aggressive and nasty looking ants.
Wary of their interest, the family
thought it best to move the picnic to a
more peaceful location. Being in the
middle of jack jumper ant territory, Robert
Heddle’s family was right to be cautious.
When confronted on its own territory, the
jack jumper is likely to become very
aggressive, and its vicious sting has been
known to cause an anaphylactic reaction
(extreme allergic response) and,
occasionally, death.
Now allergy director at the Department
of Respiratory Medicine, Flinders Medical
Centre and Flinders University of South
Australia, immunopathologist Robert
Heddle is one of just a handful of jack
jumper ant experts in Australia.
40_PATHWAY
Together with Simon Brown and
Michael Wiese from the Royal Hobart
Hospital, Dr Heddle has documented
anaphylactic reactions to the jack jumper
ant around Australia. Most commonly
found in Tasmania, Victoria, the ACT, the
Snowy Mountains, coastal NSW, the
Adelaide Hills and small pockets in the
Blue Mountains and Western Australia, the
jack jumper is a serious risk to those with
an allergy to its sting.
Australia and skipper ants in parts of
Victoria.
Jack jumpers have a black body and
orange/brown jaws/pincers and limbs,
and live in underground nests. Sometimes
found under rocks, they can stray far from
the nest in search of food and have been
known to turn up in people’s houses and
kitchens if the nest is located close to
inhabited areas.
It is one of two ant groups within the
genus Myrmecia, the other being inch, or
bulldog, ants – the latter a name that aptly
indicates their level of ferocity and
aggression. While the two ant groups
share some characteristics, bulldog ants
are larger, about 15 to 25mm long,
whereas jumper ants are generally 10 to
15mm long and often display jerky,
jumping movements.
When in attack mode a jumper grasps
its victim in its jaws then bends its body
back to sting with its tail. Even if you are
not allergic to it, the sting is typically very
painful. Large local swelling can last for
several days and minor allergic reactions
such as swelling of the lips, face and
eyes, congestion and watering of nose
and eyes, hives or welts on the skin and
headaches, anxiety and flushing are
common.
The jumper ant most frequently
associated with allergic reactions is
commonly known as the jack jumper or
jumping jack, although jumper ants are
also known as hopper ants in South
A severe allergic reaction –
anaphylaxis – will spark a range of serious
symptoms including: difficulty breathing
and/or talking; swelling of the tongue and
throat; coughing and wheezing; chest
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Page 41
Ant enthusiast and allergy specialist,
Dr Robert Heddle
tightness; abdominal pain, nausea and
vomiting; confusion, loss of
consciousness and or/collapse; and in
children paleness and floppiness.
If the victim is unable to get help
quickly, there is a real risk of death and
several cases have been recorded in
recent years.
However, in a recent interview
Professor Simon Brown warned that the
extent of death caused by the jack jumper
remains unclear because it is not
recognised as a cause of death on
Australia’s mortality register. Professor
Brown believes deaths from jumper jack
ant stings may be misdiagnosed by
doctors as a heart attack or listed as
cause unknown, making it hard to judge
the extent of the problem.
"You've got to look carefully for ant
sting allergy, because it doesn't leave any
characteristic features at post-mortem,"
he says. "People generally know that bees
and wasps can cause sting anaphylaxis
but a lot of doctors who sign death
certificates and who do post-mortems
have no idea that ants cause the same
problem and simply don't think of it as a
possibility."
A person’s risk of developing a severe
reaction to an ant sting is related to
exposure. Once exposed to the venom
the body will develop antibodies and the
next time you’re stung the body
automatically swings into defence mode,
sometimes triggering an allergic reaction.
The severity of the reaction is hard to
anticipate, with many people experiencing
both severe and mild reactions over time.
with jack jumper ant venom extracts was
effective at switching off jack jumper ant
allergy and preventing allergic reactions
when patients were stung again.
In the past couple of years, however, a
study performed by Professor Brown’s
team in Tasmania demonstrated that
immunotherapy (“desensitising therapy”)
Professor Brown says success
requires accurate diagnosis of the species
involved. Although he is now based at the
University of Western Australia, he is
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working to establish a treatment program in Tasmania
and has begun a national study with collaborators
including Dr Heddle into anaphylactic reactions and
deaths from venom of jack jumper and other stinging
ants.
While only 2-3 per cent of the population is likely to
present any reaction to the jack jumper sting, it is
impossible to know whether someone falls into the risk
category in advance, and as most jack jumpers live in
bushy areas, it is wise for everyone to be cautious of
these potentially deadly creatures.
However, suggests Dr Heddle, more than just
warning people about the dangers of being stung by a
jack jumper, it’s time Australians took a broader interest
in these fascinating creatures. With studies proving their
venom has powerful antibiotic qualities – no bacteria will
grow in the venom unless it is highly diluted – it is just
possible we may have more to learn than to fear from
these ancient insects.
What is
immunopathology?
mmunopathology is the medical specialty that deals with the study,
I
diagnosis and management of conditions in which the immune
system does not function properly.
Immunopathologists contribute to the diagnosis and care of
patients in whom the immune system is either overactive (as in
allergic and autoimmune disorders) or underactive (such as primary
and secondary immunodeficiencies). They may also be involved in
the diagnosis and care of patients with cancers, with organ
transplantation and in prevention of disease by immunisation. In the
laboratory, immunopathologists design, perform and supervise a
variety of tests of immunefunction that aid in the diagnosis and
evaluation of disease.
Contact details for Australian Ant Venom Allergy
Study:
Becoming an immunopathologist requires a qualification as a
medical practitioner (including internship). Following your internship
Australia in general: A/Prof Simon Brown or Ellen
MacDonald
Emergency Medicine Research Unit
Department of Emergency Medicine
Fremantle Hospital
Alma Street
Fremantle, WA 6160
Tel: (08) 9431 3733
Fax: (08) 9431 3733
Email: fh.edresearch@health.wa.gov.au
South Australia and western regions of NSW and
Victoria that would drain to Adelaide:
Respiratory/Allergy Unit, Flinders Medical Centre
Flinders Drive
Bedford Park SA 5042
Tel: (08) 8204 4033
Fax: (08) 8204 5632
Email: pam.hudson@fmc.sa.gov.au
42_PATHWAY
you need to train as a specialist in pathology, internal medicine or
both. There are three categories of immunopathologists:
1.
those who are primarily responsible for providing laboratory
services;
2.
those who provide both patient care and laboratory services;
3.
those who are primarily responsible for patient care.
Specialist training requires a minimum of five years in a registrar
position accredited by the Royal College of Pathologists of
Australasia. This means that although you are undergoing further
study, you are actually working and earning as a doctor at the same
time. Once you have completed all the requirements and
examinations and are accepted as a Fellow of the College,
you are entitled to use the letters FRCPA after your name.
For more information visit the RCPA website at
www.rcpa.edu.au
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lP ia t hfWe
s
t
y
l
e
ay lifestyle
arts + culture
44
travel
53
food + wine
58
restaurant reviews
62
events in Tasmania 66
conference calendar 67
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ARTS + CULTURE
Ferrari safari
TAKE 42 FERRARIS, ADD SPECTACULAR TASMANIAN
SCENERY AND FASTEN YOUR SEAT BELT FOR AN
AMAZING RIDE. BY GREG CLARKE.
PHOTOGRAPHER: JERRY GALEA
erraris and bushwalking? Betting your
house that these are twains never to
meet could be considered the action of
someone perfectly sane. But if you think
Tasmania is the sole preserve of
bushwalkers, you might want to
reconsider before wagering the castle.
F
Forty-two Ferraris worth collectively
about $10 million united from across
Australia in September for the annual
National Ferrari Tour, held for the first time
in Tasmania. The eight-day tour took in
Tamar Valley wineries and east coast
fishing villages. In prancing-horse style,
the Ferraris even tackled a soupçon of the
44_PATHWAY
Cradle Mountain Lake St Clair National
hugged the blacktop, breezing through
Park.
twists, climbs and dips.
But the Ferraris’ considerable abilities
The drivers and their passengers
did not extend to negotiating the walking
returned the waves of the locals as they
trails that twist from Cradle Mountain.
entered Strahan, once the front line in the
Mostly they had a love-in with the
battle to save the Franklin River and now
bitumen – Tassie’s roads have a
one of Tassie’s highlights.
reputation within the fast-car brethren as
Strahan hunkers down by the gigantic
some of the best touring roads in the
Macquarie Harbour, whose waters are
world. On the roller-coasting road that
swelled by the Southern Ocean but also
slivers through UNESCO World Heritage
the wild Franklin and Gordon Rivers. The
wilderness and the Tasmanian highlands,
rainforests hereabouts are thick with the
connecting Strahan on the west coast to
ancient verdancy of pines and myrtles, an
other parts of the island, the roadsters
imprint of Gondwana, and many of them
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are old enough to make a whippersnapper
of the 19th century.
Strahan, an unobtrusive outpost in the
Tasmanian wilderness, is bookended by
harbour and forest. The only way to get a
Ferrari into these parts would be to cash
in a brace and build a road. Nobody has
been inspired yet, for there are so few
roads that the only effortless way to
explore is to tour the Gordon River. Along
with the crayfish boats, purpose-built craft
depart from the wharf by the esplanade.
