PathWay #14 - Cover
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PathWay Summer 2007 - Issue #14
Summer 2007 | Issue #14
MAGIC BULLET
Magic bullet:
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from the CEO
Welcome
to the 14th Edition of PathWay
elcome to our special “Pink” edition
of PathWay, in recognition of the
National Breast Cancer Awareness
Campaign currently underway in Australia.
Pathologists are integrally involved in
breast cancer – in fact, every breast
cancer detected is diagnosed by a
pathologist.
W
In this edition, we examine the
discipline of Anatomical Pathology, and
look at the group of pathologists who
provide this vital service.
Ten years ago, to diagnose a breast
cancer, pathologists would only look at
two sections of tissue/samples under the
microscope. Today, it’s closer to 50-70
sections.
This has revolutionised the approach
to treatment of breast cancer, as each
diagnosis is individualised, enabling
patients to receive tailor-made therapy
and providing the best chance of a cure
or at least slowing the disease’s progress.
We also profile Professor Lai-Meng
Looi, an eminent Anatomical Pathologist
in Malaysia, who outlines what being a
pathologist has meant to her. Professor
Looi has played a critical role in the
development of pathology in Malaysia,
including the development of training and
accreditation programs.
Our cover story this edition, ”Magic
Bullet Theory”, highlights cutting-edge
work being done by pathologists in
Australia today in an area of pathology
entirely different to that of cancer
diagnosis.
Professor David Ma, a haematologist
from St Vincent’s Hospital in Sydney and
the Victor Chang Cardiac Research
Institute, and his colleagues are involved
in adult stem cell research that is very
likely to change how people with
ischaemic heart disease are treated. Adult
stem cells, in combination with GCSF
(Granulocyte Colony Stimulating Factor)
are being injected into some patients with
angina and heart disease to promote the
development of new blood vessels in the
heart. Initial studies are showing great
promise. It is particularly great to note that
GCSF, which is part of Professor Ma’s
trial, was first cloned by the College‘s
Distinguished Fellow, Professor Donald
Metcalf, and his colleagues.
There are a lot of them with 30-60
homicides a day!
As usual we look at some very
interesting travel destinations such as
Slovenia and China and explore some
regional Australian restaurants.
I hope you enjoy our special “Pink”
edition of PathWay.
Dr Debra Graves
CEO, RCPA
Also on the cardiac front, we look at
the new test for cardiac failure, B-type
natriuretic peptide, or BNP, which will be
available on the medical benefits schedule
shortly for use in emergency situations to
diagnose heart failure. This test will
certainly help speed up the diagnostic
process for those patients presenting to
emergency departments with shortness of
breath, thus helping to ease some of the
strain on our emergency system.
This edition’s disease investigation
looks into non-alcoholic fatty liver disease
– a problem that is increasing in our
society, particularly with the obesity
epidemic facing developed nations.
On an entirely different note, we talk
with Dr Tim Lyons, Forensic Pathologist,
about the time he spends in Rio de
Janeiro assisting with post-mortems.
PATHWAY_1
ADVISORY BOARD
Contents
Dr Debra Graves (Chairman)
Chief Executive, RCPA
Dr Tamsin Waterhouse
Deputy CEO, RCPA
Dr Edwina Duhig
Director of Anatomical Pathology QHPS
(Prince Charles Hospital)
Dr Andrew Laycock
Chairman Trainees Advisory Committee, RCPA
PATHWAY
Summer 2007
Issue #14
Dr David Roche
New Zealand Representative, RCPA
Wayne Tregaskis
S2i Communications
PUBLISHER
Wayne Tregaskis
COVER STORY
EXECUTIVE EDITOR
Dr Debra Graves
Magic bullet theory:
EDITOR
Kellie Bisset
Australian haematologists are driving cutting-edge stem cell
research
ART DIRECTOR
Jodi Webster
FEATURES
ADVERTISING SALES DIRECTOR
Sue Butterworth
Foreign correspondence
6
12
Work on the wild side: Associate Professor Timothy Lyons takes
his chances in Rio
PUBLISHING CO-ORDINATOR
Andrea Plawutsky
In profile
PathWay is published quarterly for the Royal College
of Pathologists of Australasia (ABN 52 000 173 231)
14
Standard bearer: Professor Lai-Meng Looi happily tries out the
jobs she has to delegate
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4 O’Connell St Sydney 2000
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Testing testing
21
Heart starter: how will a new pathology test to diagnose heart
failure fit into the medical landscape?
Disciplines in depth
27
Suspicious minds: Anatomical pathologists are medicine’s private
detectives
The Royal College of Pathologists of Australasia
Tel: (02) 8356 5858
Email: rcpa@rcpa.edu.au
WASPaLM meeting
30
The pathologists have landed: three RCPA fellows head to
Malaysia for the World Congress of Pathology and Laboratory
Medicine
S2i Communications Pty Ltd
Tel: (02) 9235 2555
Email: wayne@s2i.com.au
Spotlight on disease
33
Sober tidings: our livers are far from indestructible
PathWay
Email: pathway@rcpa.edu.au
http://pathway.rcpa.edu.au
Bright ideas
38
Code red: A Brisbane pathologist’s novel idea could save the
hospital system millions
FOR FURTHER INFORMATION ON THE ROYAL COLLEGE OF
Innovations
PATHOLOGISTS OF AUSTRALASIA OR ANY OF THE FEATURES
Space lab: Auckland has pioneered a new twist on the traditional
pathology museum
IN THIS ISSUE OF PATHWAY CHECK OUT THE WEBSITE
www.rcpa.edu.au
RCPA elections
Some new college office bearers outline their collective vision
41
44
REGULARS
From the CEO
PERTH CHEF
CHRIS TAYLOR
PAGE 58
1
Welcome from RCPA CEO Dr Debra
Graves
Under the microscope
4
News + views
Conference calendar
65
Postscript
68
Dr Pam Rachootin has discovered a
new kind of pathology
LIFESTYLE
Travel
48
Slovenian rhapsody: beauty and charm abound in this old world gem
Travel doc
53
A date with dynasty: Dr Adeline Tan finally got to visit the land of her
forefathers
Private passions
56
Treasure hunter: Dr Malcolm Dodd’s passion has invaded his house
Recipe for success
58
West side story: Perth chef Chris Taylor is an ambassador for home
grown produce
A DATE WITH DYNASTY
PAGE 53
Dining out
61
Cross country: head outside the big cities and you’ll be rewarded with
plenty of fine dining
The good grape
64
Red hot reds: Ben Canaider has found the summer answer for red wine
lovers
Rearview
66
In cold blood: History’s love affair with bloodletting
PATHWAY_3
under the microscope: news + views
Colleges and universities unite to
tackle workforce shortage
T
medical students,” RCPA CEO Dr Debra
Graves said.
their six-year degree and later being able
new plan of attack against Australia’s
“Importantly, this will occur when the
students are most heavily influenced
about the choices they will make about
specialisation – the outcome of which is
we hope to see more pathologists and
radiologists in the coming years out of the
UNSW medical program.”
opportunities offered in the first two years
The scheme, which will begin next
year and is due to be rolled out over the
next three years, is a collaboration
between UNSW, the specialist Colleges
and the NSW Institute of Medical
Education and Training.
preclude graduates from obtaining their
he Royal College of Pathologists of
Australasia (RCPA) is involved in a
desperate shortage of pathologists.
Under the plan – an Australian first –
medical students at the University of NSW
(UNSW) will be able to work towards
specialising in pathology and radiology as
part of their undergraduate degree.
The move could shorten training with
the RCPA and Royal Australian and New
Zealand College of Radiologists by up to
a year.
“The benefit of the pathway is the
increased exposure to pathology and
radiology afforded to a greater number of
It will involve students taking
pathology or radiology electives during
to take advantage of extra training
after graduation. Together, these initiatives
will allow graduates to seek advanced
standing during their specialist training.
UNSW Dean of Medicine Professor
Peter Smith said specialising would not
general medical degree.
“This decision benefits the students,
the medical profession and the broader
community,” he said.
The university has plans to extend the
scheme to other areas of specialisation.
SARS sparks surge in
microbiology trainees
he severe acute respiratory syndrome
(SARS) crisis four years ago played a
role in inspiring more medical students in
Hong Kong to study microbiology,
according to a leading Hong Kong
pathologist.
T
Dr Kam Cheong Lee, President of the
Hong Kong College of Pathologists, said
statistics for microbiology trainees
suggested an upsurge of trainees after the
SARS pandemic in 2003, which affected
more than 8000 people and resulted in
774 deaths.
College records show there was one
new trainee in 2002 and one in 2003, but
this jumped to four in 2004 and six the
following year. There were four trainees
last year.
Dr Lee, who was offering his personal
view and not that of the College, said the
very impressive achievement of some
microbiologists during the SARS period,
which received extensive publicity, was
possibly why medical students were
attracted to the field.
Succession planning for the anticipated
retirement of some microbiologists might
have been another factor in the increase in
the number of trainees.
Given the increase in applications for
training posts, it seemed the crisis may
have opened medical students’ eyes to
the possibilities of microbiology, Dr Lee
said.
“However, it is also possible that
applicants to microbiology vacancies tend
to refer to SARS as their reasons to join
the specialty just to make their cases
more convincing.”
diseases could still be devastating, even
in this day and age.
Dr Lee, who is Head of Pathology at
Princess Margaret Hospital in Hong Kong,
said it was unknown if there was any
Nevertheless, the fact that
microbiologists were quite active in the
clinical services rather than purely in the
laboratory had become better known, Dr
Lee said.
long-term knock-on effect of SARS on the
More medical students had also
people still do not appreciate the need of
become aware of the fact that infectious
4_PATHWAY
Dr Lee: impressive achievements
uptake of microbiology or if it was a oneoff spike.
“Some microbiologists tend to think
that this could be a one-off effect as most
a medical microbiologist service,” he said.
College
fellows
lauded
wo RCPA Fellows have recently
T
received prestigious awards.
Professor Colin Masters has been
awarded the Victoria Prize for Science for
his ongoing work towards a cure for
Alzheimer’s disease.
Professor Masters, Executive Director
Hope on the horizon for
New Zealand pathology
breakthrough meeting with the Director General of the NZ Ministry of
A
Health last month has left the RCPA optimistic that long-awaited
progress on the crisis facing New Zealand pathology services may be
imminent.
“We are confident that collaboration, leading to long-term solutions, will
be possible with the Director General of Health [Stephen McKernan],” RCPA
CEO Dr Debra Graves said.
New Zealand’s pathology crisis has partly been caused by too few
of the Mental Health Research Institute of
Victoria at the University of Melbourne,
believes he has discovered the cause of
the disease – a build-up of protein in the
brain called beta-amyloid plaques, which
lead to memory loss and profound nerve
degeneration.
Knowledge gained from his work is
being applied to other diseases such as
Creutzfeldt-Jakob disease.
He and a colleague at the Mental
Health Research Institute, Professor Ashley
pathologists. Despite a 5% population increase in the past five years, the
Bush, are currently working with Prana
number of full-time equivalent practising pathologists has dropped by 7%.
Biotechnology on a method of destroying
Many are on the verge of retiring and too few are training to replace them.
plaques that involves removing copper and
“This is at a time when the complexity and volume of tests available and
being undertaken is increasing dramatically,” Dr Graves said.
The lack of a national framework on training has exacerbated the
problem. The RCPA has been calling for a centrally funded national
pathology training scheme for some time and after last month’s meeting, it
zinc ions, which bind amyloid together. This
could lead to new drug treatment with an
agent called PBT2, which is about to
undergo clinical trials.
Meanwhile, Professor Jane Dahlstrom,
said progress in establishing the Medical Training Board was a step in the
Professor of Pathology at the Australian
right direction.
National University and Senior Anatomical
However, the ongoing process of the country’s 21 District Health Boards
Pathologist at ACT Pathology and the
awarding tenders for pathology services remained a major issue causing a
Canberra Hopsital, has received the 2007
detrimental impact on New Zealand healthcare, the College said.
Carrick Award for Teaching Excellence in
The onerous tendering contracts under which many laboratories were
biological sciences, health and related
working included no room for volume and cost growth for 5–10 years and
studies. She will receive $25,000 to
could threaten the financial viability of pathology providers.
advance her teaching career and support
“The state of the working environment … is affecting the ability of
pathologists and laboratories to plan for the future,” Dr Graves said.
“New Zealand risks being left seriously behind in terms of services
available.”
However, she said she was looking forward to working collaboratively
her ongoing commitment to excellence in
teaching.
The Carrick Awards for Australian
university teaching are conferred by the
Carrick Institute for Learning and Teaching
with Mr McKernan and welcomed his stated intention to consult with the
in Higher Education and according to
medical profession to develop services strategically.
Education Science and Training Minister
* For a full overview of the crisis facing New Zealand pathology, see
PathWay issue #12 available at www.rcpa.edu.au.
Julie Bishop, acknowledge the vital
contribution made to the quality of student
learning.
PATHWAY_5
cover story
Magic bullet
theory
CUTTING-EDGE STEM CELL RESEARCH BY AUSTRALIAN HAEMATOLOGISTS COULD HAVE
FAR-REACHING IMPLICATIONS FOR A WIDE RANGE OF DEBILITATING DISEASES.
BIANCA NOGRADY REPORTS.
ou’re mowing the lawn on a fine
Sunday morning, when suddenly an
invisible band wraps around your chest,
squeezing tightly and painfully until you
can hardly breathe. This is what patients
with angina pectoris fear: the ‘elephant
sitting on my chest’ sensation that strikes
with little warning and lasts for up to 20
minutes.
Y
Like most pain, angina is the body’s
warning that something is wrong. The
arteries that nourish the heart muscle with
oxygen-rich blood are being slowly
strangled from the inside, as fatty plaques
build up and constrict the blood flow.
The lack of oxygen, or ischaemia,
activates pain fibres in the heart to make
the body slow down and reduce the
crippled heart’s oxygen requirements to a
manageable level.
In 2001, more than 260,000
Australians reported experiencing angina,
according to a National Institutes of
Health survey.
For most patients, the symptoms are
relieved by medication. Surgery can open
the narrowed arteries – or in more severe
cases, replace the blocked section
entirely. However, for a small number of
patients, even the best treatments that
medicine has to offer are not enough to
relieve their pain and discomfort.
6_PATHWAY
These are the ‘no option’ patients,
who have tried every available medical
treatment short of a total heart transplant.
And they’re the patients haematologist
Professor David Ma and his colleagues at
St Vincent’s Hospital and the Victor Chang
Cardiac Research Institute in Sydney are
trying to help, using the 21st century’s
‘magic bullet’ – stem cells.
Exciting possibilities
Stem cells are cells that have yet to
develop into their final cell type, whether
that be a skin cell, heart muscle cell, an
insulin-producing cell, or any hundreds of
other cell types. This makes them
extremely valuable in medicine, because
in theory, stem cells can be used to
regenerate a huge range of damaged
tissues.
Professor Ma’s current research with
stem cells and angina began around five
years ago, when evidence began to
emerge about the potential uses of adultderived stem cells – in particular, stem
cells derived from adult bone marrow.
This attracted the attention of
researchers at the Victor Chang Cardiac
Research Institute, who then initiated a
collaborative study with researchers at St
Vincent’s Hospital, including Professor Ma.
“The idea of this whole study is that
stem cells will open up more vessels by
developing new vessels, to improve
oxygen transport and blood to the heart
and then improve the heart muscle’s
function,” says Professor Ma, Professor of
Haematology at the University of New
South Wales and St Vincent’s Hospital in
Sydney.
It’s a straightforward aim but a
complex process, because bone-marrow
derived stem cells are not easy to get to.