There are various ways to cruise the
Gordon. You can sail or take a luxurious
catamaran, or even a seaplane that puts
down on the river. The bewitching
rainforest, including coveted huon pines,
lurches over the Gordon and provides
playgrounds for platypuses, eagles and
wallabies.
The harbour also shelters Sarah
Island, once a notorious convict hellhole,
and modern pursuits: fish farms that
produce renowned seafood flourish in
Macquarie’s waters.
Japanese-born Tetsuya Wakuda is one
of Australia’s most feted chefs. Tasmania’s
ocean trout is a Tets icon. While
Macquarie Harbour nurtures his fish, Tets
champions the surrounds.
“Forty per cent of Tassie is either
World Heritage Area or national park.
There is clean air and water. Of course the
produce is good. It’s natural logic. People
talk about organic, but what’s organic if
the air is polluted? Tassie is beyond
organic. It’s a wonderful place.”
My first night with the Ferrari cadres is
spent in Launceston, the state’s largest
city after Hobart. Near dusk I find my way
into Cataract Gorge following a walking
trail past the reinvigorated seaport, built
on the Tamar River beside the CBD.
The 1918 Complete Guide to
Tasmania drooled over the gorge: “No
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other place in the Commonwealth can
boast such a sight within 10 minutes’ walk
of the city centre.”
Indian princess, could surely make a
success of Bollywood if her Ferrari
fortunes were to diminish.
There are walking trails scarped from
walls of rock, swimming holes – the South
Esk River flows through the gorge –
peacocks and a single-span chairlift. The
WWI-era guide reported, “after following
the path a spacious concert ground is
reached where there is a refreshment
room and appliances for billy-boiling”. I
can’t find the billy facilities, but this is still,
with peacocks, towering trees and a
suspension bridge, a great place for a
picnic. Or, simply, like elsewhere in
Tasmania, to stand mouth agape and
marvel at masterpieces by Mother Nature.
On their lap of Tasmania the
landscape changes more regularly than a
pop diva in concert. From forest, to hills
ravaged by mining ventures overlooking
Queenstown, from Alpine plateaux to
somnolent coastal villages. Only
committed fashionistas would deny that
nature’s costume changes are far more
fetching.
Among the Ferrari Club of Australia
numbers are John, the Sydney accountant
turned franchise king; Frank, the high-end
butcher, a winner of Victoria’s retailer of
the year; and Veena, who, looking like an
46_PATHWAY
In Hobart I catch up with Frank, 43, on
top of Mount Wellington. He’s travelling
with his dad’s best mate, Wal Amiott, 63.
Wal and Frank’s friendship has firmed
since Frank’s father died. At 1270 metres,
forested Mount Wellington rules over
Hobart. The mountain is Rock-of-Gibraltar
steep. There are spectacular views over
the D’Entrecasteaux Channel and Bruny
Island, and Hobart.
Wal ruminates over why it has taken
him so long to return. Frank as ever
speaks through his moonbeam smile.
“Tassie gives me that sense of country
Victoria, but with a lot more to do. This is
an absolute great place for a family
holiday. Everybody is just so friendly. I’m
going to keep my rally notes and I’m
going to come back with the family. We’re
going to enjoy it a little more leisurely.”
On top of Mt Wellington, Frank’s
gazillion-dollar baby is relegated to a
silver medal behind the astonishing view.
Yet as is the manner of supermodels, she
makes quite an impact on the surrounds
and just perhaps, while lounging on the
mountain, offers up the leitmotif of the
tour: if you do go walking in the
Tasmanian wilderness, consider wearing
Ferrari-red. You’re certainly going to stand
out if you need to be found.
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ARTS + CULTURE
Orchestral notes
from a small island
SONIC HEALTHCARE DIRECTOR COLIN JACKSON IS HAPPY TO CALL HOBART HOME AND THE
TASMANIAN SYMPHONY ORCHESTRA ONE OF HIS ENTHUSIASMS, WRITES GREG CLARKE.
PHOTOGRAPHER: ROB BURNETT
s a director of the main board of
Sonic Healthcare, Colin Jackson’s
brief takes in a workforce of about 14,500
people. Travel for Jackson, including
shuttling through many of the planet’s
time zones on regular eight-day
circumnavigations of the globe, is a
constant.
A
Some of the world’s great cities,
including London, are as familiar to him as
a favourite pair of shoes, but Jackson
feels the pull to return home to Hobart.
“Leo Schofield wrote in one of his
columns – ‘When the door of the plane
opens and you breathe in that fresh air,
you know you’re home.’ I love coming
back.”
Jackson’s apartment looks to the
city’s waterfront, over the sandstone
warehouses of Salamanca, to where the
Aurora Australis readies for a return to
Antarctica. The light-filled home is
furnished with an aesthete’s interests,
including oil paintings and a great oak
dining table from France.
Originally a Melburnian, Jackson has
lived in Hobart for 35 years. There was an
interregnum when he and wife Dianne left
for post-graduate studies in the UK. “We
came back in 1977. We were only going
to be in Hobart for three months, and here
we are. I’m a big Tasmanian ambassador.”
Jackson’s unofficial ambassadorship
includes championing the Tasmanian
Symphony Orchestra, of which he is also
a director. “It’s a good old Beethovensize, small symphony orchestra,” he says.
With 47 members, the TSO specialises
in repertoires of the classical and early
romantic periods, including Beethoven
and Mozart, who wrote scores for
orchestras of the TSO’s size. “During the
recent 250th Mozart anniversary, the TSO
got a lot of exposure,” says Jackson.
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Colin Jackson, director of the main
board of Sonic Healthcare
Sebastian Lang-Lessing
Photographer: Alastair Bett
As part of the celebrations of Mozart’s
oeuvre, the TSO performed statewide. In
March it performed at night at Port Arthur.
Under lights the former convict
settlement, including the main prison on
the hill and great boulevards of elms, can
look far more spectacular than its
torturous history should suggest. A
tangible eeriness remains, however.
The finest convict relics in Australia
provided the setting as a sellout crowd,
and any ghost with a mind for mischief,
was entertained with performances
including Symphony No 9 and the
accompanying Ode to Joy, sung by
massed choir. Cannon booms and
fireworks made memorable cameo
appearances.
The TSO has good form when it
comes to playing in unusual venues.
Its CV includes performances in
forests, secretive coastal coves, mines
and caves.
Short Break
THE HENRY JONES ART HOTEL
AND THE TSO HAVE TWO-NIGHT
HOBART PACKAGES THAT
INCLUDE TSO CONCERT TICKETS
FROM $284 PER PERSON.
CHECK WWW.TASBREAKS.COM.AU
AND PAGE 64 OF THIS ISSUE.
48_PATHWAY
“All of the musicians,
without exception, are
incredibly flexible and very
committed to their orchestra.
They do great things in terms of
their commitment to their art, at
their own personal sacrifice,”
says Jackson with the
enthusiasm that characterises
him.
The TSO’s chief conductor,
German Sebastian LangLessing, initiated the Port Arthur
performance. The high-energy,
passionate Lang-Lessing was
secured in 2004 in a
considerable coup for the
orchestra. “He has a worldwide
reputation,” says Jackson. “He invigorates
everyone.”
For Lang-Lessing, Tasmania just might
be a muse. “I love this state. I love the
landscape, the beaches, the light, the
purity of the air, the food and the people.
This state is in a continuous process of
change and development and if we all are
smart enough, it will stay and to many
people, become the most desirable part
of the world to live in.”
Lang-Lessing has flats in Berlin and
Hobart. “It's not contradictory to live in
the ‘natural state’ and yet be ambitious,
creative, innovative, dynamic and
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passionate about your job,” he says. “You
The TSO’s activities now include film and
can work hard here (in Hobart) as it’s easy
podcasts. And while it has found its niche
to relax after your job is done.”
playing classical music, it also plays a lot
It may come as a surprise to many
that little Tassie has a symphony
orchestra. The TSO’s home in the
Federation Concert Hall by the Hobart
waterfront might make the capital the
smallest city in the world with a full-time
professional orchestra.
of contemporary Australian music. An
Established in 1948, the TSO was
formed in a partnership with the ABC. It
was the first Australian orchestra to have
a weekly radio program – Journey into
Melody ran nationally from 1956 to 1969.
plenty of instances where the TSO might
Australian composers series has just been
released on CD.
According to the PlaybillArts website,
Beethoven Academie, a Belgian orchestra,
put itself up for sale on eBay after losing
its government grant. There have been
have suffered a similar fate.
“A number of years ago the orchestra
funding was threatened,” says Jackson.
“There was a petition taken up which had
30,000 signatures on it. Now, that is huge
in Tasmanian terms. We fight to preserve
it tooth and nail.”
Before his directorship, Jackson was
the CEO of Diagnostic Services Pty Ltd
and vice-president of the Australian
Association of Pathology Practices. While
he remains a fellow of the Australian
Society of Certified Practising
Accountants, Jackson’s two sons call
their dad Sparky, after Chevy Chase’s
character in National Lampoon’s Vacation
movies. The term of affection stems from
Jackson’s regular spouting of new ideas.
Let’s hope the big ideas continue for
Tassie’s little symphony orchestra.
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ARTS + CULTURE
Days of wonder
THE TEN DAYS ON THE ISLAND FESTIVAL IS AN ARTISTIC AND
CULTURAL SHOWCASE NOT TO BE MISSED, WRITES GABI MOCATTA .
asmania has spawned a thriving arts
and cultural scene, and it is this that is
celebrated every two years in the Ten
Days on the Island festival. An exaltation
of all that is artistic and inventive in
Tasmania, Ten Days on the Island is a
cultural treat that should not be missed.
Over 10 days from March 23 to April 1,
artists from Tasmania, as well as from a
diverse collection of isles as far flung as
Sardinia, Hawaii, Newfoundland, Taiwan,
Cape Verde, New Zealand and Manhattan,
will be let loose on Tasmania to create a
wonderful range of cultural displays.
Festival artistic director Elizabeth
Walsh is passionate about the 2007 event.
“It’s a showcase for Tasmania’s creative
spirit,” she says. “It’s about people who
live here on our island, this very special
place, and it’s about connections of
people living on islands elsewhere. Island
living is a shared experience.”
There will be theatre from Ireland, with
the Corn Exchange’s much lauded Dublin
by Lamplight playing at Hobart’s historic
Theatre Royal. More theatre will come
from Denmark, with that country’s awardwinning children’s theatre company
performing the classic Hans Christian
Andersen tale The Little Match Girl.
T
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New Yorker Benjamin Bagby’s solo
performance of the epic Norse tale
Beowulf is also set to dazzle crowds, and
from New Zealand, the fast-paced
comedy Wheeler’s Luck is sure to be a
favourite.
Visiting musicians include Sardinian
songstress Simona Salis, who will perform
in three locations around the state, and
Lura, whose Portuguese and Cape Verde
rhythms will also electrify audiences
around Tasmania.
Visitors to the state will be able to
partake of the festival in many locations.
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Ten Days is more than just a celebration of the arts. “It’s a
showcase for our fabulous Tasmanian island environment,
for our wilderness, and for our food and wine.”
Where?
Venues all over Tasmania,
including Hobart, Launceston,
Cygnet, Bridport, Longford,
Port Arthur, Lillico.
When?
23 March – 1 April 2007
Find out more:
www.tendaysontheisland.org
Tel: (03) 6233 5700
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“One of the great things about the
festival,” says Walsh, “is that we present
work right across the island. This isn’t just
a Hobart-centric event.”
Even small communities in far-flung
corners of the state will participate. The
picturesque small towns of Cygnet in the
south, and Bridport in the north-east, for
instance, will host a major new Ten Days
commission, Isle of Plenty. Here, largescale, site-specific works by top
Tasmanian artists will be the centrepieces
for celebrations of local identity, food and
cultural traditions.
All over the state, guest international
artists will be joined by Tasmanian
performers doing what they do best.
Against the haunting backdrop of the
former penal settlement of Port Arthur, a
new work by 25 leading Tasmanian
sculptors, painters, sound and video
artists, printmakers and performance
artists will become part of an exciting new
Ten Days event, the Port Arthur Project.
In Hobart, Dream Masons, a sound,
song and light spectacular will be staged
over four nights against the historic
sandstone backdrop of Salamanca Arts
Centre. Strung Out, in the northern
Tasmanian town of Longford, will be the
finale of the 2007 event, and will feature
15 classical string ensembles performing
all over the town.
A runaway success of Ten Days 2005,
the Pacific Crystal Palace will again be a
focal point in 2007. Modelled on the
1800s German Spiegeltents, traditionally
travelling cabaret venues often with richly
decorated interiors, this ornate venue will
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be located at Hobart’s Princes Wharf,
accommodating an audience of 300 for
music and cabaret acts. The tent is a
showcase for Pacific Islander design,
featuring inlaid shell work and
sandblasted glass rich with fern motives.
Next year’s festival will introduce the
Palace Salon, a cafe/bar and the grooviest
of meeting places for audiences
heading to Pacific Crystal Palace
events.
For the 2007 festival’s inspirerin-chief, Walsh, Ten Days is more
than just a celebration of the arts.
“It’s a showcase for our fabulous
Tasmanian island environment,
for our wilderness, and for our
food and wine,” she says. “It’s
about the artists, of course, but
it’s also an experience that’s
unique, because we’re inviting
people into our communities
here. That’s something real,
with integrity and openness.
That’s something very
special for visitors to take
away with them. That’s
what sets Ten Days on the
Island apart.”
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TRAVEL
WATER WORLD
BE IT BOATING OR JUST PLAIN FLOATING, THE APPLE ISLE HAS MUCH TO OFFER THE WATER
LOVER. GABI MOCATTA EXPLORES THE ATTRACTIONS.
PHOTOS COURTESY OF TOURISM TASMANIA
Bay of Fires
PHOTO COURTESY OF TOURISM TASMANIA AND GEORGE APOSTOLIDIS
ne of the best things about living on
O
an island is the water that surrounds
it. Tasmania, therefore, easily qualifies as
a water lover’s paradise.
In fact the state is an archipelago of
more than 300 islands with a coastline of
more than 3000 kilometres, and its bays,
coves, lagoons, peninsulas, beaches,
capes and channels are the perfect
territory for watery diversions. Sailing, sea
kayaking, surfing and just seaside landlubbing are what waterside life in
Tasmania is made of.
It has been said that Tasmanians own
more watercraft per capita than the
inhabitants of any other state. These are
much in evidence in the state’s waterside
capital, Hobart, where on weekday
evenings in summer hundreds of white
sails grace the harbour for Twilight
Racing. Hobart is so in love with the sail
that it holds a Regatta Day public holiday
each year in honour of it.
This beautiful waterside city is also
famously the end point of annual
bluewater classic the Sydney-to-Hobart
Yacht Race, which starts on Boxing Day.
The world’s top racing teams and their
high-tech boats start to arrive just before
New Year, and there’s an almighty
celebration in Hobart’s dockside precinct,
with much popping of champagne corks.
This is a great time to be in Hobart:
there is a food festival, street buskers and
much revelry on the dockside, just spitting
distance from the Sydney-to-Hobart finish
line.
You don’t have to be a sailor to enjoy
waterside life in Tasmania, but when
visiting the state’s capital, the opportunity
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"You can almost guarantee you'll get some rough weather during the race, after
all it's five days long. The hardest thing about the race is getting started there's so many yachts on the water you can't see the starting line!"
Malcolm Mohr
Chemical Pathologist, Royal Melbourne Hospital
Sydney-Hobart, mid 1990s
to go out onto the water shouldn’t be
missed. A crewed harbour cruise under
the billowing sails of replica 18th-century
square rigger Lady Nelson is
unforgettable, or fly out into Storm Bay
under the rigging of 17-time SydneyHobart veteran yacht Mirabooka.
There’s more sedate cruising to be
had on Hobart Cruises’ jaunt up the
Derwent River to one of Tasmania’s bestknown winery/restaurants, Moorilla
Estate, or there’s the cruise south down
the D’Entrecasteaux Channel for
wonderful food at waterside Peppermint
Bay restaurant.
Sydney to Hobart Yacht Race
PHOTO COURTESY OF TOURISM TASMANIA AND RICHARD EASTWOOD
SAILING:
The Royal Yacht Club of Tasmania www.ryct.org.au, the Derwent
Sailing Squadron www.dssinc.org.au and Bellerive Yacht Club
www.belleriveyachtclub.com.au all organise twilight sailing and racing.
Visiting sailors can often be accommodated on request.
THE LADY NELSON
Cruise Hobart’s beautiful harbour on an 18th century square-rigger
Tel: (03) 6234 3348
www.ladynelson.org.au
MIRABOOKA
Cruising under sail on a Sydney-Hobart yacht
Tel: (03) 6224 2477
www.baycharters.com.au
STORMBREAKER
Sailing adventures into west coast rainforest wilderness
Tel: (03) 6471 7422
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Just south of Hobart, there are some
spectacular island seascapes to take in,
with a Bruny Island Charters sea journey
round the wild southern reaches of Bruny
Island. This takes in waters that are home
to seals, whales, albatrosses and
dolphins. Or there’s sea cruising along the
Tasman Peninsula with Tasman Sea
Charters. The cruise takes in 50
kilometres of awe-inspiring 300-metrehigh cliffs as well as spires, caves and
sea stacks – and marine wildlife to boot.
On the wild west coast, out of the
pretty village of Strahan, there are cruises
aplenty on the vast expanse of Macquarie
Harbour, a waterway more than six times
the size of Sydney Harbour and bordered
by rugged wilderness. Strahan is the
gateway to the primeval World Heritage
rainforest of the Gordon River, and
cruising the river is an unmissable
Tasmanian experience.