Patients are first given a hormone
called granulocyte-colony stimulating
factor (GCSF, see box page 9) that
stimulates the bone marrow to produce
stem cells, then pushes the stem cells out
of the bone marrow and into the blood. In
the first part of the study, 20 patients were
simply given the GCSF to investigate the
safety of the treatment. The second stage
of the study involved giving patients
GCSF, then extracting stem cells from
their blood and reinjecting them into the
coronary arteries to see what effect this
would have on the health of their
damaged hearts.
To collect the cells, doctors put
patients’ blood through a centrifugation
machine that spins the blood to separate
out the various cell types. This process
generates around 200 mL of white blood
cells, including the stem cells, which are
>
“We also have a collaboration with an orthopaedic team looking at
the effects [of stem cells] on vertebral discs … and we’re also
collaborating with the neurology teams on spinal cord injury and
Parkinson’s disease” – Professor David Ma
“In my view, the training
to become a pathologist
is unique among
medical specialties as it
provides a sound
scientific foundation for
laboratory-based
translational research”
PHOTO CREDIT: IAN BARNES
– Professor David Ma
then put through another separation
process to extract approximately 10 mL of
stem cells.
Finally, this highly concentrated sample
of stem cells is injected back into the
patient’s coronary artery, with the hope
that the stem cells will migrate into the
smaller capillaries and the heart muscle,
creating new vessels and regenerating
heart muscle tissue damaged by lack of
oxygen. However, doctors still had to
ensure the stem cells migrated to where
they were needed most.
“This study is quite unique because
we also make the patient do some
8_PATHWAY
exercise as well before we actually give
GCSF and the stem cell reinjection
the cells back,” Professor Ma says.
process. The researchers were also
“The reason is that we want to induce
a controlled type of stress to the heart, so
that allows the heart to secrete the right
type of cytokines [chemical messengers]
to attract the stem cells to stay in the
right area.”
This study, the results of which will be
presented early next year at a cardiology
meeting in the United States and which
have been submitted for publication, was
intended mainly as a safety study of the
hoping to get some inkling of whether the
treatment would be successful. The
results were positive.
“Some patients noticed their
medication [requirements] dropped
significantly – almost a 10-fold reduction,”
Professor Ma says.
The study also recorded statistically
significant improvements in measures
such as chest pain, quality of life and also
exercise stress test performance.
But then came the twist.
Hearty findings
“We found that just giving GCSF alone
would achieve as much benefit as with
injection of the stem cells in the coronary
vessels,” Professor Ma explains.
“That was a little bit unexpected.”
At the time the study was launched,
there were very little data about the
effects of GCSF in humans in this
situation, but since then, several other
small-scale studies have discovered a
similar pattern of GCSF benefit.
So how is GCSF alone able to achieve
the same benefit as the stem cell
therapy? Cardiologist Professor Robert
Graham, Executive Director of the Victor
Chang Cardiac Research Institute, says
GCSF does more than just get stem cells
moving.
“During the time we did the first trial,
what we came to know from other
people’s studies was that GCSF, in
addition to mobilising stem cells from
bone marrow, appears to directly activate
GCSF receptors on heart muscle cells and
protect against the effects of ischaemia,”
Professor Graham says.
“This activates a survival pathway and
allows the cells to be more tolerant of a
lack of blood supply than before.”
So the heart muscle cells that
previously were dying because of a lack
of oxygen were now able to survive, even
in their oxygen-poor situation.
The stem cells mobilised by GCSF
also appear to be getting to the right
place in the heart without needing to be
directly injected into the area.
circulation, GCSF increases production
and mobilisation of white blood cells,
which makes it a valuable treatment for
patients whose white blood cells have
been depleted by chemotherapy or
disease.
GCSF is a relatively safe agent, with
patients in the study experiencing no
serious adverse events, despite concerns
about the possible effects of mobilising
white blood cells on heart function.
Upping the ante
GCSF, we will probably be able to
mobilise just as much stem cells in the
patient without having to inject it.”
The second study will also be larger,
involving 40 patients instead of the 20 in
the first trial, and unlike the first trial, this
one has a control arm.
“We have built in a placebo arm and
we use the subjects as their own control,”
Professor Ma says.
This means the trial will have two
stages – in the first stage, one group of
As with all exciting and unexpected
scientific findings, this one needs to be
confirmed, so Professor Ma and his
colleagues are now conducting a second
trial to further investigate their discovery.
patients will be given GCSF and the other
“So the emphasis has now shifted,”
he says.
the treatments to pass. The two groups
“In the first study, we were actually
looking at injecting the stem cells; in the
second study we’re saying that using
received the GCSF in the first stage will
group will be given saline fluid as a
placebo. Then, after the results of that
stage are recorded, all patients go through
a ‘washout’ period to allow the effects of
are then swapped over. Those who
be given saline, and those given saline in
the first stage will be given the GCSF.
GCSF: an Australian
pathology success story
ranulocyte-colony stimulating factor (GCSF), which Professor Ma and
G
colleagues are using as a central plank in their work, was first cloned by a
team led by RCPA Distinguished Fellow Professor Donald Metcalf.
Professor Metcalf is one of the world’s pre-eminent biomedical experts,
having headed the Cancer Research Unit at the Walter and Eliza Hall Institute of
Medical Research in Melbourne and having been at the forefront of
experimental haematology since the 1960s.
His work on the colony-stimulating factors GCSF, CSF/IL-3 and GMCSF has
led to understanding of how our immune system’s white blood cells get ready to
It may be that the oxygen-starved
heart muscle is sending out strong
enough chemical signals to attract and
trap the stem cells.
It’s an exciting finding, because GCSF
is already widely used, particularly by
haematologists. As well as mobilising
stem cells from the bone marrow into
fight disease, and spawned a cancer treatment that has saved millions of lives.
The results of his work are now being used successfully in clinics around the
world, helping address the need to stimulate white cell production in the very
young and old, and in at-risk patients with inadequate host-defence systems.
They have also given us valuable information about what goes wrong in
leukaemias and lymphomas.
PATHWAY_9
>
PHOTO CREDIT: IAN BARNES
Pathologists at the
cutting edge
ustralian pathologists are very much at the forefront when it comes to stem
cells, both in the research field and the clinical field, according to
haematologist Professor John Rasko, Director of Cell and Molecular Therapies
at the Sydney Cancer Centre, Royal Prince Alfred Hospital.
A
“They span the gamut from basic research all the way to clinical trials
involving stem cells, and I mean that in the rainbow of colours for all different
stem cells,” Professor Rasko says.
While embryonic stem cell research is still mired in controversy, there are few
such problems in the field of adult stem cells.
“There has been such an explosion of excitement internationally and within
Australia in terms of the relatively recent realisation that there are stem cells in
many organs of the body that were previously unrecognised, and a number of
these are approaching reality in terms of clinical applications,” Professor Rasko
says.
For example, haematologists play a life-saving role in delivering bone
marrow stem cell therapies to patients with blood cancers and some inherited
conditions. Pathologists are also the key figures in the well-established field of
pre-implantation diagnosis of genetic disease, in the context of in vitro
fertilisation.
Less established but equally exciting are mesenchymal stem cells – stem
cells that can differentiate into anything from fat cells to bone cells. These have
shown great promise in treating degenerative joint diseases, as well as graft
versus host disease – a devastating disease that results when a bone marrow
transplant attacks the recipient’s body. Several pathologists in Australia are
researching the potential of mesenchymal stem cells.
Pathologists are not only involved in the bench-to-bedside aspect of stem
cells, but are also helping to shape policy and practice for the collection,
handling, transport and manipulation of stem cells, Professor Rasko says. In
Australia, pathologists have spearheaded an initiative to establish specially
designed labs to handle stem cells.
10_PATHWAY
“There has been such an
explosion of excitement
internationally and within
Australia in terms of the
relatively recent realisation that
there are stem cells in many
organs of the body that were
previously unrecognised”
– Professor John Rasko
“Even people with cardiomyopathies, which are not traditionally due to lack of blood
supply, may benefit because there is an ischaemic component to those as well”
– Professor Robert Graham
The doctors administering the
treatments and recording the results are
blinded to the treatment type, so they
won’t know which treatment their patients
are receiving. Only at the end of the trial
will the results be ‘unblinded’ to decipher
the effect.
The trial, and his work as a
haematologist, has provided Professor Ma
with the opportunity to be involved ‘from
bench to bedside’.
types of cells in the blood, including white
blood cells.
“The aim is to make sure that
measurement of blood stem cells is well
standardised because the number of stem
cells in the blood is so small that the error
is quite high.”
Stem cells not only have benefits for
patients – they are also having the bonus
effect of bringing together a range of
different medical disciplines, Professor
“Although I’m a practising
haematologist, I do devote significant
effort into basic and translational
research,” he says.
Ma says.
“The unique aspect of haematology is
that we do have contact with the patient
as well.”
cross-fertilisation of information and
Professor Ma says he was attracted to
pathology because it covered such a
broad scientific foundation.
involves the haematology and cardiology
“Pathology provides the scientific
platform for understanding the cause and
processes of human diseases.
Chang Cardiac Research Institute and a
“In my view, the training to become a
pathologist is unique among medical
specialties as it provides a sound
scientific foundation for laboratory-based
translational research.”
imaging.
Professor Ma began his pathology
career as a specialist in haematology at
Sydney’s St Vincent’s Hospital – a field he
chose because it allowed him to be
directly involved in not only identifying the
cause of disease, but also care of the
patient.
neurology teams on spinal cord injury and
“We have really broadened our
research collaboration, which is also
exciting because it allows networking and
knowledge.”
For example, this angina study
departments of St Vincent’s Hospital, as
well as cardiologists from the Victor
radiologist to monitor the effects of the
treatment using magnetic resonance
“We also have a collaboration with an
orthopaedic team looking at the effects [of
stem cells] on vertebral discs … and
we’re also collaborating with the
Parkinson’s disease,” Professor Ma says.
Astonishing potential
Even within the study currently being
conducted, there is also the possibility
that the GCSF treatment may have
He then spent several years in various
overseas institutions exploring the rapidly
growing field of stem cell research – an
area he had always been attracted to.
benefits for patients with other conditions
“I would say stem cell research is the
focus of this century – it’s a huge area,”
Professor Ma says.
circulation in their extremities. In theory,
He is now in the process of setting up
a quality assurance program under the
auspices of the RCPA to standardise
measurement of haemopoietic stem cells
– stem cells that give rise to the various
vessels and improving the state of cells in
beyond angina. For example, patients
with peripheral vascular disease are at
risk of limb damage and loss due to poor
GCSF could benefit these patients by
encouraging the growth of new blood
oxygen-deprived tissues.
“Even people with cardiomyopathies,
which are not traditionally due to lack of
blood supply, may benefit because there
is an ischaemic component to those as
well,” he says.
And finally, research with stem cells is
also leading to the development of new
techniques and technologies that are
likely to have wide-ranging applications.
For example, the technique used in
the first study to separate the stem cells
from the rest of the white blood cell
population is very new, and at the time of
the study, was only being used in a few
centres around the world for research, not
clinical purposes.
The study is also breaking new ground
in developing a protocol for using GCSF
in a cardiology setting rather than the
haematology setting, according to
Professor Graham.
So far, GCSF has been largely used by
haematologists in larger doses, with the
aim of significantly increasing the number
of white blood cells, he says.
However, in the cardiology setting, a
careful balance has to be struck between
the number of stem cells and the number
of white cells.
“You will increase the viscosity of the
blood by increasing the number of white
blood cells, and an early concern was that
this may induce an infarct by causing
sludging of cells in the blood vessel,”
Professor Graham says.
Instead, the researchers used a lower
dose of GCSF over a longer period of
time.
But in the end, those who stand to
gain the most from this research are the
patients whose angina has made their life
a misery, and this is foremost in the mind
of researchers like Professor Ma.
“Hopefully, we get something that will
help patients – that’s the ultimate drive.”
A similar principle may apply in
patients with stroke and possibly even
heart failure, Professor Graham says.
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
PATHWAY_11
foreign correspondence
Work on the wild side
WHAT’S SO COMPELLING ABOUT RIO – A CITY WHERE THERE ARE UP TO 60 MURDERS A DAY?
PHOTO CREDIT: TIMOTHY LYONS
ASSOCIATE PROFESSOR TIMOTHY LYONS EXPLAINS HIS ONGOING FASCINATION TO KELLIE BISSET.
t’s not a routine tourist destination and is
undeniably dangerous, but forensic
pathologist Timothy Lyons is addicted to
Rio de Janeiro.
There was no-one around, and he
made the wise choice to part with his
money: “I decided a long time ago that
arguing with guns is not a good idea.”
Since 1998 he has been on four study
trips to Brazil’s largest city, and would
love to make at least one more visit.
Forensics, Rio style
I
This is despite an obvious disincentive
– the Brazilian homicide rate is between
1000 and 5000 per million people,
compared to Australia’s relatively tame
12–20 per million.
“There is a level of violence there we
simply don’t see,” says Associate
Professor Lyons, Head of the Newcastle
Department of Forensic Pathology (a
division of Hunter Area Pathology).
“There is a lot of violent street crime
and there are about 30 to 60 homicides
per day – a lot of them are drug-related
and assassination-type murders.”
Everyone he has met in Rio has been
mugged, and Professor Lyons didn’t
have to wait long to experience the event
for himself.
Late one night he was held up at
gunpoint while withdrawing money from
an ATM, despite being within 50 metres of
a hotel and on a big main road.
12_PATHWAY
When in Brazil, Professor Lyons spends
his two to three weeks’ study leave at the
Instituto Médico Legal for central Rio,
which covers a population of about 7
million people.
The department processes about
15,000 cases a year, of which about
13,000 are homicides. Eight pathologists
are on duty each day – and they have a
lot of work to churn through.
Despite this, forensics in Rio is not a
full-time occupation, and pathologists will
often find themselves doing other work,
such as surgery.
Very few doctors have one job in a
health system Professor Lyons describes
as “a mine of confusion”.
“Everything is run down and underfunded but they make valiant attempts to
maintain professional standards,” he says.
“Their standards of autopsy are not as
high as ours, but they have had to
develop techniques to get work through
quickly.
“Amongst the chaos, the facilities they
have developed are good. They do
toxicology and ballistics – probably not to
the detail we do – and they have a good
system of educating their mortuary
technicians. There are always a lot of
medical students coming through. They
have an active system of teaching.”
There is also an effective system of
describing injury patterns, and “excellent”
body charts that describe entrance and
exit wounds clearly and neatly.
Then, apart from the homicides, there
are the AIDS-related problems and tropical
medicine rarely encountered in Australia.
“It has hugely increased my
knowledge in terms of violent trauma such
as gunshot wounds,” Professor Lyons
says.
“I would like to spend three months
there on sabbatical to become more
actively involved.
“People say ‘why do you go back’ but
it is completely and utterly different to
what I have experienced in Australia. I find
it very enriching.”
PHOTO CREDIT: TIMOTHY LYONS
“Rio is not at war, but there is almost a
civil war over drugs. It is a bit like being in
an armed conflict”
Above: Rio coconut sellers Inset: Professor Lyons outside the necropsy room
Right: Mortuary technician
Seasoned visitor
Professor Lyons first thought of visiting
Rio after meeting some Brazilian forensic
police at a Melbourne conference. They
invited him to their city and he first visited
in 1998 as an observer. But on
subsequent trips he has become more
involved, taking part in teaching, and
being escorted to crime scenes.
“They seem to have adopted me. I
think they keep threatening to give me a
job there,” he says.
“It is interesting to understand the
issues that have arisen out of the drugrelated problems and you do bring back
some thoughts and ideas about that.
“Rio is not at war, but there is almost
a civil war over drugs. It is a bit like being
in an armed conflict.”
Now he’s a seasoned visitor, Professor
Lyons knows there are some things in Rio
you just don’t do – like use ATMs. He
changes money in cafes instead.
And he only needed to wander into
downtown Rio on a Saturday morning
once to realise a stroll quickly turns into a
“sprint from people who might rob you”.