Adventurous visitors can ply the
waters of Macquarie and the Gordon
under the sails of the sturdy yacht
Stormbreaker, which conducts daily
journeys into this pristine domain in
summer, or for cruising on a sleek
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STAYING ON THE WATER:
"I loved participating in the Sydney to
THE HENRY JONES ART HOTEL
Hobart race. It was a long sea voyage
Hobart Harbourside
Tel: (03) 6210 7700
info@thehenryjones.com
www.thehenryjones.com
SOMERSET ON THE PIER APARTMENTS
Right on docks and in the centre of
Sydney-to-Hobart revelry
Tel: (03) 6220 6600
enquiry.hobart@the-ascott.com
www.somersetonthepier.com/home.htm
PEPPERS SEAPORT
Stay on the waterfront in Launceston
Tel: (03) 6345 3333
seaport@peppers.com.au
www.peppers.com.au/Seaport
with great companionship accompanied by
a typically enthusiastic crew. We got lost
for a short while - I was navigator - but
we soon got back on track. Even if you
didn't win, the celebrations and welcome
on arrival in Hobart were wonderful.
Participating in the race was a great
start to my ongoing interest in off-shore
sailing!"
FREYCINET ESCAPE
Cruising and five-star beach camping on the
Freycinet Peninsula. Serious hideaway luxury.
Tel: (03) 6257 0018
info@all4adventure.com.au,
www.all4adventure.com.au/global/wineglass/
catamaran in utmost luxury, there’s the
MV Discovery. Discovery’s Wilderness
Escape cruise is a two-night, three-day
journey on the treacle-dark, tannin-stained
waters of the Gordon.
This cruise goes to places few visitors
ever get to, and the chance to use sea
kayaks as well as a small expedition boat
makes it feel like a true journey of
discovery. But then there’s outstanding
food on the mother ship, and your luxury
private cabin with floor-to-ceiling views of
the rainforest to remind you you’re
cruising in utmost comfort.
For truly rugged water-lovers, sea
kayaking is the way to see Tasmania. One
of the world’s ultimate sea-kayaking
experiences is a fly-in paddling adventure
on the South-West Wilderness’ remote
Bathurst Harbour and Port Davey. These
expansive wilderness waterways are
surrounded by rugged peaks and
sweeping button-grass plains, part of a
600,000-hectare protected realm so
unpeopled it feels like the edge of the
world.
Richard Benn, Head of Microbiology,
Royal Prince Alfred Hospital
Sydney-Hobart, 1967
Tasmanian adventure company
Roaring 40s Ocean Kayaking takes
groups to this remote corner of Tasmania
every summer, and its Wilderness on
Water trips are one of Tasmania’s best
water-based adventures.
The azure seas of the Freycinet
Peninsula are another prime kayaking
spot, and there are countless bays,
beaches and headlands right around
Tasmania that are ideal sea kayaking
territory.
If we’re talking in the water, rather
than on it, Tasmania comes up trumps
again. For surfing and sail boarding it has
some of the best waves in the country:
the legendary break at the Tasman
Peninsula’s Shipstern Bluff is known
worldwide, and with swells that traverse
the planet from as far away as South
America, Tasmania’s north-west coast has
some of the best surfing and windsurfing
in the country.
For those who get their thrills
underwater, there are giant kelp forests,
huge sea caves and wrecks to discover.
Lucky divers may even get to spot an
ethereally beautiful weedy sea dragon, a
relation of the seahorse and one of the
prizes of diving in the cool, clear waters of
Tasmania.
The state offers a veritable seafood
smorgasbord. Wonderful oysters and
succulent mussels grow here, and
Tasmania’s scallops are famously the
best. Skilful snorkellers can harvest
abalone by the armful, and crayfish are
also present in abundance.
Tasmanian chefs have long been in
love with this maritime plenty: there are
scores of great places to eat seafood from
the simplest fish and chips to the most
sophisticated feast.
And the simplest way to enjoy the
water in Tasmania? Plunge in and swim.
Find a beautiful, deserted east coast
beach with waters of sapphire blue, strip
off and gasp – the water’s not the
warmest, but it is tropical clear and
refreshing. Towel off on the fine, blond
beach and dream under a warm southern
sun.
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"They say the weather during the race
is an ordeal but we had the
extraordinary experience of being
becalmed in Bass Strait for a couple
of hours! A highlight was the sighting
of the Aurora Australis in the night sky
but nearly being run down by a
freighter certainly wasn't!
Ernest Finckh, retired.
EATING ON THE WATER:
MARQUE IV
One of Hobart’s smartest restaurants, right on the
dockside waterfront.
Past President RCPA. Emeritus Professor
Tel: (03) 6224 4428
www.marqueiv.com.au
University of Sydney, Founding Director
PROSSERS ON THE BEACH
Pathology Westmead Hospital
Sydney-Hobart 1980
Seafood to die for in beachside Hobart suburb
Tel: (03) 6225 2276
www.prossersonthebeach.com
ANGASI AT ST HELENS
Overlooks the world-renowned Bay of Fires beach
Tel: (03) 6376 8222
PEPPERMINT BAY
Cruise to this waterside restaurant in a gorgeous
seaside setting south of Hobart
Tel: (03) 6267 4008
www.peppermintbay.com.au
MOORILLA ESTATE
One of Tasmania’s oldest wineries can be reached
by water for meals and wine tasting
Tel: (03) 6277-9900, www.moorilla.com.au
PHOTO COURTESY OF TOURISM TASMANIA AND JANET HODGSON
KAYAKING:
CRUISING:
ROARING 40S OCEAN KAYAKING.
BRUNY ISLAND CHARTERS.
Tel: (03) 6267 5000
www.roaring40skayaking.com.au
Tel: (03) 6293 1465
www.brunycharters.com.au
FREYCINET ADVENTURES.
WORLD HERITAGE CRUISES’ MV DISCOVERY.
Tel: (03) 6257 0500
www.freycinetadventures.com.au
Tel: (03) 6471 7940
www.worldheritagecruises.com.au
DIVING:
TASMAN SEA CHARTERS.
EAGLEHAWK NECK DIVE CENTRE.
Tel: 1300 554 049
www.tasmanseacharters.com.au
Tel: (03) 6250 3566
www.eaglehawkdive.com.au
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TRAVEL
Walking from Cradle Mountain
to Lake St Clair
ROBERT ECKSTEIN DISCOVERS THE UNSPOILT BEAUTY OF
TASMANIA’S CRADLE MOUNTAIN NATIONAL PARK.
n the first day of my return visit to
the ‘Overland Track’ in Cradle
Mountain National Park, it was blowing a
gale outside, and we were huddled, very
cold and very wet, in a small wooden hut,
eating out of lunchboxes and wondering if
it could get any worse. Within an hour of
starting the walk, the weather had turned
to sleet. It was a bad start for five Sydney
based baby boomer medical practitioners
and their partners, but as happens in this
part of Tasmania, the weather cleared to
reveal a stunning snow-covered
landscape, and a day later we were in
autumn sunshine.
O
My previous visit had been 12 years
ago in summer, and it had left a yearning
to return. On that occasion, I had left my
wife at home with our small children. This
time she was going to share the
experience. The 6 day walk is along a
track about 70 kilometres, which winds
through the northern part of the
Tasmanian Wilderness World Heritage
Area starting near Cradle Mountain and
ending at Lake St Clair. The scenery is not
just spectacular, but also remarkably
variable. The passing days bring a
succession of mountains, lakes, plateaus,
waterfalls and a stunning range of
vegetation varying from alpine terrain to
rainforest. Side- tracks lead to historical
landmarks, abandoned mines, and the
highest peak in Tasmania, Mount Ossa.
Apart from the well-defined track, and
the huts, all that the eye can see is totally
pristine. There are no powerlines in the
distance and no litter at your feet. The
Parks and Wildlife Service of Tasmania
controls the numbers of walkers allowed
into the Park each day to about 50. The
majority of walkers use the six extremely
basic public huts along the track. Most of
the walkers are fit, youthful,
environmentally oriented, and probably
vote for the Greens. Their backpacks look
very heavy, containing all their food and
other personal items required for the six
day walk.
On both of my trips, I took the softer
but more expensive option of the
commercially organised guided walk run
by Cradle Huts Pty Ltd. Groups of up to
10 walkers set out each day with two
guides. The guides, who are usually in
their early 20’s, impress with their physical
strength, culinary ability, love of the bush
and good humour. I was cheerfully
retrieved after taking off in the wrong
direction one morning. The huts were
simple but very comfortable. The hot
showers require a bit of vigorous manual
pumping, but once you are in them do the
job well. The huts are stocked with good
food and plenty of wine. Even with this
option, you still carry a moderate sized
backpack and need to be fairly fit. As I
discovered, you really need to be
prepared for any kind of weather at any
time of the year. The commercial
operators check your gear before you go.
Also, the side tracks can be seriously
muddy - like suddenly up to your waist if
you aren’t careful, but there are now
duckboards over many parts of the main
track, and the walk is definitely easier
than it was 15 years ago.
What hasn’t changed is the unspoilt
beauty and grandeur of this area of the
Tasmanian wilderness, which words can’t
really describe. There is a buzz in the
physical challenge of doing the walk and
the sharing of the experience with your
fellow walkers. The Tasmanian wilderness
has a quality that speaks strongly to
anyone that has grown up in Australia.
You’ll feel a lot better after six days here,
even if you do the luxury baby boomer
version, than you will after six days in a
five star city hotel. And my wife agrees
with me.
Robert Eckstein is the Clinical Associate
Professor, Anatomical Pathology, Royal North
Shore Hospital and the University of Sydney
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FOOD + WINE
A taste for Tassie
HE MAY BE WELCOMED ALL OVER THE WORLD FOR HIS INNOVATIVE AND AWARD
WINNING FOOD BUT FOR ACCLAIMED CHEF TETSUYA WAKUDA, THERE’S NO PLACE HE’D
RATHER BE THAN IN A FISHING BOAT OFF THE COAST OF TASMANIA. JUSTINE COSTIGAN
DISCOVERS THE REASONS BEHIND TETSUYA’S ENDURING LOVE OF THE APPLE ISLE.
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Tuna Tartare with Goat's Cheese
t started almost 20 years ago with a
search for perfect ingredients but it
didn’t take long for Tasmania’s beautiful
landscape, clean rivers and oceans, and
pure, sweet air to work their magic. Not
only did Tetsuya Wakuda discover the
quality produce he was looking for, but in
the process developed a deep and
enduring appreciation for Tasmania’s
natural beauty.
I
“I dream of a little house down there
(in Tasmania),” smiles Wakuda, “Close to
the water so I can catch my own fish. But
I don’t know when it will happen because
nobody will let me retire,” he laughs.
World famous for his influential style
and unique approach to food, Wakuda
started out with little more than a sense of
adventure and lively curiosity when he
arrived in Australia from his native Japan
in 1982. Only 22 and with plenty of
ambition and courage, he took a job as a
kitchen hand at Fishwives restaurant in
Surry Hills, Sydney. A year later he was
introduced to legendary chef Tony Bilson
who needed a sushi chef for Kinsela’s,
one of Sydney’s most popular restaurants.
Absorbing everything he could about
running a business as well as teaching
himself the fundamentals of classical
French cuisine, Wakuda discovered not
only his own love of cooking but the
realisation that his customers liked his
food too. Within a short while he left his
mentor to strike out on his own, opening
Tetsuya’s in 1985 in a small shopfront in
Rozelle. It was an instant success – with
loyal customers booking out the
restaurant and creating daily waiting lists.
In 2000 the tiny restaurant moved to
stunning new premises in Kent Street,
Sydney. And despite the increase in the
restaurant’s size, the waiting lists remain.
Acclaimed by top chefs around the
world his style is best summed up by
fellow chef extraordinaire, Chicago based
Charlie Trotter. “Tetsuya is part of an elite
group of international chefs that has
influenced other chefs through their
personal styles and unique approaches to
food. His culinary philosophy centres on
pure, clean flavours that are decisive, yet
completely refined. His amazing
technique, Asian heritage, sincere humility,
worldwide travels and insatiable curiosity
combine to create incredible, soulful
dishes that exude passion in every bite."
A dish that exemplifies this soulfulness
and passion has to be his famous
signature creation, the Confit of Ocean
Trout. Described as one of the world’s
most photographed dishes, the Confit
uses ocean trout from some of the world’s
cleanest waters off the coast of North
West Tasmania. Farmed by Petuna, a
family company based in Devonport, the
ocean trout is now one of the company’s
most important products. But it wasn’t
always this way. When Wakuda first
visited Petuna, ocean trout was a poor
second to its best seller, salmon. Yet when
Wakuda tasted the trout and prepared it
for his friends he knew he had found
something unique and special. Over the
years Wakuda’s feedback has helped
Petuna develop a unique and in-demand
product – long discussions about when to
harvest, when to purge, and which season
is the best has led to the creation of a
product that is now exported widely
throughout Australia and overseas.
“Its very important where I source my
ingredients. My customers like to know
where things come from. To my
customers Tasmania means clean water
and air and good quality produce,” says
Wakuda.
Ocean trout is not the only Tasmanian
product Wakuda is passionate about;
Wagyu beef, leatherwood honey, oysters,
salmon, lobster and abalone, fresh fruit
and vegetables, walnuts, beer and wine
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are just some of the Tasmanian sourced
the island. As Wakuda and Schofield sit in
ingredients used in his kitchen that excite
a field on the edge of a forest tasting
this dedicated chef.
Leatherwood honey fresh from the hive,
Although it may have been the
produce that originally captured Wakuda’s
attention, the chef is now just as
enthusiastic about the island itself. “It’s
the most beautiful place I have ever been.
You can feel the nature. It’s very hard to
explain but I’m so pleased when I hear
that people want to go (to Tasmania).
Everyone must go there and see it for
themselves.”
its hard not to be envious of their
Wakuda’s passion for Tasmania was
recently harnessed in a documentary
produced by Australian Gourmet Traveller.
Together with writer and food lover Leo
Schofield, the magazine filmed the two
enthusiasts as they journeyed around the
island meeting local producers, farmers
and wine-growers as well as their
adventures out on the water and in the
wilds of Tasmania’s national parks and
protected areas. ‘Tetsuya’s Taste of
Tasmania’ has a charming home-movie
quality to it and, as was certainly the
intention, is a powerful inducement to visit
Wakuda’s food and the best ingredients
wonderful Tasmanian experiences.
But if a Tetsuya-style Taste of
Tasmania tour is out of the question, find
a date in your diary about three months
hence and book a table at Tetsuya’s in
Sydney. A menu filled with some of
Tasmania’s best produce, it’s really the
only way to experience both the
extraordinary flavours and textures of
Tasmania has to offer. His signature dish is
sure to be on the menu for as Wakuda
himself admits, “my customers just won’t
let me take it off.”
As Wakuda nears the 25th anniversary
of his arrival in Australia (May 2, 2007) its
possible that in the near future he may
decide to put away his chefs knives for
good. If he does, it won’t be hard to find
him. He’ll be somewhere on a boat in
Tasmania, enjoying the peace and quiet of
one of Australia’s most beautiful places.
Confit of Petuna Ocean Trout with Konbu,
Daikon & Fennel
Tetsuya's Restaurant,
529 Kent Street, Sydney.
Ph: 02 9267 2900.
www.tetsuyas.com
For more information about the “Tetsuya's
Taste of Tasmania” DVD and Tetsuya’s Taste
of Tasmania Gourmet Breaks visit
www.tastravel.com.au
..................................
..Histopathologist
The benefits include:
• Quality
practice
environment
•
•
•
•
•
•
• Negotiable
terms and
conditions
This unique pathology practice is exceptional in many ways. An upsurge in the demand for
its innovative approach has created the need for a motivated, enthusiastic and ambitious
professional who shares the same focus on quality of service provision.
Direct control of lab facilities and technicians.
Scope to develop a second speciality within the practice.
Collaboration with a world leader in the field.
Close links and regular interaction with clinicians.
A focus on professional excellence, not just on numbers alone.
Opportunities for joint research projects, with direct access to optimal facilities and
practitioners.
• The chance to design a package which combines equity potential with the aspirations of
the individual.
To find out more about this remarkable employer, please
telephone Jeremy Wurm on 03 9602 1666, in confidence.
Alternatively, send a CV (Word format, up to 5 pages)
career@brookerconsulting.com.au
www.rustonpoole.com
...........................................
60_PATHWAY
50_PATHWAY
• Location
Perth
219BRO
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Oh so cool
BEN CANADIER DRINKS TO THE IMPRESSIVE WINES BEING PRODUCED IN TASMANIA.
asmania is arguably Australia’s most exciting
wine region. The potential – now starting to be
realised – is enormous for high quality sparkling and
table wines. Whereas the mainland has boomed on
the back of good quality, high volume products,
Tasmania will always make less, but finer, wine.
And there is one reason for this greater quality –
climate.
T
Cool climates make for better grapes (and
apples). When harvesting seasons receive just
enough sunshine and just enough warmth
to guarantee ripening, a wonderful
juxtaposition occurs within the grape:
ripeness and sugars are balanced by
natural acidity.
The resultant fermented grape
juice does not then taste like Ribena
or port; it tastes like wine. True
beverage wine. Thanks to the acidity,
there is length and refreshment; the
weight is not over the top and the
flavours are more ethereal and
lifted. Tasmanian wines, at their
best, have this elegance and
finesse.
Cool climate viticulture – not to
mention small wineries and no great
economies of scale – mean prices
are higher, of course. Yet apparently
it is vulgar to talk about money …
Getting a geographical handle
on Tasmanian wines isn’t so
straightforward. There is an
unofficial north and south division,
but the island state is more like an
oddly patterned patchwork of
relatively tiny vineyards.
The Tamar Valley and the
Pipers Brook areas dominate the
north, the Coal River and Freycinet
areas the south. Some larger
investment has gone into Tasmania
in recent times, with Hardys making
more sparkling wine, pinot noir,
chardonnay and pinot gris in the
north, and forestry business Gunn’s
(owner of Tamar Ridge) establishing
large vineyards in the north-east of
the state.