Instead he saves his walks for safer times
of the week.
“I enjoy it now because I know what
to do,” he says.
In any case, he’s also no stranger to
violent countries.
He once hitched through Colombia
and Ecuador and has lived and worked in
Cape Town, “where there is so much
murder and mayhem it is almost zany”.
He also travels regularly to Papua New
Guinea with the Australian Defence Force
– one of the most dangerous destinations
he has ever encountered.
So returning to Rio doesn’t faze him in
the least. In fact, he’s actively learning
Portuguese in preparation for his next visit.
Despite the many poor areas of the
city, parts of it are awash with private
money and it’s the centre of the world for
plastic surgery.
It also boasts some stunning
architecture.
“Around the area of the medicolegal
institute is a myriad of little streets which
have Portuguese and Spanish
architecture of the 1700s and 1800s,”
Professor Lyons says.
“It is run down but there are loads of
little restaurants and bookshops and
antique shops.
“One of the things I like about Rio are
the fruit stalls. You can choose from 50
different Amazon fruits which are crushed
and liquidised into all colours and
textures.”
Equally engaging are the local people,
who have a dry and cynical humour,
similar to Britons and Australians.
The level of violence obviously takes
its toll on the population’s psyche though,
and people are wary. Many doctors carry
at least one – if not two – guns.
But on the plus side, safety appears to
have improved over the time Professor
Lyons has been visiting.
There is a functioning underground rail
network called the metro, which is a wellpoliced and safe mode of travel around
the city.
And in spite of their privations, the
locals are warm and hospitable.
“The people I have met have been
beautiful,” Professor Lyons says.
“You can’t understand the medicine
without understanding the culture.”
PATHWAY_13
in profile
Standard bearer
PROFESSOR LAI-MENG LOOI HAS SQUEEZED MYRIAD ACHIEVEMENTS INTO HER NOTABLE
PATHOLOGY CAREER. REBECCA GREATREX REPORTS.
rofessor Lai-Meng Looi can’t
remember a time when she didn’t
want to be a doctor.
P
And after a 50-year career that has
transformed pathology in Malaysia and
seen her named a Companion of the
Crown by the King, this consultant
anatomical pathologist has never lost her
original focus – describing a pathologist
as “first and foremost a medical doctor”.
The fourth of six children, Professor
Looi, who holds the Chair of Pathology at
the University of Malaya’s Faculty of
Medicine, grew up in Bentong, a small
town surrounded by jungle.
It was the sort of place that “people
would go by, on their way to other big
cities”, but it had a small hospital where
her father worked as a hospital assistant
and she would visit him there.
“He was always very busy, but very
patient, and people related to him,” she
says.
“I guess I got used to the hospital and
clinical environment.”
Forced to move to Kuala Lumpur at
the tender age of 16 to continue her
education, Professor Looi describes it as
“an adventure in a sense, but not too
unusual because my elder siblings did the
same thing”.
She rented a room and enjoyed the
freedom to make her own decisions.
“It was quite nice to be away from
home!”
She gained a Malaysian Federal
Scholarship to study medicine at the
University of Singapore, where she
discovered her love for microscopy and
14_PATHWAY
enjoyed “drawing the cells and structures
I saw down the microscope”.
Her artistic talents expanded beyond
histology, though.
“I enjoyed sketching people and
landscapes, and abstract things like
designing posters with psychedelic
colours.”
Her creativity also extended to poetry,
writing and drama.
While thoroughly enjoying her five
years in Singapore, it was there, in her
fourth year, that she decided on
pathology as “the subject that made the
most sense”.
It appealed because “it explained how
disease occurs and affects the body, the
signs and symptoms that patients
develop and gave the logical basis for
treatment”.
Professor Looi describes her years at
Singapore as a good experience, not only
because of the quality of teaching, but
because the students were given the
freedom to do things their own way.
“It was entirely up to you,” she says,
“and I liked that because it allowed you to
learn at your own pace.”
Buckets of calm
Aileen Wee, Professor of Pathology at the
National University of Singapore, has
known Professor Looi since they were
fellow students and describes her not
only as smart, but as one of the “calmest,
most unruffled persons I have met.
Nothing can fluster her.”
These qualities stood the professor in
good stead when she returned to Kuala
Lumpur as a houseman at the General
Hospital – “the busiest and largest
hospital in Malaysia” – which was short of
doctors.
“Suddenly you have to take care of
the ward and you’re only a houseman,”
she says.
Daily ‘bucket duty’ involved carrying a
pail full of surgical resections from the
operating theatre to the pathology
department, where she got to know all
the pathologists and would linger around.
At the end of the year, she was
offered chances to train in surgery and
paediatrics, but not in pathology:
“Nobody was very interested in pathology
at that time.”
But as pathology remained her main
interest, she investigated the MPath
program at the University Hospital, where
she was advised to acquire another year
of clinical experience.
After another year at the General
Hospital she enrolled in the two-year
MPath. The department had strong links
with the Royal College of Pathologists in
the UK, which enabled her to receive
solid training from visiting members of the
college. By 1982 she held both the MPath
and the MRCPath qualifications and had
developed a serious interest in research –
in particular, amyloidosis.
Its occurrence in the Malaysian
population became the subject of her
doctoral research. Other research areas
included tactoidal proteins, renal
pathophysiology and cancer progression
and have resulted in more than 200
publications.
>
PHOTO CREDIT: TED ADNAM
“Once I even cleaned the windows
and the toilets so the cleaners could
not make lame excuses”
PATHWAY_15
CV in brief
PROFESSOR LAI-MENG LOOI
1975
MBBS
1980
MPath
1982
MRCPath (Member, Royal College of Pathologists)
1984–99
Head, Department of Pathology, Faculty of Medicine,
University of Malaya
1985
MIAC (International Academy of Cytology)
FRCPA (Fellow, Royal College of Pathologists of
Australasia)
1986–
Professor (Chair), Department of Pathology, Faculty of
Medicine, University of Malaya
1986–
Senior Consultant Histopathologist, University Hospital,
Kuala Lumpur
1987
MD (Doctorate in Medicine)
1993
FRCPath (Fellow, Royal College of Pathologists)
1993–
President, College of Pathologists, Academy of Medicine
Malaysia
Professor Looi describes her research
skills as “mainly in diagnostic pathology;
very patient-focused, to establish what
kind of treatment is suitable for the
patient”.
Scrubbing in
It is this aspect of her job that she
considers the most important and, in
order to avoid losing touch, she is still
rostered onto regular surgical pathology
and autopsy duty like the other
anatomical pathologists in the
department.
“We have a trainee with us and take
the trainee from very basic pathology right
up to very difficult cases. It works out
very well. I don’t regret that I have to look
at an appendix or something else very
straightforward.”
She had just settled into her doctoral
research when her mentor, Professor
Prathap, died unexpectedly, leaving a
huge vacuum in the pathology
department as most of the senior staff
had emigrated to Australia, and “the rest
of us were very green”.
Nevertheless, she was made Head of
Department shortly afterwards and
suddenly found herself having to cope
with a triple workload of research,
teaching and administration.
1997
FAMM (Fellow, Academy of Medicine of Malaysia)
1999
Malaysian National Scientist
1999–2003
Deputy Dean (Postgraduate Programmes), Faculty of
Medicine, University of Malaya
It was a hard time and Professor Looi
became used to doing quite a bit outside
office hours.
1999–2007
Regional Councillor (Malaysia), RCPA
2000
JSM (Johan Setia Mahkota) – Companion of the Crown
2001
ASEAN Outstanding Scientist & Technologist Award
ASEAN-COST
She found that she enjoyed those
times, with no phone calls and
interruptions, and so this was when she
focused most on her research.
2003
Rotary Research Foundation Gold Medalist
2004–2006
National Representative (Malaysia), Royal College of
Pathologists
2005
FAMS (Fellow, Academy of Medicine Singapore)
2005
Honorary Fellow, College of Pathologists of South Africa
2005
FASc (Senior Fellow, Academy of Sciences, Malaysia)
2007
President, 24th World Congress of Pathology and
Laboratory Medicine
2007–
16_PATHWAY
Director-at-Large, Bureau of the World Association of
Societies of Pathology and Laboratory Medicine
“I certainly worked quite a lot at the
weekends,” she says. “I spent a lot of
time in the department and it was more or
less my second home.”
Today, though, she tries to protect her
weekends, and spend a bit more time
with her family.
An old teacher once advised her to try
everything at least once before asking
someone else to do it.
Consequently, she tried to perform the
work herself before delegating it.
“It is also harder for others to pull the
wool over your eyes if you have done the
job before. Once I even cleaned the
windows and the toilets so that the
cleaners could not make lame excuses.”
Playing the guitar was a youthful pursuit;
Left: sitting atop the family's first car.
Dr Leslie Lai, Consultant in Chemical
Pathology and Metabolic Medicine at the
Sunway Medical Centre in Malaysia, has
known Professor Looi for about 10 years
and comments on her fun-loving nature.
“She is a very likeable person who
always brings a bit of fun and laughter
into everything.” This may help explain
why Professor Looi has been awarded
‘Best Lecturer’ seven times by her
students.
Even as a child, she would enjoy
teaching her younger siblings and helping
her mother, who taught English in a
Chinese school.
“I like to share ideas and explain
things and I enjoy taking tutorials,” she
says.
Raising the bar
Under Professor Looi’s leadership, the
Pathology Department at the University
Hospital has become the most reputable
in Malaysia – partly because she
encouraged the staff to do their
doctorates and to sit their fellowship
exams, and partly because she upgraded
the MPath course to match the standard
set by both the Royal Colleges in the UK
and Australasia.
Malaysia is another string she can add to
her bow.
She was also instrumental in creating
a training program for Sudanese
specialists that she feels has
internationalised the department.
Professor Looi oversaw the
introduction of immunohistochemical and
molecular techniques into diagnostic
pathology across Malaysia, and has seen
pathology become more widely
recognised by the public, describing the
current climate as a “great time for
pathology”.
Another long-term colleague, SoonKeng Cheong, Professor of Haematology
at the International Medical University in
Malaysia, describes her as “capable,
independent and forward-looking” and
admires her ability to rally people round
an objective.
One such objective, achieved in 1999,
was to unite Malaysian pathologists under
one professional body- The College of
Pathologists, Academy of Medicine Malaysia.
Professor Looi organised help from
the British Council “when we were quite
short of expertise” and strengthened links
with other overseas colleges, including
the RCPA. She served as the RCPA
Malaysian Councillor until recently and
also worked to get the pathology
department accredited as a training centre
towards the FRCPA.
And after four years of effort, the
introduction of a national accreditation
scheme for medical testing laboratories in
This increased public profile
contributed to the regulation of pathology
laboratories through the Pathology Bill,
which had languished for two decades
until it was passed this year. Professor
Looi describes this as a big achievement.
Eventually she plans to retire
completely from pathology to write books
and spend more time on a less vigorous
pursuit: fishing.
“It’s nothing very grand. I just take a
rod and a worm and go down to the river,”
she says. “Some of the fish are
respectable enough to cook for dinner,
but it doesn’t matter whether I catch
anything, I just enjoy the quiet time.”
She is quietly modest about her
achievements, too, saying only, “I did
what I could!”.
PATHWAY_17
close up
False colour scanning electron
micrograph (SEM) of liver cells with
PHOTO CREDIT: SCIENCE PHOTO LIBRARY
cirrhosis.
.4PRO".0
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testing testing
Heart starter
PATIENTS WILL SOON HAVE PUBLICLY FUNDED ACCESS TO A NEW PATHOLOGY TEST THAT
DIAGNOSES HEART FAILURE. MATT JOHNSON EXAMINES THE ROLE IT WILL PLAY IN MEDICAL
DECISION-MAKING.
uby is 70 years old and has lived at
To confirm the diagnosis the doctor
R
would normally request a series of tests,
since her husband died six years ago.
including pathology, that can point
home alone and remained active
She sees her doctor regularly and is
treated for high blood pressure and
osteoporosis. But for the past two weeks
she has been getting short of breath with
just mild exertion. Last night, her
dyspnoea (breathlessness) became so
bad she called an ambulance and was
rushed to hospital.
Following a physical examination, the
towards heart failure. Or he could choose
a single blood test that might definitively
identify the problem.
In November, this test for BNP, or Btype natriuretic peptide, will be funded on
the Medicare Benefits Schedule for the
first time, but only for use in hospital
to predict the seriousness and likely
outcome of the disease.
But despite the test’s successful
performance in research trials, there
remain questions about when it should be
applied and how to use it appropriately.
People are asking, while BNP is
accurate, does it diagnose heart failure
any better than a trained doctor, and if
not, what is its place?
emergency settings.
Funding approval for testing of BNP –
a hormone that is directly related to heart
emergency department doctor suspects
failure – follows cumulative research that
Ruby’s heart is failing, causing fluid to
confirms the test’s ability to not only
build up in her lungs.
accurately diagnose heart failure, but also
Vicious cycle
Anatomically, Ruby’s heart and lungs
reside side by side in her chest. The right
side of Ruby’s heart pumps blood though
her lungs for it to become infused with
PATHWAY_21
>
oxygen and unload carbon dioxide. That
diffusion of gases occurs across a
membrane made up of one thin capillary
cell and one thin lung cell and is only 0.5
to 1.0 µm thick. Any thicker, and the
diffusion could not occur before the blood
leaves the lungs.
resistance, blood backs up into the
pulmonary circuit. If this occurs the fluid
in the pulmonary circuit can start to force
its way out of the capillaries, thickening
the barrier between the blood and the
lungs and increasing the distance oxygen
has to travel to get into the blood.
The left side of Ruby’s heart then has
to pump that oxygenated blood through
her much longer systemic circuit,
delivering the oxygen to her cells. When
the left ventricle, through injury, age or
disease, cannot pump against the
Ironically, the body’s response to this
lack of oxygen is to get the heart to pump
faster and further increase Ruby’s blood
pressure in an attempt to circulate more
blood. This places more strain on her left
ventricle, and too often speeds the rate of
BNP levels:
what they mean
CAUSES OF INCREASED BNP LEVELS
• CARDIAC FAILURE
• HEART ATTACK (MYOCARDIAL INFARCTION)
• PULMONARY EMBOLISM
• LIVER CIRRHOSIS
• OBSTRUCTIVE PULMONARY DISEASE
• RENAL FAILURE
• INCREASED AGE
WHEN A DOCTOR MIGHT CHECK BNP LEVELS
• TO ASSIST WITH THE DIAGNOSIS OF HEART FAILURE
PARTICULARLY WHERE THERE ARE CONFOUNDING
FACTORS
• TO MONITOR RESPONSE TO THERAPY FOR CARDIAC
FAILURE
• TO DETERMINE WHEN A PATIENT CAN BE DISCHARGED
22_PATHWAY
failure. This vicious cycle is why heart
failure is associated with such a poor
prognosis.
It’s estimated that 5–10% of
Australians older than 65 have a degree of
heart failure.
Unlike other cardiovascular
conditions, heart failure is actually
increasing in incidence and is now the
leading cause of hospitalisation for
patients over 65.
The increase may partly be due to
better treatment of heart attacks
(myocardial infarctions), allowing patients
who would previously have died to
survive, but with a damaged heart.
The self-propagating nature of the
condition within an ageing population also
means the already substantial burden it
imposes on the healthcare system will
undoubtedly increase.
This increase in the rate of heart
failure has occurred despite two decades
of diagnostic and therapeutic advances
that have decreased the morbidity and
mortality of chronic heart failure once it
has been diagnosed.
So there is a suspicion that the vast
majority of patients with early – or
‘symptomless’ – left ventricular
dysfunction remain undiagnosed until the
disease process is firmly established.
Part of the problem with developing
an early diagnosis is that most of the tests
for heart failure – electrocardiograms
(ECGs), chest x-rays and blood tests for
electrolytes, albumin, blood urea nitrogen,
creatinine, glucose, liver enzymes and
thyroid-stimulating hormone – all look for
changes caused by the failure, not the
failure itself.