The effect of such companies operating in Tasmania has
been seen in mainland sales and marketing representation. Over
the past five years Tasmanian wines have achieved a higher
presence thanks to a more consistent and keener-priced range of
reliable wines.
BAY OF FIRES, PIPERS RIVER, NORTHERN TASMANIA
The Hardys home in Tasmania, this is where their compelling
flagship sparkler, Arras ($50), now comes from. Bay of Fires’
second label, Tigress, is priced about $22. The 2005 and 2006
rose and sauvignon blanc have both been outstanding – the
latter showing the potential SB has in the Apple Isle. All the
wines in the Tigress range are worth trying.
TAMAR RIDGE, KAYENA, NORTHERN TASMANIA
Priced about $20, the riesling, sauvignon blanc and
chardonnay from the last two or three vintages have excelled as
far as price/quality rapport goes. The chardonnay in particular
has depth and quiet power lurking behind a lean and minerally
fruit curtain. All the wines exemplify Tasmania’s wonderful edge
of natural acidity.
FREYCINET, VIA BICHENO, SOUTHERN TASMANIA
Near the edge of the east coast, Freycinet shares its name with
the nearby coastal national park, home to the appropriately named
Wine Glass Bay. Freycinet’s vineyard is a remarkable amphitheatre
of wine-growing happiness. The pinot noir ($60) and chardonnay
($30) not only produce outstandingly elegant, deep table wines, but
also combine to make Radenti ($65) – one of Australia’s best
sparkling wines. Search these wines out.
MEADOWBANK, CAMBRIDGE, SOUTHERN TASMANIA
More good sauvignon blanc ($28), Grace Elizabeth
Chardonnay ($33), and Henry James Pinot Noir ($42) here,
complete with an excellent cellar door and restaurant. The wines
all display Tasmanian purity of fruit and acidity, but also show
some interesting winemaking artefacts, weight and character.
STEFANO LUBIANA, GRANTON, SOUTHERN
TASMANIA
Steve Lubiana left the Riverland for Tasmania in 1990 and now
makes an exceptionally drinkable and pure range of wines from the
Derwent Valley, less than 20 kilometres north of Hobart. Primavera
Pinot Noir ($25) is invariably berried, cherried and very well
structured, the acidity keeping the fruit flavour in line and on
length. Great wine and great reliability.
Stefano Lubiana
Primavera Pinot 05
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RESTAURANT REVIEWS
Top finds
Marque IV
PathWay makes the rounds...
Three, One, Two
Three, One, Two has just picked up another of Australia’s top
food awards - The Age Good Food Guide 2007 Best New
Restaurant and Chef of the Year awards swiftly followed by the
Australian Gourmet Traveller Award for best new restaurant.
With such universal praise Three, One, Two is clearly one of
Australia’s most impressive new restaurants.
Chef Andrew McConnell has an excellent cooking pedigree
having cooked/owned/consulted to some of Melbourne best
restaurants – think The Prince’s Circa and Mrs Jones - and
while his own distinctive style may be strongly influenced by
French technique his food has a lightness of touch and a
distinctively Australian flavour that is unique.
McConnell’s food is simply about pleasure – it’s interesting,
delicious and often surprising but never so avant garde that you
have to wonder what you’re eating. It’s never an exercise in
bravery only in delightful anticipation.
The confit of ocean trout with cauliflower crumb, seared
scallops and caper and raisin dressing is a case in point.
Using superb ingredients, McConnell is not afraid to add his
own touch creating a dish of sweet, sour and salty flavours
dominated by the silky texture and freshness of the fish. We
heard ooohs and aahs all around us as a table of four tucked
into this impressive dish. A salad of smoked tomato, zucchini
flower and asparagus with fromage blanc and purple radish
sprouts did the same.
Despite the quality of food and the hottest new restaurant tag,
Three, One, Two is not pretentious, maintaining the local
restaurant atmosphere that is so much a part of the building’s
history. Service is friendly rather than formal, the design modern
without being stark. McConnell has even developed a weekend
breakfast menu that has the locals pouring in for home made
crumpets with clover honey to eat with their cappuccinos while
browsing the weekend papers. The change in mood and menu
only proving how versatile McConnell and business partner
Pascale Gomes-McNabb can be. With the new restaurant tag
soon to be obsolete, punters are predicting a Restaurant of the
Year Award in 2007.
- Justine Costigan
Three, One, Two
312 Drummond Street, Carlton
Ph: 03 9347 3312
Open Lunch Fri-Sun, Dinner Tues-Sat, 6.30pm-late
8 course degustation menu $90 per person.
A la carte about $140 for two excluding drinks.
62_PATHWAY
Marque IV has quickly established itself as one of the best
restaurants in Hobart. Perched on the waterfront of Sullivan’s
Cove, it is housed in a converted wharf building with the water
lapping just metres away.
Being Tasmania, it was just 13 degrees on the day of our visit –
20 degrees cooler than the day before – and the heaters were
on. A cat patrolling the decks of Windward Bound, a sail
training ship moored at the pier, kept us under close watch.
The warm and welcoming decor complements the view, with
the large space partitioned discreetly. Described by chef Paul
Foreman as modern Australian sprinkled with European and
Mediterranean influences, the food relies heavily on Tasmanian
ingredients, changes with the seasons and is very good.
Our entrees were three plump scallops on a roll of smoked
salmon filled with wasabi scramble, and Balmain bugs in
cognac, garlic and eschalots presented in a small bowl with a
beurre noisette pastry. The bugs looked lovely and tasted good,
although the subtle, sweet bug meat was a little overwhelmed.
Better to have stuck to local produce such as the Bruny Island
oysters or the Rannoch quail.
The blue eye (trevalla) was served with lemongrass, ginger and
kaffir lime with a side of daikon and citrus salad and flat noodles
with wasabi mayonnaise. Our Marrawah beef was perfectly
cooked and came with a delicate truffled bearnaise and a crisp
warm salad of baby vegetables.
Portions are generous but not excessive, making the deserts
irresistible despite the best of intentions. A gin and lime brulee
tart was a wonderful blend of tart and sweet flavours
accompanied by buttermilk ice cream and candied cumquats,
again perfectly presented. A blueberry and hibiscus “lasagne”
consisted of French pastry layered with fresh blueberries, cream
and hibiscus flowers.
The menu opens with a selection of “amuses”, such as sashimi
of ocean trout, to tempt the palate. A seven-course “signature”
tasting menu, for $100 per person, helps the indecisive. Many
gluten-free and vegetarian choices are available.
The service is professional, friendly and unobtrusive. A carefully
chosen list of wines by the glass, at about $8 each, allows the
opportunity to experiment. The full wine list is extensive but
quite expensive (very few choices under $35), and includes
quality Tasmanian options.
– Tony James
Marque IV – The Restaurant
Elizabeth Street Pier, Hobart
Ph: 03 6224 4428
Open 7 days for dinner (except Sundays in winter) and lunch Sunday to
Friday
About $130 for two, plus drinks
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Marque IV
Cibo Ristorante
Rapide
In its 10-year history, Adelaide’s Cibo has evolved from a
Roman-style brash and busy trattoria to a stylish and more
elegant restaurant. It is now heading back down the trattoria
path – albeit in a fairly upmarket manner.
Under new ownership, Rapide has lost nothing of its intimate
Although the service, wine list and overall trappings remain top
notch, it’s very much a place for gregariousness, where
customers pounce on their plates with relish rather than
treating their surroundings as a temple of fine dining.
Calabrian-born, Tuscan-trained executive chef Salvatore Pepe
runs a meticulous kitchen and everything from the crisp, thin,
wood-oven pizza to the luscious gelati is exemplary.
venue in suburban Camp Hill, Brisbane.
The main dining room is a handsome place with parquetry
floors and long, polished wooden counters with racks above
for glasses and loaves of crisp, wood-oven-baked focaccia. At
one end is the wood oven, at the other a glamorous walk-in,
temperature-controlled wine room that houses a fine cellar list,
much of it top-level Italian. There is also a reasonably priced
smaller list of less glamorous wines.
atmosphere and style. Annie Walters (co-owner with her
husband, chef Sam Walters) welcomes diners as if they are
part of an extended family at this modern yet cosy 50-seat
The French-influenced food and attentive service are equal to
Brisbane’s best. Sam Walters’ enthusiastic approach to his
new role spills into every aspect of the food – each dish is
made in-house, and the night we visited there was
complimentary fennel seed bread (served with olive oil and sea
salt), and a zesty taste starter of tomato and basil consomme.
The pricing structure is simple, with entrees $17, mains $29
and desserts $12. And unlike many restaurants, it is possible to
enjoy three courses, given an emphasis on tight and crisp
flavour combinations instead of over-large portions.
I hit the jackpot with my entree, the confit vine-ripened tomato
with marinated fetta and salsa verde. This dish’s simplicity
Outdoor dining is a feature at Cibo. The lower courtyard is
enclosed and heated in winter, and in summer it is one of the
best outdoor dining spaces in town, along with an upper
terrace that has fine views over the city.
belied its vibrant combination of flavours, and paired with a
The menu has increasingly focussed on dishes cooked in the
wood oven or over the mallee-root grill. These include slowroasted half duck seasoned with fennel seeds and sage,
chargrilled marron and the most delicious Roman-style pizzas.
liveliness of my tomato.
One of the best dishes on the menu is the tagliatelle with blue
swimmer crab meat, but you should also pay close attention to
the daily specials or you could miss out on dishes such as a
blue fin tuna carpaccio with shaved fennel; thick, chargrilled
veal cutlet stuffed with fontina cheese and wrapped in
prosciutto; or house-made saffron pappardelle with lamb and
spinach ragu topped with fresh goat’s curd. This is Italian
cooking at its best.
mushrooms and tarragon jus was the stand-out – a superb
And as you would expect from a restaurant that has spawned
a chain of highly successful coffee shops, the coffee is
excellent
the small but quality-driven wine list, Lilly Pilly Noble Sauvignon
– Nigel Hopkins
Cibo Ristorante
8-10 O’Connell Street, North Adelaide
Ph: 08 8267 2444
Open Sun-Fri noon-2.30pm, daily 6-9.30pm .
About $135 for two plus drinks
glass of the Monte Antico Sangiovese (Tuscany) ($10), it made
for a flying start. My partner’s Moreton Bay bug boudin with
asparagus and white truffle oil was subtle, without the intense
Atlantic salmon, sauteed mussels, fettuccine, chickpeas and
saffron and white wine sauce made up a first-class main meal,
but my partner’s roasted eye fillet with Paris mash, wild
combination. Organic broccoli with toasted pine nuts and
almonds and parmesan ($7) was an ideal accompaniment.
With room left for dessert, everything on the menu beckoned.
My partner took on the toffee and peanut souffle with espresso
ice-cream, and I tried the apple tart tatin with rum and raisin
ice-cream. Having also enjoyed a glass of a new addition to
Blanc 2002 ($8.00), we both felt replete.
– Louise Martin-Chew
Restaurant Rapide
Shop One, 4 Martha Street
Camp Hill, Brisbane
Ph: (07) 3843 5755
Open Wed-Fri noon-2.30pm, Tues-Sat from 6pm
About $120 for two plus drinks
PATHWAY_63
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In ancient Greece, Hermes, the God for Hospitality
Chatts
decreed "that all must provide good food and drink to any
In a town where service standards determine how long a
restaurant will be around, Sydney CBD restaurant, 'Chatts',
should make it to the next Millenium.
who knock on their door - or suffer the 'wrath of Hermes'."
- Chatts' owner, Kostas' belief in Greek folklore.
Locally within the epicentre of the city's financial district in
O'Connell Street, 'Chatts' has earned an enviable reputation for
service and yet it has only been around for three years and is the
first restaurant of its owners.
An unusual scenario in super-competitive Sydney.
Husband and wife owners, Greek-born Niki and Kosta Zigouris,
are the key to this relatively quick success. Their attention to
detail, their professional but friendly attentiveness and the fact
that they just seem to be having fun, all make for a formidable
combination.
Location helps too. 'Chatts' is positioned at street level in one of
the city's open glass office atriums where people- watching is de
rigeur.
Its menu is as mouth-watering as it is diverse - and while not a
Greek restaurant, there is subtle Mediterranean flair running
through several of its signature dishes such as the BBQ octopus
with mixed leaves, cherizio, cloves, semi-dried tomatoes and
gremolata dressing ($26.50) and its 'Corfus' - Artichoke, roast
capsicum, marinated eggplant, haloumi and olives ($20).
But before the Mediterranean flavours seduce your appetite,
there is also a 'Saganaki' prawns entree ($18.50), Sushi and
Tempura bento with nori rolls, salmon sashima, miso soup,
prawns and vegetable tempura (Entree $18.50; Mains $26.50)
and even a daily Curry of the Day ($23).
In many respects, this family-run restaurant has it all - at least
that's what an 80 year old Texan customer says - and he should
know, he lunches at 'Chatts' every day!
- Wayne Tregaskis
Chatts at O
17 O'Connell Street, Sydney
Tel: 9233 1913
Open: Breakfast and lunch 7:15am - 4pm Monday - Friday
Dinner 6 - 9pm Monday - Thursday
The Henry Jones
Art Hotel
rom a time of adventurers,
seafarers, whaling captains
and traders, with exotic cargoes
coming from all over the world,
The Henry Jones Art Hotel's
buildings were often the very first
sight and impression early
travellers would have had of
Tasmania.
F
Australia's only dedicated Art
Hotel, The Henry Jones still
makes an impactful impression.
The Hotel presents an
environment in which people can
experience art in a new and more
immediate way. With a continuously
changing exhibition, the Hotel has
been created to present itself as
part of a fusion of art, heritage,
tradition and nature.
The Henry Jones Art Hotel
25 Hunter Street Hobart, Tasmania,
Australia 7000
Ph: +61 3 62 10 7700 Email:
info@thehenryjones.com
www.thehenryjones.com
PHOTO CREDIT: TOURISM TASMANIA AND CHRIS WILSON
64_PATHWAY
PathWay #10 - Text
14/11/06
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Page 65
http://pathway.rcpa.edu.au
a
riveting,
pathological
[P athWay]
read....
PathWay informs, entertains and celebrates the
vital contribution pathologists make to
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developments, issues and the people who make
pathology an exciting and rewarding profession.
Contents
T H E R O YA L C O L L E G E O F PAT H O L O G I S T S O F A U S T R A L A S I A
ADVISORY BOARD
Dr Debra Graves (Chairman)
Chief Executive, RCPA
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Vice President, RCPA
Associate Professor Jane Dahlstrom
Representative, Committee of Deans of
Australian Medical Schools
PATHWAY
Autumn 2005
Jim Clarke
Nuance Multimedia Australia
Wayne Tregaskis
S2i Communications
Annette Sharp
Representative, Pathology Section,
Commonwealth Department of Health and Ageing
PUBLISHER
Jim Clarke
EXECUTIVE EDITOR
Dr Debra Graves
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COVER STORY
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We asked 5 experts from around the world
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REGULAR FEATURES
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News and Letters
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10
Virtual Microscope
How the merging of information technology and traditional
microscopy techniques is offering new opportunities for
quality assurance
14
Profile
Nadia Mikhael is a Canadian pathologist and
academic who is inspiring medical students
to join the profession
17
Interview with The Hon Tony Abbott MP,
Minister for Health and Ageing
The Royal College of Pathologists of Australasia
Tel: (02) 8356 5858
Email: rcpa@rcpa.edu.au
FOR FURTHER INFORMATION ON THE ROYAL COLLEGE OF
59
63
Backpage
68
Anita Punton takes a look at the history of
autopsies and finds some surprising stories
PATHWAY LIFESTYLE
HOMES + GARDENS
20
WA Beachhouse
44
Haematologist Andrew Barr and his wife,
Kerry, found a hideaway in a rammed-earth
house among dunes near Margaret River
RESTAURANT REVIEWS
FOOD + WINE
Waterside dining
Restaurant reviews from around the country
Biopsies
The small samples that play a huge role
28
Chemical Pathology
An in-depth look at one of pathology’s most fascinating disciplines
32
Farmhouse cheeses
The ancient art of cheese-making
is alive and well in Australia
Hepatitis
The Alphabet of hepatitis - is it A, B or C, etc?
36
TRAVEL
PATHOLOGISTS OF AUSTRALASIA OR ANY OF THE FEATURES
IN THIS ISSUE OF PATHWAY CHECK OUT THE WEBSITE
Conference Calendar
24
PathWay
Email: pathway@rcpa.edu.au
http://pathway.rcpa.edu.au
Travel Medicine
Being prepared is the best way to prevent travel related illness
www.rcpa.edu.au
GIVING THE DEAD BACK
THEIR IDENTITY
PAGE 10
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42
Crossword
Pathology and the Law
Pathologists are often called upon to act as expert witnesses.
Dave Hoskin finds out what happens when science meets the law
S2i Communications Pty Ltd
Tel: (02) 9225 7889
Email: wayne@s2i.com.au
Letter from RCPA CEO,
Dr Debra Graves
GP column
Communication strategies for explaining
the risk factors in medical treatment
FEATURES
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Algate Ridge
48
A wine success story from the Adelaide Hills
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HOME ENTERTAINMENT
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the best from the latest technology
64
MOTORING
Discovering Australia’s Top End
55
Pathologist John Slavin and family
discover the delights of California
58
Chris de Fraga looks at the latest options
in family vehicles
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PathWay #10 - Text
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12:23 PM
Page 66
Events in Tasmania
Nov 2006-Nov 2007
Rolex Sydney Hobart Yacht Race
Kings Pier Marina, Hobart
26 Dec 2006 - 01 Jan 2007
The highlight of the Australian yachting
calendar, the arrival of this race is
heralded with much partying and
celebration in Hobart.