Using sound waves, echocardiograms
allow doctors to watch the heart beat and
assess ventricular function, but they’re
rarely available in local general practice
and smaller emergency departments,
where most ‘early’ patients present.
And even in larger emergency
departments, where they are commonly
“BNP seems to be a very powerful predictor of
mortality and this could be useful in determining which
patients on a transplant list are at a higher risk and
need a more urgent transplant”
– Associate Professor Hans Schneider
Symptoms
of heart
failure
used, studies suggest they correctly
• Difficulty breathing or
shortness of breath,
when exercising or at
rest
• Swollen legs, ankles or
feet from a build-up of
fluid (oedema)
• Weight gain (from
increased fluid
retention)
• Decreased ability to
exercise
• Tiredness after normal
activities
• Cough with activity or
at rest
• Once a diagnosis has
been made, these
symptoms may be
used to help classify
the disease and
monitor therapy
BNP hits the spotlight
identify only 25–30% of failure cases with
left ventricular dysfunction.
All these areas of uncertainty have left
GPs unsure of when to initiate further
invasive and expensive tests, and even
within emergency departments where
there are more diagnostic facilities
“We’ve known about BNP for a while but
it was not initially considered as a test for
the causes of dyspnoea,” explains Dr
Samuel Vasikaran, Chemical Pathologist
at Royal Perth Hospital.
“For a long time BNP was principally
available, doctors often remain tentative
studied as a hormone that affected salt
when diagnosing failure.
and water levels in the body, and it’s
A recent survey of one North
American hospital (Circulation 2002; 106:
416–22) found casualty doctors admitted
taken a long time to clarify its diagnostic
potential when it comes to heart failure.”
BNP is a neurohormone produced
uncertainty in diagnosing cardiac failure in
principally by the ventricles of the heart
40% of cases, especially where they had
and released when the heart muscles
to differentiate between dyspnoea caused
become overstretched.
by heart failure and dyspnoea due to
Released into the blood, BNP reduces
other causes. It’s understandable, then,
the cardiac load by dilating blood vessels
that the medical community was excited
and reducing their blood volume by
by the discovery of a hormone secreted
increasing the amount of urine they
by the heart when it’s under stress that
excrete. It also opposes the
could be used to diagnose heart failure.
vasoconstriction and hypertension caused
>
PATHWAY_23
“There’s potentially a link between BNP and death from a myocardial infarction, and it’s
being investigated if it can be used to identify these patients”
– Dr Samuel Vasikaran
by the body’s response to the shortness
of breath.
There are now numerous studies
showing a correlation between BNP levels
and heart failure. Compared with
echocardiography, one study found up to
97% of incorrect clinical diagnoses of
dyspnoea in an emergency department
setting were correctly diagnosed based
solely upon BNP measurement.
Interestingly, the BNP gene contains a
destabilising sequence that suggests the
release and breakdown of BNP is
relatively rapid, with the hormone
synthesised in bursts in response to
ventricular overload.
“The initial studies used in the general
practice setting used BNP levels to help
decide if a patient should be referred to a
cardiologist or for an echocardiogram,” Dr
Vasikaran explains.
“In this setting, BNP was found to be
very useful as a screening process as it
had good sensitivity, and a negative result
ruled out heart failure and meant the
patient didn’t have to undergo
unnecessary tests.”
The studies referred to by Dr
Vasikaran include a 2002 New Zealand
study, where 305 patients, all of whom
had shortness of breath or ankle swelling,
were randomised into two groups after an
initial cardiac assessment (The Lancet
2002; 360:545-546).
Half the patients were reviewed by
GPs who were given the BNP results, with
the other half forming a control group
reviewed by GPs using customary clinical
assessment without the BNP result.
The study found the GPs who had
access to the BNP result improved their
diagnostic accuracy by 21% compared to
an 8% improvement in the control group.
Interestingly, the increase in accuracy was
mainly due to GPs ruling out heart failure
if the BNP result was normal.
“The initial studies stimulated a lot of
interest and that prompted people to think
BNP could be useful in emergency
departments to investigate if dyspnoea
was failure related,” Dr Vasikaran says,
adding that the promise in this setting is
now being investigated in several large
studies, including a well-structured trial at
The Alfred Hospital in Melbourne.
Investigations deepen
Associate Professor Hans Schneider,
Director of Pathology Services at The
Alfred, is heading one of these studies
and attempting to clarify when and how
BNP should be used in the emergency
department.
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24_PATHWAY
Testing options
he actual test for BNP is relatively simple and requires
His study is designed to assess how
well BNP can determine left ventricular
dysfunction in patients at high risk of the
condition but without known cardiac
dysfunction, symptoms of heart failure or
previous diagnosis of either condition.
While he shares the enthusiasm for
BNP as a test, he is concerned some of
the earlier studies may not have been
sufficiently well designed to be entirely
accurate in terms of whether it diagnoses
heart failure more accurately than a
doctor.
Too often, he says, the test doesn’t
actually change a patient’s diagnosis.
“From what I’ve seen from the
published studies, the performance of the
BNP test is about as good as an
emergency department doctor,” Professor
Schneider says.
“Most studies suggest using both the
doctor and the test gives better results,
but we need a large randomised control
study to establish when the test actually
affects the decision made by the doctor.
“There is probably a clear benefit
when the doctor really is unsure, but an
early assessment of our results suggests
that when the doctor says there’s failure,
they’re right, and when they say there is
no failure, they’re also right. It doesn’t say
the test is bad, just that the benefits may
be overstated. Those early studies had
enormous publicity, especially from the
point of view of triaging patients – and
some, like the New Zealand study, were
very well constructed, where BNP was
used to not only identify patients with
heart failure but also to help manage their
care and their medications, and that led to
less hospital admissions and
readmissions.”
However, Professor Schneider warns
the test could easily become overprescribed.
He is more confident of the role of
BNP testing once patients have been
diagnosed with heart failure, and says it
might also be useful in determining which
patients require an urgent heart transplant.
“In these patients there are definitely
benefits in monitoring their BNP level to
T
only 5 mL of blood, but two test procedures are currently
available.
One tests for raw BNP levels, and a second looks for only a
portion of the BNP molecule, called the NTproBNP test.
“In my opinion the two tests are pretty much the same,”
Professor Schneider says.
“The only real difference is that NTproBNP testing is a little
more stable and isn’t affected by time or temperature, so if
we are moving towards having 24-hour testing seven days a
week it could be more practical.”
While both tests have good sensitivity and accuracy,
interpretation of the results remains an open field.
“Renal failure, pulmonary embolism and other conditions
affect BNP levels,” Dr Vasikaran says, “and it also increases
with age so to determine a reference range of what are truly
normal and abnormal values will take very large numbers of
patients – and possibly years – before we gather the data.”
assess how well we are managing their
condition and to optimise their treatment
regimes,” he says.
“BNP seems to be a very powerful
predictor of mortality and this could be
useful in determining which patients on a
transplant list are at a higher risk and
need a more urgent transplant.”
BNP has also been investigated by a
number of other researchers trying to
determine if it should be added to the
current battery of tests applied to patients
who complain of ischaemic chest pain.
“There’s potentially a link between
BNP and death from a myocardial
infarction, and it’s being investigated if it
can be used to identify these patients,”
Dr Vasikaran says.
“But it’s simply too early to tell if it will
be effective.”
Research published in June in the
Journal of the American College of
Cardiology (2007; 50 (3): 215-16) with the
headline “Utile or Futile” looked at this
question.
The authors found a sufficient link
between mortality and BNP to claim a
single BNP value in these patients is
sufficient to assign them with a risk level,
and that BNP and other neurohormones
may be the unifying link in patients who
die from coronary artery disease.
So while its final use is yet to be
determined, it appears BNP – a test that
has been around for some time – may
actually be among a new generation of
cardiac tests that will not only help
diagnose patients before they become ill,
but improve outcomes if they manage to
slip through the net.
Until then, doctors and pathologists
might have to move past their conception
of the heart as just a pump and start
thinking of it as a gland, excreting
hormones that can dramatically affect its
function.
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
PATHWAY_25
Not just Quality Assurance!
A resource for the Pathology community
RCPA Quality Assurance Programs—
RCPA Quality Assurance
more than just broad range, world class,
Programs are offered in the
accredited external quality assurance
following disciplines:
programs.
RCPA QAP offer educational support for
Anatomical Pathology
your quality initiatives:
Benchmarking in Pathology
z
Seminars
Chemical Pathology
z
Workshops
Cytopathology
z
Forums
Haematology
z
Educational supplements
library
Immunology
Microbiology
z
Educational exercises
Serology
z
Virtual Images library
Synovial Fluid
z
Case study exercises
Transfusion
Quality Systems Certification Organisation No: 9013
NATA Accredited Proficiency Testing Scheme Provider Number: 14863
www.rcpaqap.com.au
disciplines in depth
Suspicious minds
ANATOMICAL PATHOLOGISTS ARE MEDICINE’S PRIVATE DETECTIVES, WHOSE WORK INVOLVES
PLENTY OF INTRIGUE AND DRAMA. LISA MITCHELL REPORTS.
t’s a bit like doing 30 crossword puzzles
a day, says Dr Rohan Lourie of the
4000–5000 medical cases he investigates
annually.
I
As an anatomical pathologist, he and
680 other probing perfectionists around
Australia and New Zealand spend up to
five hours a day propped over their
microscopes.
Tens of thousands of Australians turn
to these doctors each year for answers
when diagnosed with cancer. “Will my
tumour kill me?” they want to know, and
“how long have I got?”
Anatomical pathologists are behind a
revolution in cancer therapy. They are
categorising cancers so efficiently that
drugs are now being developed to target
specific malignant cells, eliminating the
blanket destruction of healthy and harmful
cells caused by chemotherapy.
Unlike their well-publicised forensic
colleagues on CSI: Crime Scene
Investigation, anatomical pathologists are
‘the quiet achievers’, often perceived as
introverts huddling in basements with the
lab mice, Dr Jeanne Tomlinson grumbles
through a smile.
Bah humbug! There is intrigue aplenty
in their work, she says.
“We see a lot of bread-and-butter
stuff, but once or twice a day you get
something that really interests you that’s a
bit difficult. You’ve got to be like a private
investigator, ringing clinicians for more
information, looking at texts, showing it to
your colleagues. It’s really very satisfying
when you nail a case,” says Dr Tomlinson,
who works with Douglass Hanly Moir
Pathology in Sydney.
Bizarre but true
Tell Dr Mary Miller she lives a cloistered
life hunched over a microscope and she
will tell you about the time she returned
an arm to a murderer and thwarted the
beating of an innocent man.
Dr Miller is an anatomical pathologist
at Middlemore Hospital in Auckland,
which specialises in bone tumour
referrals. She is sometimes called upon to
return limbs to patients. They like to bury
them, she says, recalling the handover of
one young man’s frozen arm, which had
been amputated below the elbow.
“A couple of years later, he was
convicted of rape and murder,” she says.
“As soon as they said a ‘one-armed
man’ [on the news], I knew who it was…
I suppose losing his arm didn’t prove any
barrier to carrying out his activities.”
Back-office medicos, eh? Hospitals
would grind to a halt without them.
Anatomical pathologists are essentially
the diagnostic arm of medicine. They
examine cells, tissues or organs which are
prepared and placed on slides, then
stained with various inks and dyes to
reveal information upon examination
under microscope. Larger specimens may
also be viewed with the naked eye
(grossly or macroscopically), before being
sampled.
“I’ve had specimens such as a whole
leg – mid thigh down to the foot – with a
tumour around the knee,” says Dr Andrew
Laycock, an anatomical pathology
registrar (trainee) at Western Diagnostic
Pathology in Perth.
Samples are collected by biopsy.
There is the incisional biopsy (cutting
away a small piece of tumour), and the
excisional biopsy (removing the entire
tumour from a patient). The smallest
biopsy available is fine-needle aspiration
cytology, which involves inserting a fine
needle to extract cells. And there is the
core biopsy, which uses a larger needle to
extract a larger sample.
PATHWAY_27
>
PHOTO CREDIT: IAN BARNES
Dr Tomlinson: We see a lot of bread-and-butter stuff, but once or twice a day you get something that really interests you
Cutting to the truth
While the bulk of anatomical pathologists’
work involves the scrutiny of tumours,
they also view biopsies of bowels, livers,
kidneys and other organs for various
diseases – inflammatory (Crohn’s disease),
bacterial (tuberculosis), viral (hepatitis C)
and metabolic (haemochromatosis, which
causes cirrhosis of the liver).
In their laboratories you will find
gleaming stainless steel benches, body
bits drowned in formalin, cutting
machines, staining and labelling
machines, microscopes, scalpels, knives,
and dictaphones to record proceedings.
Biopsy specimens are fixed in
formalin, placed in containers, then put
into a machine that impregnates the
tissue with wax. This produces a firm
block that can be cut finely into sections
that are only one cell – or even less than
one cell – thick.
Where anatomical pathologists practise
•
Public sector – government-run laboratories
servicing public hospitals
•
Private sector – boutique or large
multidisciplinary laboratories
•
•
28_PATHWAY
Working as specialists in paediatrics,
women’s health, forensics or neuropathology,
or in hospitals with centres of cancer expertise
Working as academics within universities
“Those slices are then put on a glass
slide and stained with different stains to
bring out different features in the tissue,”
says Dr Tomlinson. Hundreds of stains are
available to help categorise cells.
Thirty years ago, breast cancer was
breast cancer, and mastectomies were the
treatment tool of the day. Today, the
ability of anatomical pathologists to
categorise, diagnose and prognose
cancers more efficiently is an enormous
contribution to modern medicine. It has,
however, doubled and even tripled the
workloads of pathologists.
Just another day in the office
On a typical day at Douglass Hanly Moir
Pathology, around 500 cases are divided
between 15 colleagues. Some cases
might require 30 or 40 slides each. They
might end up with 2000 tissue blocks that
need to be stained and examined by
attentive eyes.
“Before staining and labelling
machines came in about 20 years ago, it
was all done by hand. So there has been
some automation,” Dr Tomlinson says.
But cutting of samples is still
performed by manually operated
machines.
This is certainly no profession for
slackers. Anatomical pathologists earn
their whites over 13 years. The first six
years are spent acquiring a medical
degree, followed by a year as an intern,
“You’ve got to be like a private
more information, looking at
Common conditions
texts, showing it to your
diagnosed by anatomical pathologists
investigator, ringing clinicians for
colleagues”
- Dr Jeanne Tomlinson
•
Skin disorders – solar damage-related disorders,
such as basal cell cancer, squamous cell cancer,
actinic keratoses (pre-cancerous skin damage),
another as a resident, and another five
years as a trainee pathologist in either a
public or private-run laboratory.
“You need to have good visual skills
and attention to detail, an urge to
complete things,” suggests Dr Lourie,
who works at Mater Pathology Services in
Queensland.
“To have 100 slides and to know that
you must look at each carefully and with
the same level of detail… it takes a
certain personality.”
Anatomical pathologists may gain
expertise within certain areas, such as
kidney, bone or lung pathology, by
working in hospitals that have developed
a centre of expertise. Some sit specific
exams to specialise in paediatrics,
women’s health, neuropathology, or the
CSI specialty, forensics.
The new era for anatomical pathology
is taking examinations from a cellular level
to a molecular level, and using microarray
technology (still largely research-based) to
conduct rapid analysis of large amounts
of genetic material.
“What we’re doing now is trying to
figure out at the molecular and genetic
level what the abnormalities are, and
specifically making treatments targeting
those abnormalities,” Dr Laycock says.
Recently, he used polymerase chain
reaction (PCR) to amplify specific regions
of a DNA strand as part of his
investigation into a lump on the salivary
gland of a young boy. Fine-needle
aspiration cytology revealed some
inflammatory cells, while staining revealed
fungal elements, but PCR confirmed and
identified the fungus.