Hobart Summer Festival
Sullivans Cove Area, Hobart
28 Dec 2006 - 07 Jan 2007
Yachts, street theatre, food and wine all
feature in this fun waterfront festival that
brings Hobart summer alive.
Taste of Tasmania (The Taste)
Princes Wharf Shed No.1, Hobart
28 Dec 2006 - 03 Jan 2007
Tasmania’s fun food festival. A vast
dockside warehouse becomes the setting
for hundreds of food stalls where visitors
can sample the best of Tasmanian
produce.
The Falls Festival, Marion Bay,
30 Dec 2006 - 01 Jan 2007
The Falls music festival rocks Marion Bay
over the New Year’s period. A musical
feast in a gorgeous, rural setting.
Rolex Sydney Hobart Yacht Race
www.rolexsydneyhobart.com
Moorilla Hobart International
Domain Tennis Centre,
Hobart 05 Jan 2007 - 13 Jan 2007
ITU Hobart International Triathlon
Sullivans Cove, Hobart
18 Feb 2007 - 18 Feb 2007
Big-name players visit Hobart for this
international Tennis event in January.
Watch, or partake in, this gruelling event
as it makes its way around Hobart’s
picturesque harbour.
One Day International Series
Australia v New Zealand
Bellerive Oval, Hobart 14 Jan 2007 and
16 Jan England v New Zealand
Cricket lovers will enjoy these
international games at beautiful Bellerive
Oval.
Australian Wooden Boat Festival
Hobart Waterfront, Hobart
09 Feb 2007 - 12 Feb 2007
This wonderful waterside event celebrates
Tasmania’s maritime heritage and present,
with hundreds of wooden boats and tall
ships, a seafood festival, a boat building
competition, and plenty of waterfront
merrymaking.
66_PATHWAY
10 Days on the Island
Venues across the state
23 March 1 - April 2007
Tasmania’s biennial arts festival celebrates
music, drama, visual arts, dance and
song. An amazing line up for 2007
features dozens of international and local
acts at venues across the state.
Hydro Tasmania Three Peaks Race
Tasmania, across the state,
06 Apr 2007 - 09 Apr 2007
A gruelling sailing and running challenge,
this race takes place on the Easter
weekend, and has the reputation of being
one of the toughest in the country.
Targa Tasmania rally
Hobart 17 Apr 2007 - 22 Apr 2007
This annual rally takes to Tasmania’s
challenging roads in April, back for
another year of adrenalin-charged
excitement.
Antarctic Midwinter Festival
15-24 June 2007
Celebrating Tasmania’s links with the
frozen continent, this festival also injects
much merrymaking into the darkest days
of the year, and incorporates the Longest
Night Film Festival.
Mark Webber Challenge
Across the state, Nov 2007
Mark Webber’s tough multi-sport
adventure challenge returns to the state in
2007, with teams competing across
Tasmania’s rugged terrain to raise money
for charity.
PathWay #10 - Text
14/11/06
12:23 PM
Page 67
2006 - 2007
Conference Calendar
NOVEMBER 2006
17
Renal Pathology Course
17 - 18 November 2006
Brisbane, Australia
wendy_thomas@health.qld.gov.au
AUGUST 2007
SEPTEMBER 2007
16
27
First World Congress on Pathology
Informatics (WCPI)
16-17 August 2007
Brisbane, Australia
ASCCP Biennial Scientific Meeting
27 - 30 September 2007
Gold Coast, Australia
gmedley@bigpond.com
www.pathologyinformatics.org/
24
Health Law Conference - Regulating
the Scientific Frontier
24 - 25 November 2006
University of Sydney, Australia
healthlaw@law.usyd.edu.au
OCTOBER 2007
20
14
24th World Congress of Pathology and
Laboratory Medicine
20-24 August 2007
Kuala Lumpur, Malaysia
HSANZ Annual Meeting
14 - 17 October 2007
Brisbane, Australia
acadmed@po.jaring.my
HSANZ
JANUARY 2007
18
Annual Postgraduate Neuropathology
Course
18-20 January 2007
Sydney, Australia
cliveh@med.usyd.edu.au
MARCH 2007
2
Pathology Update 2007
2-4 March 2007
Sydney, Australia
Medical
Conference
evep@rcpa.edu.au
MAY 2007
27
5th Asia Pacific International Academy
of Pathology Congress and Chapter of
Pathologists Annual Scientific Meeting
27-31 May 2007
Singapore
iap2007@ams.edu.sg
www.ams.edu.sg/iap2007
JUNE 2007
3
Thredbo
13 - 17 August 2007
www.docski.com.au
11th Greek/Australian International
Legal & Medical Conference
3 - 9 June 2007
Crete, Greece
jennycrofts@ozemail.com.au
PATHWAY_67
PathWay #10 - Text
14/11/06
12:23 PM
Page 68
BACK PAGE
Uncommon complaints
EVER WONDERED WHETHER THAT STRANGE LUMP OR ITCH MIGHT MEAN YOU HAVE A
RARE DISEASE? SPARE A THOUGHT FOR THE SUFFERERS OF THESE MEDICAL
ODDITIES, WRITES ANITA PUNTON .
here are many ways human beings
can get sick, but most diseases fall
into relatively few categories, such as
heart disease, cancer or diabetes.
T
If one of those doesn’t get you, there
are about 6000 rare diseases, one of
which might have your name on it. While
some are familiar to the general public,
such as cystic fibrosis or tetanus, others
are so rare that you would have to be
unlucky indeed to find yourself in their
clutches.
BABY’S GOT BLUE EYES … AND
SKIN
In 1820, a Frenchman named Martin
Fugate migrated to Kentucky to claim a
land grant on the banks of Troublesome
Creek.
Unbeknownst to him, Fugate was a
carrier of a rare recessive gene for
hereditary methaemoglobinaemia, a
disorder that results from high levels of
methaemoglobin in the blood. Due to an
enzyme deficiency, the blood has a
reduced capacity to carry oxygen, making
the arterial blood of sufferers brown
instead of red and giving their skin a blue
tinge.
Against incalculable odds, Fugate
managed to marry a woman who was also
a carrier. Their marriage produced seven
children, four of whom had blue skin.
As they lived in an isolated area,
successive generations of the Fugates
tended to marry their relations, resulting in
more and more blue-skinned people.
Despite the arresting colour of their
skin, the blue Fugates were actually very
healthy individuals, usually living past the
age of 80 with no serious illnesses.
68_PATHWAY
In the early 1900s, railways were
introduced to Kentucky, and the Fugates
began to move out of their communities
and marry into unrelated families that
were highly unlikely to carry the recessive
gene. Thus the strain of inherited blue
began to disappear.
However, there are still some presentday descendents who bear traces of the
disease, usually evident in their dark blue
lips and fingernails
I ZINK I VAS ’IT ON ZE ’EAD ….
NO?
In 1999, an American woman in her
late 50s suffered a stroke, leaving her with
a bizarre side effect. Although she had
never been to Britain, she began to speak
in an accent described as a mixture of
Cockney and English West Country.
There are only a few documented
cases of foreign accent syndrome. The
first was reported in 1941 in Norway, after
a young woman suffered shrapnel injury
to the brain during an air raid.
As she recovered, she was left with a
strong German accent. This was
particularly inconvenient considering that
Norway was at war with Germany at the
time.
According to researchers at Oxford
University, a sufferer of this condition
need never have heard the adopted
accent. They believe the condition arises
from damage to the areas of the brain
responsible for language production.
Subtle changes to vocal features, such as
lengthened syllables, altered pitch or
mispronounced sounds are responsible
for making a patient's voice sound similar
to a foreign accent.
I WANT TO SUCK YOUR BLOOD
Bram Stoker based the protagonist of
his horror novel Dracula at least in part on
a real person, Vlad Tepes, commonly
known as Vlad the Impaler. Dracula’s
peculiarities have become the stuff of
legend: as well as his penchant for
drinking blood, he was deathly pale, only
ventured out at night and had an aversion
to garlic.
But the same peculiarities can be
attributed to sufferers of a condition called
porphyria. Is it possible that the real
Prince Vlad suffered from the same
condition? Porphyria is actually a group of
related disorders. A common symptom is
acute abdominal pain, and there can also
be severe nerve and brain problems.
People with extreme forms of this
hereditary ailment are so sensitive to light
that they can get sunburnt on a heavily
overcast day. In its most severe form,
which is very rare, sufferers’ teeth and
bones become fluorescent.
As for the garlic, David Dolphin, of the
University of British Columbia,
hypothesised in 1985 that, as the disorder
causes the body to fail to produce one of
the enzymes necessary to make haem,
the red pigment in haemoglobin, and
eating garlic stimulates the production of
haem, garlic could turn a mild case of
porphyria into a very painful one.
Even the vampire's desire to drink
blood may be connected to porphyria, as
severe attacks of the disease can be
relieved by a large injection of a blood
derivative called haematin. It’s possible
that drinking blood could produce a
similar result.
PathWay #10 - Cover
14/11/06
12:42 PM
Page 4
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PathWay #10 - Cover
14/11/06
12:42 PM
Page 1
PathWay Summer 2006 - Issue #10
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