“If that had not been confirmed, it
might have festered and spread to the
central nervous system and brain and
caused all sorts of problems”.
skin rashes
•
Small gastrointestinal biopsies with gastritis,
colitis, polyps
•
Common tumours – colon, breast, lung and
prostate cancer
•
Less common tumours – lymphoma, melanoma,
bone lesions, salivary gland and thyroid lumps,
brain tumours
Says Dr Tomlinson: “Before, we would
just divide lymphoma into small-cell
lymphoma, which was good, or large-cell
lymphoma, which was bad. Now we know
lymphomas have a specific genetic
‘fingerprint’ that allows us to make a
specific diagnosis. There are now over 30
different types of lymphoma, each with its
own unique behaviour and treatment.”
Australians can now rejoice instead of
And while drug companies are
developing specific drugs to treat refined
categories, those drugs are also
tremendously expensive.
been tagged as an aggressive lung cancer
“You want to know that the patient is
going to respond before you put them on
a drug that costs $50,000,” Dr Lourie
says.
At least one anatomical pathologist
has emerged from the shadows of his
colourful television counterparts on CSI.
In 2005, Dr Robin Warren, a senior
pathologist at the Royal Perth Hospital,
(now retired) and his colleague, Professor
Barry Marshall from the Microbiology and
Immunology Department at the University
of Western Australia, took the Nobel Prize
for Medicine for their investigative work
on peptic and gastric ulcers, which led to
a cure via antibiotics. Seventy thousand
belly aching.
“The general public don’t know what
we do, and we are often undervalued by
our colleagues,” says Dr Tomlinson, whose
recent handiwork had a 37-year-old
woman rushed to hospital for treatment of
a rare fungal infection that had otherwise
destined to kill her.
“She’ll never know that I did it, or that
I was the person who put her on the right
path.”
Nor did the chap about to be ‘beaten
up’ by his wife’s family ever know that Dr
Miller proffered the vital piece of
information that whisked vengeance from
their minds:...
“A woman who had an ectopic
pregnancy thought her partner had
caused her to lose the baby because he
had beaten her up the night before,” Dr
Miller says. “I explained to her that she’d
had a miscarriage because the baby was
implanted in the wrong place… people are
interesting!”
PATHWAY_29
WASPaLM meeting
THE PATHOLOGISTS HAVE LANDED:
WASPaLM 2007
THREE RCPA FELLOWS PACKED THEIR BAGS AND HEADED FOR KUALA LUMPUR RECENTLY TO
ATTEND THE WORLD CONGRESS OF PATHOLOGY AND LABORATORY MEDICINE.
Dr Beverley Rowbotham,
haematologist at Sullivan
Nicolaides Pathology,
Brisbane
ith a theme of “Meeting the
challenge of globalisation and
miniaturisation”, the recent 24th World
Congress of Pathology and Laboratory
Medicine promised a first-class program –
and it didn’t disappoint.
W
Held in Kuala Lumpur, Malaysia, in
August, this very successful meeting
offered something for all the pathology
disciplines.
It was organised by the College of
Pathologists, Academy of Medicine of
Malaysia on behalf of the World
Association of Societies of Pathology and
Laboratory Medicine (WASPaLM), and
there were many highlights.
But I was particularly fascinated by an
iconoclastic presentation by Dr Jerry
Spivak, from the Johns Hopkins Division
of Hematology at Johns Hopkins
Medicine, on the WHO criteria for
diagnosis of the blood disorder
polycythaemia vera.
It was his opinion that the WHO
should stick to eradicating smallpox
and polio.
30_PATHWAY
Several editors have asked him to
present his argument for the wider use of
red cell mass investigations in
myeloproliferative disorders in their
journals. Myeloproliferative disorders are a
group of conditions that cause an
overproduction of blood cells (platelets,
white and red blood cells) in the bone
marrow, and polycythaemia vera is one.
His thesis is that increased red cell
mass, which cannot be recognised from
the haematocrit alone in many patients, is
the major risk factor for thrombosis
(clotting) in both polycythaemia and
another myeloproliferative disorder,
essential thrombocythaemia, and not
increased platelet or white cell counts.
He argues that adequate venesection
is the treatment of choice if increased red
cell mass has been demonstrated. His
logic certainly demands a wider audience.
Other highlights included an elegant
presentation by Dennis Lo, Professor of
Chemical Pathology at The Chinese
University of Hong Kong, on the biology
and diagnostic applications of plasma
nucleic acid; a presentation by Associate
Professor Szu-Hee Lee from Sydney’s St
George Hospital on the sources of error in
bone marrow diagnosis and ways to
address them; and a review by Associate
Professor John Gibson, from the Institute
of Haematology, Royal Prince Alfred
Hospital, Sydney, of the WHO
classification of myelodysplasia, giving
praise where it was due.
WASPaLM, founded in the late 1940s,
represents 38 societies in 28 countries
and the biannual conference is one of its
major activities.
On this occasion, there were a
thousand delegates from all corners of the
globe, including a very watchful
contingent from the RCPA, which will be
hosting WASPaLM in conjunction with
Pathology Update 2009 in Sydney.
Our Malaysian colleagues were most
generous hosts and the food was
wonderful. The RCPA’s WASPaLM
congress has big shoes to fill!
"It was clear that there is still work to
be done in coordinating international
responses to mass disasters"
Associate Professor David
Dr Jeanne Tomlinson,
Sullivan, Department of
Anatomical Pathologist at
Clinical Biochemistry, Royal
Douglass Hanly Moir
Prince Alfred Hospital,
Pathology, Sydney
Sydney
his well-organised and eclectic
international meeting was held on the
outskirts of Kuala Lumpur in a resort that
has been constructed along the side of an
abandoned tin mine.
T
Above: A/Prof David Sullivan with Dr Jeanne
Tomlinson
Left: Prof Lai-Meng Looi with Dr Bev
Rowbotham
The chemical pathology fraternity
were left wondering about the heavy
metal levels in the waterslide theme park
at the bottom of the complex, but the
meeting addressed a number of more
important issues.
The keynote speaker was Professor
Colin Self, from the School of Clinical &
Laboratory Sciences at University of
Newcastle upon Tyne Medical School and
inventor of the elegant technique of
enzymatically amplified immunoassays.
He outlined the history and future
potential of monoclonal antibodies.
n the field of anatomical pathology, Dr
I
John Epstein, Professor of Pathology,
Urology and Oncology and an attending
pathologist at The Johns Hopkins
Hospital, gave two lectures on prostate
pathology. He gave practical criteria to
use in diagnosing prostatic intraepithelial
neoplasia, or PIN, a common precursor of
prostate cancer, and prostatic cancer in
small core biopsies.
A terrific lecture was also given by Dr
Keith Kerr, a consultant pathologist from
the University of Aberdeen School of
Medicine, Scotland. In 25 minutes he
succinctly classified and described the
spectrum of interstitial diseases of the
lung.
In forensic pathology, Australian RCPA
Plenary sessions dealing with
automation and workforce issues
benefited from diverse perspectives
provided by a variety of international
members of the faculty.
fellows were heavily involved in the
Workshops on general chemical
pathology topics such as inflammation
and metabolic syndrome were very well
attended, filling the smaller venue.
taking a leading role.
The Australian presence and
participation was prominent, as befitted
the fact that the next WASPaLM meeting
will be held in Sydney.
program. It was clear that there is still
work to be done in coordinating
international responses to mass disasters,
but Australian forensic pathologists are
Another highlight was a lunchtime
symposium presented by South African
pathologists dedicated to managerial
topics of strategic planning, budgeting
and conflict resolution, which was very
instructive.
PATHWAY_31
Pathology Update 2008
14-16 March
Sydney Convention and Exhibition Centre, Darling Harbour, Sydney
PATHOLOGY UPDATE IS REGULARLY PRAISED AS ONE OF THE MOST IMPORTANT
EDUCATIONAL EVENTS ON THE PATHOLOGY CALENDAR. PATHOLOGY UPDATE 2008
PROMISES TO BE NO DIFFERENT.
Offering exceptional opportunities to exchange expertise and knowledge, Pathology
Update 2008 will have a focus in the Innovations Program on Patient Safety and
include a concurrent Trainees Program.
An impressive list of distinguished international speakers includes:
•
Dr Dione Bailey: Product Manager for CGH/CNV Agilent
Technologies, USA.
•
Dr Angelo Dei Tos: Director of Anatomical Pathology in the General
Hospital of Treviso, Italy.
•
Dr Wendy Erber: Lead Haematologist for the Eastern Region
Haemato-Oncology Diagnostic Service and Director of Haematology
at Addenbrooke’s Hospital, UK.
•
Dr Stephen Raab: Director of the UPMC Division of Pathology Healthcare
Research and Quality, USA.
•
Dr Christopher Smith: Clinical lecturer in virology at Cambridge University, UK.
The Trainees Program has an assortment of sessions: microscopy workshops; tips on managing the work/life/study balance;
medical ethics as it relates to pathologists; and pathology data management, confidentiality, security and communication. The
day will kick off with a free breakfast, hosted by the Trainee Advisory Committee, and will give trainees a chance to meet their
local rep, learn about the role of their advocates and raise any training issues they may have.
As well as an important professional event, Pathology Update 2008 has a fun and relaxing social program that will give you a
chance to meet with other pathologists and our international speakers in a relaxed and informal environment. The Update will
kick-off with the Welcome Cocktail Party, ‘Jive at Five’ at the trade exhibition on Friday, March 14 with a special cocktail. The
industry dinner of the year is not to be missed on Saturday, March 15 at Doltone House. Nestled on the upper deck of the
historic Finger Wharf at Pyrmont Point’s newly restored Jones Bay Wharf, this unique building has been transformed from its
industrial origins into a modern designer space with charming heritage feature.
For the full program please visit www.rcpa.edu.au/pathologyupdate
EARLY BIRD REGISTRATION CLOSES ON MONDAY 21 JANUARY 2008
- BOOK NOW!
http://www.rcpa.edu.au/pathologyupdate/
32_PATHWAY
spotlight on disease
Sober tidings
IF YOU THOUGHT YOUR LIVER
WAS VIRTUALLY
INDESTRUCTIBLE, THINK AGAIN.
AFLD: it’s an acronym you can’t
change the way obesity and liver disease
pronounce and when you spell it out
are assessed.
N
– non-alcoholic fatty liver disease – it
doesn’t contain a single positive word.
But if you’re overweight you should
MATT JOHNSON REPORTS THAT
NON-ALCOHOLIC FATTY LIVER
DISEASE IS FAST BECOMING A
MAJOR CONCERN FOR
PATIENTS AND DOCTORS ALIKE.
know about it.
The discovery of the link between
Nothing escapes your liver. Not the
packet of chips you ate last week, or the
bottle of coke you called breakfast the
week before. It knows about the chocchip muffin and coffee you had for
obesity, NAFLD and cirrhosis is not good
morning tea, and it knows about the two
news in the middle of an obesity
aspirins you took last Sunday morning.
epidemic, but it may provide individuals
Lying directly downstream from your
and their doctors with both the
intestines, anything absorbed by your gut
information and motivation they need to
is carried via your blood to the liver.
PATHWAY_33
>
“It’s quite stunning, but improve the diet and other factors and liver function improves –
and even the cellular changes can reverse: the fat goes away, the inflammation subsides
and even the fibrosis can disappear”
– Associate Professor John Dixon
It’s your liver’s job to store what’s
good and to detoxify what’s bad, and
although you can damage an enormous
and fibrous tissue starts to infiltrate the
organ.
Too often, NASH progresses to
proportion of your liver before you can no
cirrhosis, which can produce irreversible
longer ignore the signs and symptoms, it’s
liver scarring, or lead to liver cancer. At
not indestructible.
this end of the spectrum, a liver transplant
And given the way we’re consuming
may be the only option – and it’s
kilojoules these days, we’re damaging our
projected to be the most common
most resilient organ at an astonishing rate.
transplant in the United States as soon as
It’s estimated up to a third of the adult
population may have excessive fat
2020.
What triggers the early stage of the
accumulation in their livers – and it’s not
disease to suddenly progress to NASH is
just in the morbidly obese and unhealthy
still unknown, and research is hampered
Western countries either. One study found
by the fact most patients with fatty liver
the condition in 29% of ‘healthy’
disease feel well and experience few if
Japanese adults.
any symptoms.
Worryingly, NAFLD is present in 2.6%
For clinicians such as Associate
of children, but even that figure can rise to
Professor John Dixon, Head of Clinical
a staggering 53% if the group is obese.
Studies at the Centre for Obesity
While its effect on the liver is similar to
Research and Education at Monash
alcoholic liver disease, NAFLD occurs in
University, it’s frustrating that patients
people who drink little or no alcohol. And
present to him in relatively advanced
aside from its link with obesity, it also has
stages of the disease when it could have
a strong association with diabetes.
been identified much earlier.
The nature of the beast
“Prevention is the key in dealing with
the obesity epidemic, but we’re not really
NAFLD actually describes a spectrum of
doing well there, so we can confidently
conditions from mild liver steatosis (fat)
predict there will be an increase in fatty
through to non-alcoholic steatohepatitis
liver disease – and a proportion of these
(NASH), where the liver becomes inflamed
patients will progress to NASH and some
will develop cirrhosis,” he says.
“It’s an almost entirely preventable
disease with little more than lifestyle
NAFLD: THE FACTS
•
changes.”
Because fat accumulation in the liver
The most common liver disease in
the world – it affects 10–24% of the
world population
is so common among overweight people,
•
Can affect any age range – already
present in 10% of US children
not only identify those patients likely to
•
Strongly associated with polycystic
ovaries and obstructive sleep
apnoea
markers that indicate which of those
the challenges facing clinicians and
researchers such as Professor Dixon is to
have NAFLD, but also the biological
patients are likely to develop NASH.
And here is where pathology testing
plays a role.
34_PATHWAY
Liver function tests offer GPs an
opportunity to identify the disease, but
there is no definitive blood test for
NAFLD.
“Raised ALT (alanine
aminotransferase) levels would be the
most common abnormality detected in
the liver function tests of people with
NAFLD,” explains Clinical Professor John
Burnett, Head of the Department of
Clinical Biochemistry at PathWest at the
Royal Perth Hospital.
“But up to 80% of people with NAFLD
can have no abnormality in their ALT
levels so it’s not a reliable screen for the
disease.”
Professor Burnett says ALT levels can
even remain normal in the presence of
advanced fibrosis and cirrhosis.
“ALT levels can also be raised in other
forms of liver disease and although an
AST (aspartate aminotransferase) to ALT
ratio >1 is associated with NASH and
advanced fibrosis, it is not sufficiently
diagnostic on its own in an individual
patient.”
As a result of the wide range of
possible symptoms and the lack of a
conclusive test, it’s becoming increasingly
recommended that NAFLD be suspected
in any overweight or obese person who is
found to have even mild elevations in their
liver tests during a routine blood testing.
“We need to reinforce that an
abnormal result on a liver function test
should trigger a clinical suspicion of
NAFLD,” Professor Dixon explains.
“It doesn’t necessarily mean the
patient has NAFLD, but it does indicate
they are at risk – especially if they are also
obese – and it should be a trigger to start
treating them globally. When you see
abnormal liver function don’t dismiss it.”
Predicting which patients could
progress to NASH has improved in recent
years, but it’s still not certain what triggers
the exacerbation of the disease.
The Spectrum of NAFLD
NASH
Cirrhosis
ILLUSTRATION CREDIT: BRETT KITELEY
Fatty Liver
“There’s always been something of a
chicken-and-egg argument: does the fat
trigger the inflammatory response in the
liver and cause the fibrous deposits, or
does the inflammation increase the rate at
which the liver accumulates fat?”
Professor Dixon says.
“Certainly having a high level of
visceral fat has an important role in either
case, and 90% of obese people have a
fatty liver, but not all of them will progress
to NASH.
1. Fatty liver
The first hit. Obesity or metabolic syndrome
cause fat to accumulate in the liver cells.
Although not normal, it probably doesn’t
permanently damage the liver but it may
sensitise it to a “second hit”.
high blood fat and central (or abdominal)
obesity. One of the central physiological
causes of metabolic syndrome is the
decreased sensitivity – or resistance – to
insulin, the hormone that controls sugar
and fat metabolism.
“As a predictor of NASH, insulin
resistance measured by obtaining fasting
2. NASH
About 10% of people with a fatty liver can
develop the serious condition Non-alcoholic
Steatohepatitis (NASH). One theory suggests a
“second hit” from various inflammatory
substances can trigger the onset of NASH in an
already fatty liver.
plasma glucose and fasting insulin levels
3. Cirrhosis
In NASH, the inflammation causes the
destruction of the liver cells and scar tissue to
form in its place. The liver may no longer be
able to function properly and severe scarring
can lead to cirrhosis and liver cancer.
are very important,” Professor Dixon says.
“Combine that with hypertension,
“Then there is a group who aren’t
obese and they do develop NASH. The
commonality is that all those who do
develop NASH have metabolic
syndrome.”
abnormal liver function tests and
X marks the spot
patient’s risk of having NAFLD are already
abdominal fat and we have to say these
patients are at high risk.”
He admits it is somewhat frustrating
that all the blood tests to determine a
relatively routine.
Metabolic syndrome is a combination of
conditions that have been identified to
increase the risk of developing
cardiovascular disease and diabetes.
Professor Dixon was among the
researchers who identified the link
between metabolic syndrome and NASH.
The exact definition of metabolic
syndrome varies slightly between health
organisations, but can be summarised as
high blood pressure, high blood sugar,
“We just have to interpret them in the
right context.”
While existing liver function tests can
identify the risk factors and liver
dysfunction of NAFLD, a definitive
diagnosis of NASH requires liver biopsy.
“The chemistry is very important as it
gives you the risk of progressive disease.
You can diagnose a fatty liver by
ultrasound, CT or MRI, but it doesn’t tell
you how much fibrosis and inflammation
>
PATHWAY_35
“Fat looks like you would expect fat to look – big white vacuoles – but that doesn’t provide a
definitive diagnosis because you can get fatty changes in other conditions such as hepatitis C”
– Dr Adrienne Morey
is present, so a biopsy is essential to
arrive at a precise diagnose of NASH.”
After collection under local
anaesthetic, the thin sample of liver
collected during a biopsy is assessed by
pathologists such as Dr Adrienne Morey,
Director of Anatomical Pathology at
SydPath, at St Vincent’s Hospital in
Sydney.
“It’s a narrow core of tissue about
20mm long and a couple of millimetres
wide,” she says.
The sample is processed and cut into
sections no thicker than three microns.
“We use a panel of stains to highlight
the various changes we are looking for.”
The presence of fat cells, fibrosis and
inflammation are assessed and graded by
the pathologist.
“Fat looks like you would expect fat to
look – big white vacuoles – but that
doesn’t provide a definitive diagnosis
because you can get fatty changes in
other conditions such as hepatitis C,” Dr
Morey says.
“We also routinely check for microorganisms and other causes of liver
disease because it’s better to optimise the
tissue you have. You don’t want to have
to go back and collect more tissue.”
The biopsy is usually accompanied by
a detailed medical history of the patient to
help the pathologist interpret the changes
they find, but it remains a subjective skill.
“All of histology is very interpretative
and labour intensive,” Dr Morey says.
“It involves multiple different
pathologists from preparation to
interpretation.”
And this is a situation that is unlikely
to change, with no new chemical or
molecular tests on the horizon.
“It’s old-time pathology, but without it
a diagnosis can’t be made.”
Reversing the damage
While the pathophysiology and diagnosis
of NAFLD is complex, the treatment is
remarkably simple.
36_PATHWAY
“The primary way of treating this
disease is weight loss, exercise, diet and
lifestyle,” says Professor Dixon, who
points out that despite the seriousness of
the condition, it responds well to even
moderate weight loss.
“It’s quite stunning, but improve the
diet and other factors and liver function
improves – and even the cellular changes
can reverse: the fat goes away, the
inflammation subsides and even the
fibrosis can disappear.”
If there is no improvement, the only
other treatment to stop progression is
weight loss surgery.
It’s an option that Ian Caterson, Boden
Professor of Human Nutrition at the
University of Sydney, sees as increasingly
necessary.
“Ultimately we need to change the
behaviour of the population at all levels:
we need town planning that provides the
opportunity for more activity, and
education about better diet, but until then
we need to manage the individual,”
Professor Caterson says.
“Losing weight by diet and exercise
will help patients, but some are genetically
unable to get to the point they need or to
stay there, so they require surgery to
reduce their weight.
NAFLD RISK FACTORS
•
Obesity, especially abdominal fat
•
Hypertension
•
Metabolic syndrome
•
Diabetes
•
Hyperglycaemia
•
Abdominal surgery
The breakthrough, he says, is likely to
come in the form of drugs that affect the
absorption of food through the gut.
“Small changes there can provide big
results without the side effects,” he says,
referring to the recent release of Byetta
(exenatide), a drug that increases the
production of insulin when blood sugar
levels rise after a large meal, and slows
the emptying of the stomach so the
pancreas and liver do not become
overloaded.
The drug was discovered by
researchers looking at how a binge-eating
lizard, the Mexican Gila monster, was able
to survive between meals. Byetta has
been approved by the Therapeutic Goods
“That allows us to then try to control
their weight with drugs without the side
effects associated with trying to achieve
significant weight loss just through
medications.”
Administration but is not listed on the
The failure of any drug to assist in
substantial weight loss comes as no
surprise to Professor Caterson.
doctors to suspect liver dysfunction.
“Drugs are unlikely to provide a magic
bullet because there are just so many
pathways that affect how we eat and how
it is metabolised.”
Professor Dixon does, however, hold
hope of an eventual breakthrough in
weight-control drugs.
“The pharmaceutical companies have
hundreds of prospective drugs in studies
because the potential is enormous.”
Pharmaceutical Benefits Schedule.
Until then, it’s a matter of educating
the public to recognise the lifestyle factors
that increase their risk, and educating
“GPs play the central role in managing
this condition,” says Professor Caterson.
“Specialists tend to focus in their own
area, but the GPs are in a position to
recognise the whole risk profile, and start
treating both the lifestyle factors while
controlling the specific problems.”
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
a pathology training system
for diagnostic cytology and histology
- Microscopic Examination Training Tool
- Maintenance of Expertise for Trainers
Four Modules now available:
•
•
•
•
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Urine cytology
Breast histology
Cervix histology
For full details, and to order, visit www.rcpa.edu.au
diagnostics
Ph: 61 2 8356 5858 • Fax: 61 2 8356 5828 • Email: inview@rcpa.edu.au • www.rcpa.edu.au
bright ideas
CODE
RED
AN INNOVATIVE LABELLING SYSTEM DEVISED BY A BRISBANE PATHOLOGIST COULD
REVOLUTIONISE PATIENT CARE AND SAVE HOSPITALS MILLIONS, WRITES KELLIE BISSET.
t’s a disarmingly simple idea: prevent
urgent pathology results from being ‘lost
in the system’ by colour-coding the
specimen containers with red stickers
before any samples are collected.
I
But up until now, no-one has thought
of it, despite a national average failure
rate of urgent pathology samples of
10–15%.
That’s as many as one in every seven
hospital patients who don’t get their
urgent pathology results within the
clinically agreed timeline of 60 minutes,
according to the Australian Council on
Healthcare Standards. But in some state
public hospital systems, patients fare
much worse, with failed delivery targets
as high as 55%.
And that’s just not good enough,
according to Dr Andrew Francis, Director
of Pathology for the Prince Charles
Hospital Laboratory Group, Pathology
Queensland.
“If I was the patient having a heart
attack, would I be happy to wait an extra
half an hour to two hours on the trolley?”
he says.
“I am passionate about patient care. I
did medicine because I care about people
who are sick and if I was on the trolley I
would want my results quickly.”
A timely intervention
Dr Francis is the brains behind
FASTPaTH, a colour-coding system for
blood sample tubes and a redesign of the
38_PATHWAY
pathology process, which has been
shown to reduce the length of time
patients spend in hospital emergency
departments by 20–30 minutes.
This time saving gives Queensland
hospital emergency departments the
potential to treat an extra 500 patients per
day, an efficiency estimated in the order of
$35–40 million a year for Queensland alone.
Dr Francis says this could be an
underestimate – and even he was
surprised by the results.
Not surprisingly, Queensland Health is
interested too.
A trial of the FASTPaTH system was
approved in 2005. This trial, led by Dr
Francis occurred on the Prince Charles
Hospital Campus involving the Emergency
Department and the Pathology
Laboratory.
And while no mandate has been given
to roll out the system statewide, the
Queensland Heath Innovation Branch
provided funding to Queensland Pathology
and Dr Francis to present the findings of
the trial and expand it to other sites across
Queensland. So far, 19 have come on
board with at least some elements of the
system, but he is keen for wider adoption
to maximise the benefits for all.
International figures for OECD countries
show that about 30 million urgent blood
test results per year are delayed
unnecessarily. Estimates of the proportion
of delays with serious consequences sit at
between 1% and 2%. So at best, 300,000
people per year in OECD countries will
suffer a preventable serious adverse event
due to system delays.
“That’s the equivalent of at least 10
jumbo jets a week falling out of the sky,”
Dr Francis says.
“These are ballpark numbers, but it is
still a lot of people – and these numbers
are optimistic when you look at the
Australian Council on Healthcare
Standards data.”
Despite this, there’s no public outrage.
And that’s because there’s no critical
mass of patients aware that the problems
they’ve encountered are also happening
to others.
“If you could do no more than put [the
tubes and bags] in a vending machine and
charge patients $5 they would pay for it,”
Dr Francis says.
“Our healthcare system does not allow
them that choice.”
Streamlining priorities
“We have almost three years of data
that has evidence to show [this system] is
simple and sustainable,” he says.
FASTPaTH, which translates as For
Access to Speedier Tests – Pathology, is a
fundamental redesign of the pathology
process.
“We have a duty of care to patients to
offer best practice.”
Before samples are collected, each
sample tube is marked with fluorescent
>
1.
Pathology test request form – ordered electronically or
handwritten by a nurse or doctor
2.
Collect the sample
3.
Label it
4.
Package it
5.
Physically transport it, either through calling the wardsman
or via the pneumatic tube system
6.
Someone at the pathology lab must receive it and
appreciate it is there and needs processing
7.
Sample must be registered on the lab’s computer system
with information including the name of the referring doctor
and where the test has to go
8.
Pre-analytical processing is sometimes required (e.g.
centrifuge)
9.
Sample is tested via machine
This time saving gives Queensland
hospital emergency departments
the potential to treat an extra 500
patients per day and could save
the state health system at least
$35–40 million a year
10. Scientist may be required to validate the result
11. Result must be transmitted back to the patient
At any of these stages, delay can be introduced. The wardsman
might stop off for X rays or other samples on the way to
delivering the sample. The lab staff have to notice it’s urgent.
Sometimes the pneumatic tube system can break down. Or if a
hospital staff member is busy and they put down the sample,
they might forget it needs to be sent or processed but the
colour reminds them these are urgent and important.
PATHWAY_39
PHOTO CREDIT: ANDREW FRANCIS
Hospital pathology ordering:
a multi-stage process
“In the laboratory where you have thousands
of bags and thousands of tubes, you have to
do something first and something second”
– Dr Andrew Francis
stickers if they are priority one or two, and
not marked at all if they are standard
priority.
Priority one – or ‘urgent’ – tubes are
denoted by a red sticker, and these are
used for emergency department patients
(such as those with suspected cardiac
arrest), and day oncology patients.
Priority two tubes are marked with an
orange sticker, and are used for intensive
care and coronary care patients and other
high-priority clinical areas such as
patients waiting to be discharged pending
their blood test results. They follow the
principle that the sooner everyone knows
the results, the sooner the patient can be
discharged.
Tubes are also placed in bags that are
colour coded: red tubes go in red bags for
urgent cases (emergency, oncology, heart
attack); orange tubes go in blue bags
(intensive care, coronary care, discharge
patients and those who suddenly get
sick); and the remaining routine samples
are placed in clear bags.
“In the laboratory where you have
thousands of bags and thousands of
tubes, you have to do something first and
something second,” Dr Francis says.
“This allows the lab staff at all stages
to pick the red bags and priority one
tubes first, the blue second and the others
later, then if coloured ones come in they
start doing the coloured ones.”
And in an era where access block in
hospitals is a significant issue, it’s not
hard to grasp the widespread implications
such a system could have if adopted on a
large scale.
40_PATHWAY
But the system doesn’t end there.
While the system has obvious
Dr Francis who as a private individual
has been granted an innovation patent for
his work (with further patents pending),
has also incorporated other features such
as stocking IV trolleys with ready-made
kits containing the bags, tubes and
pathology request forms. This saves
nurses time stocking the trolleys, looking
for sample tubes, or wandering around
trying to find request forms that they
complain are frequently stolen from
trolleys by aberrant doctors.
benefits, not everyone has been open-
There is also a method of tracking
urgent samples, so the labs know urgent
blood is on its way and can inquire if there
is a delay in arrival.
tubes at each hospital facility using local
The beauty of the system, Dr Francis
says, is that the instant the sample goes
into a container with a red label, everyone
knows it is urgent.
“The lab staff think it’s great because
it helps them. Anyone walking along can
say ‘that’s urgent, it should not be there, I
will put it straight on the machine’. It is
about the laboratory having a better
chance of getting it right first up.”
Towards best practice
minded enough to appreciate them.
To date, governments in other states
have shown little interest in embracing
FASTPaTH, and tube manufacturers have
given a lukewarm response to producing
tubes with ready-made red and orange
stickers. If manufacturers did offer this
service, it would eliminate the need for the
additional costs, (covered to date by
Pathology Queensland) of labelling the
staff or hospital volunteers.“It has been
tricky to get people to engage,” Dr
Francis says.
“It is obviously good for patients and
labs, and for manufacturers the cost is
negligible – and they could probably
charge a significant premium for it – but
they think people buy their tubes
regardless so they don’t have to do
anything.”
And as for state governments, despite
struggling with emergency department
access block, “they employ external
consultants and come up with their own
In the FASTPaTH roll-out in Queensland
involving 19 Queensland public hospital
emergency departments, one hospital
achieved a 30% improvement in
turnaround times just from using the
priority tubes and nothing else.
solutions. None of them have said gee,
And at the beginning of the roll-out,
only three of 10 large hospitals were
achieving best-practice turnaround times.
By the end, nine had reached that goal.
ago except for the fact that I care about
we really want to take it up.”
Despite the frustrations, Dr Francis
has maintained his enthusiasm.
“I may well have given up a long time
patients and it makes a difference. I am
passionate that patients deserve
something better.”
innovations
Space lab
A NEW TWIST ON THE TRADITIONAL PATHOLOGY MUSEUM HAS
PROVIDED AN INSPIRATIONAL LEARNING ENVIRONMENT FOR
AUCKLAND MEDICAL STUDENTS. KIM COTTON TAKES A LOOK..
f you wanted to study the human body in a rich
I
and inspiring environment, New Zealand’s
AMRF Medical Sciences Learning Centre would
be a good place to start.
The centre is an architectural standout – it
has even won a national architecture award –
and pays magnificent homage to the disciplines
of pathology and anatomy.
It reveres (rather than merely displays)
specimens from The University of Auckland’s
Faculty of Medical and Health Sciences and is
quickly gaining a reputation among students.
Opened in 2005, the centre was an ambitious
project borne out of a desire to combine the
faculty’s anatomy and pathology museums.
>
PATHWAY_41
“I don’t think any of us could
have appreciated just how
impressive it was going to be”
– Professor Peter Browett
But when the pathology and anatomy
departments decided on the merger, they
had little idea of the positive impact the
project would have on the university’s
students and staff.
Professor Peter Browett, head of the
university’s Department of Molecular
Medicine and Pathology, says the
motivation to create the learning centre
was to produce synergies between the
departments and to provide better access
for students to the specimens that had
previously been locked away in “tired and
old” rooms.
“We got together as a group and
thought … more of our teaching was
becoming more integrated, why don’t we
look to combine so we have a museum or
learning centre where the students can
come in and see the normal anatomy, the
radiology and pathology altogether that
they can access at anytime,” he says.
Learning curve
The remarkable transformation was the
brainchild of New Zealand architect Rick
42_PATHWAY
Pearson, who based the design on the
circular-shaped, 16th-century anatomy
theatre of the University of Padua in Italy.
In an article featured in ArchitectureNZ
magazine, Mr Pearson says “the driving
concept” behind the learning centre was
the “idea of investigation”.
“What drove artists, researchers and
physicians in all cultures throughout
history into trying to understand the
workings of the human body?” he asks.
“For me it was the fact that at the
intersection between art and science is
the notion of wonderment.”
Celebration and “wonderment” are
indeed outstanding features. Among the
1100 pathology specimens and
plastinated anatomy models – showcased
along more than one kilometre of glass
shelving – are the reminders of a previous
era of medical research and its modern
equivalent: an image of Leonardo da
Vinci’s Vitruvian Man is splayed out across
the floor of the main tutorial room, while
similar anatomical computer-generated
sketches cover the windows, evoking a
sense of morbid enlightenment.
Sophisticated lighting and
technological equipment bring visitors
back to the realisation that this is a place
of teaching and learning in the 21st
century.
Professor Browett says when the idea
was first floated to the university
management it assumed the plans would
entail another refit of a museum “where
we’ll take everything out, repaint it, put
the shelves back up and restock
everything again”, he says.
“As the presentation went on I could
see the change come over everybody –
everybody was taken by it.”
The core contains the bulk of the
specimens and is used as a tutorial room
for large groups. Desks and computers
are positioned around the sides to extend
its functionality. Six nodes, themed on the
organ systems, branch out from the core
to provide separate study areas for
individual students or small groups.
Snatched from oblivion
ack in 1985, news that part of Australia’s oldest
hospital would soon be no more left staff from the
pathology department scrambling to save their morbid
anatomy collection from being confined to the dustbin of
history.
B
Professor Stan McCarthy got to work quickly.
PHOTO CREDIT: KIM COTTON
The former pathologist at the Sydney Hospital’s
Kanematsu Memorial Institute of Pathology and now Senior
Staff Specialist and Consultant at the Royal Prince Alfred
Hospital (RPAH) Department of Anatomical Pathology was
instrumental in retaining more than 1500 specimens, as well
as cabinets full of biopsy and autopsy reports.
Some of them were more than a century old.
In a scene akin to an Alfred Hitchcock film, Professor
McCarthy and staff chauffeured the motley cargo from
Sydney Hospital to various attics and basements at
RPAH.
Professor Browett says it has made the
collection more accessible to students and has
provided another “angle of learning”.
“It’s always been there but it’s made it much
more [appealing],” he says. “We’re making
greater use of it than we did with either
museum. That’s the most gratifying thing – not
only have we created something that is
aesthetically pleasing that the university can be
proud of but it’s achieved what we want – it’s
encouraging the students to go there on their
own accord. They’re putting pressure on us to
have it open longer hours.”
Funded by the Auckland Medical Research
Foundation to celebrate 50 years of medical
research in Auckland, the learning centre is
used extensively by undergraduates in
medicine, science and nursing from The
University of Auckland and other tertiary
education institutions, as well as registrars in
pathology and radiology.
Professor Browett says plans are in play to
open the centre to senior high-school students.
“I don’t think any of us could have
appreciated just how impressive it was going to
be,” he says. “There are other opportunities
Among the stores were a distorted, two-digit cancerous
hand of a radiologist who had worked at Sydney Hospital in 1899, and
the lacy skeleton of a farmer’s pelvis and femur both eaten away by
Echinococcus multilocularis (hydatid cysts).
Professor McCarthy says he was motivated by “extreme reluctance
to discard anything that would be useful for teaching and research and
which had been retained with so much thought and dedication”.
He remained the specimens’ quiet custodian until 2001, when a
spirited and passionate museum curator, Elinor Wrobel (pictured),
contacted him.
Mrs Wrobel had been commissioned by Sydney Hospital to set up a
museum of nursing. But in her mind, the museum needed to encompass
the hospital’s entire history and it was under her expansive vision that
the Dr Eddie Hirst Pathology Museum was re-established as a section of
the Lucy Osburn-Nightingale Foundation Museum.
Over the past six years, Professor McCarthy has made the familiar
trip between the hospitals numerous times to repatriate a large number
of the specimens.
“Their preservation was due to the fact that Professor McCarthy has
such a sense of history,” Mrs Wrobel says.
“It was really an emergency thing that he did and it can never be
underestimated.”
Each specimen is carefully assessed and conserved with the
assistance of volunteers such as Dr Patricia Bale, a retired pathologist
and widow of Dr Eddie Hirst, Sydney Hospital’s former director of
anatomical pathology.
Today about 400 surviving specimens are displayed and another
1000 are awaiting conservation.
Mrs Wrobel, now also a volunteer, says her aim is to leave a
monument to the “great hospital that once was on Macquarie Street”.
The Sydney Foundation for Medical Research provided major funding
to conserve some of the morbid anatomy collection. A new fund, Adopt
a Body Part, is available for donors to adopt a specimen.
For details phone Elinor Wrobel on 61 2 9382 7427 or 61 2 9332 2260.
here that we haven’t fully utilised yet.”
PATHWAY_43
RCPA elections
New directions
FOUR NEW FACES ELECTED TO THE COLLEGE COUNCIL OUTLINE THEIR COLLECTIVE
VISION TO PATHWAY .
RCPA President
Dr Beverley Rowbotham
What experience/qualities do you
believe you will bring to your new
role?
Director of Haematology, Sullivan
Nicolaides Pathology and
Associate Professor of Pathology,
University of Queensland.
As Senior Vice President and Chairman
of the Pathology Professional Activities
Committee I have done a long
apprenticeship and I have the passion,
skills and experience for the job.
What is the core role of the college?
The College must keep hold of the
training and examination of registrars.
Recent accreditation by the Australian
Medical Council has given us this
charge. We must not lose it. The
American college has suffered because
it does not have this authority.
Our College is also the peak
advocate for pathology. We must
include all Fellows and build on our
successes. We must look to the future
and make links with our colleagues
throughout the region so that we come
to be recognised as the profession’s
leader throughout Australasia.
What are the challenges facing the
RCPA and pathology in general?
There are many challenges facing
pathology. The workforce crisis can be
solved by increasing the number of
training positions within the public and
private sectors and increased
government funding for these positions
is essential if we are to meet expanding
demand for services.
We also need reform of pathology
fees. Funding for pathology services
must reflect contemporary and changing
diagnostic techniques.
The College must be unified and
credible to successfully influence
government. I have represented our
44_PATHWAY
College in negotiations with
governments for the past four years and
believe that, in the future, we must
demonstrate that money spent on
pathology saves money throughout the
healthcare sector.
Seeking expertise from health
economists will strengthen our
negotiating position with the Federal
Government for the MoU in 2009, and
with the New Zealand Government over
the continued tendering of pathology
services.
In Australia, new increased fees for
high complexity histopathology have
already received ministerial support and
the relative value study, based on
evidence gained from a range of
Australian public and private sector
practices, will give the College sound
data to lobby for realistic fee setting
across the region.
We also need to make sure our
medical leadership survives and
flourishes in the new era of
corporatisation that has taken place in
both the public and private sectors. This
will allow our Fellows to retain a choice
of workplaces.
And if we equip our Fellows with
managerial knowledge by supporting
further training in this discipline we will
build the next generation of leaders.
I am and have been a member of
several College committees, including
the Haematology Advisory Committee
and the Genetics Advisory Committee.
I have also served on government
committees such as the Pathology
Services Table Committee and the
Department of Health and Ageing
Pathology Consultative Committee.
I have made the commitment to
work as hard as I can, with a strong and
effective Council, to achieve positive
outcomes in the issues which most
affect our future.
What are you passionate about away
from the lab?
In my life away from the College, my
major priorities are my family, friends,
and my day job as a haematologist. My
husband and I have four sons aged in
their teens to early 20s. They are
growing into young men and good
company. I am enjoying this phase of
their lives, despite the hard work and
vigilance it requires of us. My friends
and my books keep me on an even
keel, and it is a great blessing to have
an interesting and useful job.
I will take this opportunity to thank
my colleagues at Sullivan Nicolaides
Pathology who have supported me in all
aspects of my professional life,
including my commitment to College
affairs.
and Chairman of the Pathology
Professional Activities Committee.
RCPA Senior Vice
President Professor
Robert Conyers
Senior Consultant Pathologist
(sessional), Analytical Reference
Laboratories, Melbourne
What is the core role of the college?
In 2005-2006 I had the opportunity to be
a co-editor, co-author and coordinator
of the College’s 50-year history and this
reinforced to me that the College has
two major functions to perform on
behalf of its members. Firstly, it must
provide services for its members. Since
its inception it has been intimately
involved in providing training for new
pathologists and in providing continuing
professional development activities for
established pathologists. It is an
absolute requirement for Council and
the Executive Committee to ensure that
these services are maintained and
appropriately modernised.
Secondly, it has a lobbying role on
behalf of pathologists, pathology and,
most importantly, patients, to interact
with governments and other significant
organisations that affect the standards
and practice of pathology. Throughout
the 1980s, the College established its
premier position in pathology quality
assurance. Since then, with strong
leadership and considerable team effort,
the College has built significant internal
skills and valuable external networks for
dealing with governments, for securing
representation on peak pathology
committees, and in establishing a
strong, supportive management team.
What are the challenges facing the
RCPA and pathology in general?
Major concerns for the College and its
members are the depleted pathologist
workforce in Australia and New Zealand,
the winding down of pathology teaching
in many university faculties of medicine,
the impact of rapid advances in medical
science – especially in genetics and
biotechnology – on pathology practice,
and the ongoing consolidation of both
public and private sector practices.
Government funding policies for
pathology services in Australia and New
Zealand continue to be of concern to
Fellows and will remain a significant
lobbying activity by the College and its
Fellows. The Council and the Executive
Committee will need to continue to be
involved in such matters to ensure the
career futures of pathologists and the
quality standards and clinical
effectiveness of pathology practice.
The recent College elections
provided a ‘Melbourne Cup’ field of
candidates and raised many concerns
by Fellows including the nature of the
College involvement with, and services
to, Fellows in South-East Asia and Hong
Kong. Our incoming President will ask
Council and the Executive Committee to
review all the concerns raised in these
elections to ensure the College
continues to address as many Fellows’
concerns as possible going forward.
To achieve acceptable outcomes for
the College and its members, the
Council and the Executive Committee
must remain focused, be well-informed
and encourage rational debate. They
must then, however, be united in their
decision-making and policy.
What experience/qualities do you
believe you will bring to your new
role?
Over the past 16 years I have been very
involved with College affairs including
being a state councillor, member of
Council and the Executive Committee,
I have been involved in conference
organisation and representing the
College on government committees and
other professional bodies. I also bring to
my position a wide range of experience
and expertise through my involvement
with boards of health-related, not-forprofit and statutory organisations, my
senior management experience in both
public hospitals (NSW, South Australia
and Victoria) and private pathology
services (Australia and New Zealand),
my background in medicine, science,
pathology, research, ethics and
academic teaching and my involvement
in government advisory committees and
working parties.
I believe the College needs to build
solidly on its strong foundations and
history and that, in dealing with external
opportunities and threats, we act as a
cohesive and consistent team. I will
strive to work with the other members of
the Council and Executive Committee to
build a strong team to represent
members.
What are you passionate about away
from the lab?
My wife, Jan, teaches music and my
two daughters-in-law have each given
me a grand-daughter. My three sons
have been educated to tertiary level but
two fancy themselves as writers and
film-makers while the other talks about
real football. Naturally, I am not yet an
executive producer of an Australian film
but I can provide supper at Jan’s
concerts for her students. I am in
training for kitchen duties in my artsgraduate son’s coffee shop and, late last
year, I was given a present of
membership of the Melbourne Victory
Football Club. My education in the arts
and real football is thus ongoing. I enjoy
doing house renovations and repairs
and garden landscaping but prefer
others learn the follow-up, maintenance
duties. I passionately believe that
collecting red wine is only a prelude to
tasting. Recreational travelling in
regional Victoria confirms this.
PATHWAY_45
RCPA Vice President Professor Yee Khong
Department of Histopathology, Womens and Childrens
Hospital, Adelaide
RCPA Honorary Treasurer
Dr Jeanne Tomlinson
Histopathologist, Douglass Hanly Moir
Pathology NSW
What is the core role of the college?
The College serves Fellows and Trainees
who have widely different needs and
expectations. They work in different
employment settings, subspecialties,
jurisdictions and likely are at different
stages of their careers. The College
represents Fellows and Trainees across
Australasia and, in these countries, the
pathology profession in particular and
medicine in general must fulfil regulatory
requirements.
What is the core
role of the College?
What are the challenges facing the RCPA and pathology in general?
What are the challenges facing the RCPA and
pathology in general?
What are our priorities? Foremost, I believe, is a definition of our
profession and of our role in medicine and an articulation to the public
and to the purse holders of our pivotal role. Within this purview, would
be quality of service, issues relating to workforce, attraction of the best
graduates into the specialty, appropriate remuneration, and workload
and workplace conditions to allow work/life balance and reduce
attrition/burn-out.
The elected representatives, the College Management Team and the
Fellows and Trainees need to be in constant dialogue. There is a need
for communication so that the needs and expectations, on the one
hand, and the feasibility and attainability, on the other can be conveyed.
All parties should be striving hard for the profession.
What experience/qualities do you believe you will bring to your new
role?
I am currently a member of the Pathology Professional Activities
Committee, a South Australia/Northern Territory councillor, and member
of Council.
I have also been a member of the Paediatric Pathology Advisory
Committee since 2003 and a member of the National Pathology
Accreditation Advisory Council since 2005.
I am an assessor for RCPA/NATA (National Association of Testing
Authorities), and have been the AMA Ethics and Legal Committee’s
RCPA representative since 2006
I am a committed member of the College and I believe that the
interests of the Fellows are best served by a united College. I will bring
hard work and reasoning to the office.
What are you passionate about away from the lab?
I try to keep fit by jogging about once or twice a week with my wife and
playing badminton weekly. I have changed rackets, gut tension, and
shoes so many times but my badminton has hardly improved. The
group of players I play with includes an Australasian Masters gold
medalist and some very talented young players. We work up a sweat
and have a laugh. I love listening to music.
46_PATHWAY
Training of registrars,
service provision to
Fellows and
increasing the
community’s
understanding of
pathology are the
College’s main
functions, in my
opinion.
The recent election indicated that there are
misconceptions amongst the Fellows about the
governance of the College. The new Executive
Committee and Council will need to improve
communication with the membership about these
issues, such as the role of Council and its
relationship with the Management Team. Internal
divisions will distract us from dealing with the big
issues, such as the shortage of pathologists,
particularly in regional Australia.
What experience/qualities do you believe you
will bring to your new role?
I have a Masters of Business Administration and
understand modern corporate governance and
financial management practices. Having chaired
the overseeing committee for two Pathology
Update meetings in 2006 and 2007, I am
confident that I can work constructively with
Fellows across the varying regions, disciplines and
sectors, as well as the College’s Management
Team. I take seriously the fiduciary duty a member
of a governing board owes to its membership, and
undertake to serve the interests of the fellowship
to the best of my ability.
What are you passionate about away from
the lab?
To unwind after a busy week of work, College
e-mails and meetings, I like to read, exercise when
I can, listen to music (including Pearl Jam, Hi 5
and classical) and bake with my three children.
I also like to share the occasional fine dining
experience with my husband, Alistair, who
supports me in all my College activities!
lP ia t hfWe
s
t
y
l
e
ay lifestyle
travel
48
travel doc
53
private passions
56
recipe for success
58
dining out
61
the good grape
64
conference calendar 65
rearview
66
postscript
68
PATHWAY_47
travel
Slovenian
rhapsody
Overlooking Lake Bled
SLOVENIA MIGHT NOT BE THE FIRST PLACE YOU’D THINK OF FOR A HOLIDAY BUT ITS BEAUTY
AND CHARM MAKE IT WELL WORTH A VISIT, WRITES DON SWAN.
ow does one test the honesty of a
city?
H
A recent test, reported in The
Australian, involved spreading 30 mobile
phones about in each of 32 major cities in
different countries, and the winner was
Ljubljana, capital of Slovenia, where 29 of
the 30 were returned. (Sydney did not
rank so highly.)
Slovenia is an orderly country and this
lasting impression of rectitude in no way
diminishes the pleasure of a holiday there:
some might even find it comforting.
En route to other places, we planned
to briefly visit an old friend in the capital
but were invited to plan a longer stay. We
did and it was delightful – all the more so
with the benefit of a local guide, mentor,
friend and fervent nationalist.
48_PATHWAY
The main airport – an uncrowded
international airport with flights to many
European cities – is an easy 20-minute
drive from Ljubljana, where you will find a
range of hotels – new, ‘newish’ and old – to
suit most tastes and pockets.
But no marble six-star palace, as far as
we could see.
We did, however, come across the
Antiq Hotel – a boutique hotel in
cable car from the city for those so
inclined.
There are quite a few hotels in the city
or within a short walk of its most
interesting parts. We stayed at Hotel Lev,
which was well patronised by the
business traveller and tourists. Located
right in the CBD is the Grand Hotel Union,
famous locally because President Bush
once stayed there, or so we were told.
Geringiting Square in the old town. It
reeks of elegance and times past – plus it
has broadband. From the square, one can
walk up (and up) to the medieval Ljubljana
Castle. Overlooking the city and
presenting views to the Alps, it is
definitely worthwhile visiting. There is a
Caves, castles, cobbled
streets
The old city – picture postcard almost
perfect – has much to offer: wellpreserved houses, cobbled streets and
lanes, cafes, bars and clubs, markets,
>
“There are certainly some sights to see:
rugged mountains, rivers and rapids, tranquil
lakes, waterfalls, picturesque pastures and
villages, caves and caverns…”
Predjama Castle - although now welcoming to
tourists, did not originally welcome hawkers,
canvassers or strangers
PATHWAY_49
Hundertwasser, the famous Austrian architect, designed
crazy brilliant buildings and decorated many, spreading his
work from Russia to New Zealand. Whilst I can find no
evidence of him working in Ljubljana the window treatment
shown here - could have been inspired by him.
cathedral, a meandering river, tree-lined
footpaths along the river bank, quaint
shops, and many bookstores selling
books in English, German, French and
Italian.
rugged mountains, rivers and rapids,
tranquil lakes, waterfalls, picturesque
pastures and villages, caves and caverns
– and everywhere, an atmosphere of
peaceful order.
Public buildings vary, but excluding
the modern National Gallery, they
generally seem to display a certain
triumphalism writ small!
The ‘must sees’ include the city of
Ptuj – first, the castle and regional
museum, then Ptujska Klet winery and
then… who cares. Predjamski Grad (a.k.a.
Predjama Castle) is five levels of a castle
built partly in a cave and partly clinging to
the side of a cliff. A mere 9 km of
picturesque road from the castle is the
Postojna Cave and others, with traces of
prehistoric settlements. And then there’s
Piran on the Adriatic Coast, surprisingly
close to the capital and a place in which
to wander and eat great seafood.
The countryside is dominated by
forest and small, tidy farms, and supports
over half the population of 2 million. No
place of interest is very far from the
capital.
The roads are good, there are no
obvious signs of ‘hoons’ – and certainly
none of the laissez faire attitude to speed
limits and other road rules found in some
countries, including one unnamed nation
on the border…
This makes for easy sightseeing and
there are certainly some sights to see:
50_PATHWAY
Some tunnels are called caves, but
Skocjanske Jame is the mother of touristaccessible caves and not to be missed.
Of all the places we visited, the most
memorable was the area of Bled, Lake
Bled, Bled Island and all that goes with
this small slice of paradise. In short –
peace and beauty.
It is, perhaps, crowded in late
summer, but idyllic in June, and boasts
cafes, a short ride in a canvas-roofed
boat to the island, and a stroll on the
broadwalk. For those with a little luxury in
mind, Villa Bled is the place for you.
Starting life as a summer house for Tito –
the second president of the former
Socialist Federal Republic of Yugoslavia –
it is now a Relais & Chateaux property
with only 10 rooms and 20 suites,
surrounded by acres of parkland, and with
its own beach on the clear snow-fed
waters of the lake.
About 20 km from Bled is the larger,
less developed Lake Bohinj. Its beautiful,
pristine water and surrounds are perfect
for the more active: trekking, kayaking,
canoeing and cycling are just some of the
activities on offer. There is a cable car
>
Julian Alps – rugged, almost threatening
attracts climbers, walkers and believe it or not,
cyclists on its very steep roads
Above: Ljubljana River - tranquility in and through
the city centre
Left: Preseran Square – named for the country’s
pre-eminent past, with Triple Bridge in foreground.
When the original centre bridge could not cope
with traffic the solution was simple - put a one-way
bridge on each side and kept the old one for
pedestrians.
PATHWAY_51
Right: Slop Savica Waterfall – not far from Lake
Bohinj and worth a short, steep walk
Below: Alfresco Dining is popular much of the
year and in summer it is better to be early
which takes you up (yes, literally up) 1.5
km, thus giving your mountain climbing a
helpful kick-start – or so I’m told.
Statues abound in Europe and if not
every village, then every town and city has
at least one statue of a long-dead king,
emperor, queen, president or general.
Ljubljana’s central square is graced not by
a statue of a bemedalled warrior, but of its
best-loved poet: France Preseran (d. 1849).
In the same vein, the deference shown
to the respected architect, the late Joze
Plecnik, is reinforced by frequent
references to his triple bridge and his
many buildings. The country and the
capital owe Plecnik much, and the nation
recognises this – a sad contrast to the
speed with which our own heroes (other
than sportsmen and women) seem to fade
away. Perhaps Slovenes are better taught
their country’s history…
Wines and victuals
Mention was made to us of a winery in
Ptuj, but not of the wines and the
vineyards. Vines occupy only a little over
1% of the country, but this share of arable
land is increasing, which is a little
surprising considering the European
Union’s wine glut and the destruction of
existing vineyards in countries such as
France. However, Slovenia has good,
inexpensive wines that would suit most
palates, and they come in the most
unusual and elegant bottles.
Lonely Planet lists plenty of eateries
and given we were travelling with a local,
we visited none of them. But we can
recommend two top-class restaurants and
a few others well worth a visit if you are in
their region.
52_PATHWAY
Top of the range in Ljubljana is ‘JB’,
Miklesiceva 17, 1000 Ljubljana (phone
+386 1 4331 358, www.jb.slo.com).
Located in an unprepossessing part of the
city and not far from our hotel, its plain
sign and entrance belie its elegant fit-out
and appointments. The food, wine and
service lived up to all expectations.
Our second recommendation was a
surprise to us. It wasn’t too far from the
city, but a little difficult to find, especially
when coming from the other direction.
Restaurant ‘Okrepcevalnica RUJ’ (phone
+386 5 734 1720, www.ruj.veha.net)
combined rural charm with local dishes
and the best of European cuisine without
its flamboyance. And there were wines to
could be safer than dinner. Jueryuzalem
2259 Ivanjkovci is the address (phone
+386 2 7914 128).
On the coast is the restaurant
Primorka, 6323 Stunjan (phone +386 5
678 0000), where seafood is the speciality
of the house.
In a largely residential neighbourhood
of Lgseb Gana, not far from the river is
the well-patronised family restaurant
Okrepcevalnica, Pri Skofu, serving local
fare in family-sized quantities at
neighbourhood prices (Recna 8, Ljubljana,
email PRISKOFU@VOLJA.NET, phone 386
1 4264 508).
Then there is the wine bar Movia.
match the quality of the food. The
Excellent wines, as you’d expect from a
chef/proprietor explained the choices
bar next door to a city hall, and well worth
available and recommended some
a visit when a break from city sightseeing
combinations of dishes. All in all, a
is required (phone +386 1 425 5448).
rewarding experience and well worth the
Appearances to the contrary
drive with a ‘designated driver’.
notwithstanding, we did much more than
You could also try the Taverna Vino
Kupleu. Serving hearty meals, it is set on
a ridge overlooking vineyards – and lunch
eat and drink!
Our only regret was not having a few
extra days in this wonderful country.
travel doc
A date with dynasty
DR ADELINE TAN FINALLY VISITED THE LAND OF HER FOREFATHERS AND EXPERIENCED
THE JOURNEY OF A LIFETIME.
ost people go on honeymoon to
experience a little luxury and
unwind after the wedding. But my
husband and I spent five weeks
‘doing’ China by rail, road and boat.
Our aim was to travel as locals and
experience the real China – whatever
that may be.
M
Above: Newlyweds Adeline and Tony begin their journey
Top: Jiayuguan fort
An ageless panorama
I have been called Chinese all my
life. But my only links with China were
through my grandparents as I was
born and raised in Malaysia and
educated from year 12 in Australia. It
was always my dream to experience
the land of my forefathers.
We arrived at dawn in the Provincial
capital of Nanning and were pleasantly
surprised to find a bright, modern city
waking up to a new day. From there,
we headed by bus towards the
limestone scenery of Guilin. Our first
experience taught us some basic
principles of bus travel in China: there
is no timetable; no set price; no
departure until the bus is full; and
importantly, no journey without a
karaoke video being played at the
appropriate volume to prevent sleep.
Our trip began in Hanoi. Heading
north by train equipped with only
pidgin Mandarin, two guidebooks and
no real idea of what to expect, we set
off into China.
Staying at Yangshuo village just
outside Guilin, we were amazed at the
majesty of the landscape surrounding
us. This panorama has inspired
Chinese painting for centuries, but
PATHWAY_53
>
“If you don’t like yak you’re
going to struggle in Xiahe. If
you’re not eating yak curry,
you’re putting yak milk in your
tea or spreading yak butter on
your toast”
Above left: Flaming Mountains; right, youthful contemplation
despite our best efforts no amount of
photos can convey its beauty.
During our visit we climbed the famous
Yueliang Shan (Moon Hill), punted down
the Li River on a bamboo raft and made a
wish at the 1500-year-old Big Banyan
Tree. This region is a definite must for any
visit to China.
From this tranquillity we travelled via
train and bus to the industrial city of
Yichang, the departure point for a ferry
ride down the Yangzi River. Along this
section of the river lie what is left of the
famous Three Gorges, already half
submerged by the rising water levels from
the Three Gorges Dam. Planned for
completion in 2009, the dam has radically
changed river life, with millions of people
relocated from family plots to tenements in
the name of economic development. Such
a feat could not be repeated anywhere
else in the world, reflecting the true power
of the Chinese State over the citizen.
54_PATHWAY
Along ancient meridians
Having experienced the local ferry for
three nights we were happy to reach land
– and the spicy food of Sichuan Province.
The capital, Chengdu, is a great city to
spend a few days in. Friendly, modern and
easy to navigate, it also offers a great day
trip to Leshan to see a 71-metre tall
Buddha carved out of a cliff face. Most
people also visit the Chengdu panda
research base, where arriving early
guarantees the animals are awake
munching on their breakfast of bamboo
shoots.
From Chengdu we headed to Xian to
fulfil a childhood dream: no trip to China
should exclude the Army of the Terracotta
Warriors. Xian also has a significant
Chinese Muslim population, acting as a
reminder of the historic importance of the
ancient Silk Road and the cultural hotpot
of modern China.
En route to the Silk Road we visited
the Labrang Monastery in the Tibetan
foothills, one of the most important places
of worship outside Tibet. At the time of our
visit the town of Xiahe was full of Tibetan
monks taking their exams.
One thing to note is that if you don’t
like yak you’re going to struggle in Xiahe. If
you’re not eating yak curry, you’re putting
yak milk in your tea or spreading yak
butter on your toast.
Heading west along the Silk Road we
entered a vast, arid landscape where Islam
and the culture of Central Asia begin to
dominate.
Known as Xinjiang Province, the tourist
spots are few and far between. But the
very act of travelling here is a meaningful
experience. Along the way we visited
Jiayuguan, the western outpost of the
ancient Chinese empire. Here lies the end
(or the start depending on which way
Clockwise from left:
Han Jing mausoleum;
great wall at Jiayuguan;
pandas in Chengdu;
Terracotta Warriors
you’re going) of the Great Wall and a
magnificent fort.
Dotted along the Silk Road are ancient
travellers’ rest points, the most famous of
which are the World Heritage-listed Mogao
Caves, each decorated with Buddhist
imagery and icons.
By the time we arrived in the far-west
city of Urumqi, we had travelled over 5000
km, and found ourselves in the furthest
city from the sea in the world. A four-hour
flight to Beijing brought us to the China
that is probably most apparent to the
world: a sprawling industrial superpower in
the making.
In five weeks I only scratched the
surface of this magnificent country but I
like to think I gained a better
understanding of my heritage and what it
is to be Chinese.
Dr Adeline Tan is an Anatomical Pathology Registrar
at Liverpool Hospital, Sydney South Western Area
Health Service.
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private passions
Treasure hunter
PASSION FOR MEDICAL MEMORABILIA FOR DR MALCOLM DODD. KATRINA LOBLEY REPORTS.
PHOTO CREDIT: EAMON GALLAGHER
WHAT STARTED AS AN ASSORTMENT OF COLLECTABLES HAS GROWN INTO A FULL-BLOWN
r Malcolm Dodd has many passions
in life – but only one of them has
taken over an entire room of his house.
D
The 54-year-old Senior Forensic
Pathologist at the Victorian Institute of
Forensic Medicine collects vintage
medical memorabilia. And at last count,
the collection included 580 weird and
wonderful items.
The hundreds of objects, all
individually catalogued and tagged, have
taken over what was once Dr Dodd’s
home study.
uses catalogues dating from the early
1900s to identify them. His collection
includes amputation instruments, as well
as items once common in obstetrics and
gynaecology.
“I’ve got a fair old collection of really
nasty, destructive instruments that just
aren’t used anymore – hooks and
crochets and things for basically
delivering a dead foetus,” he says.
“It was pretty awful but those things
don’t happen now.”
“Now it’s a dedicated museum with
display cabinets,” he says.
His collection, in fact, often causes
him to reflect on the advances in
medicine.
“So it’s got its own room in the house,
which is fairly self-indulgent, but it came
out of necessity.”
“I’m constantly amazed by how things
have evolved. It’s nice to have a snapshot
of medicine and surgery generally.”
As with many hobbies, this one had
small beginnings.
Dr Dodd doesn’t know how much he’s
spent acquiring the collection. He’s found
items in auctions, on eBay, and through
friends, colleagues and strangers. His wife
Martine, a part-time antiques dealer, also
keeps her eyes peeled for items of
interest. “She will come across the
occasional gem just sitting there.
Sometimes you come across things
incredibly cheaply because people don’t
know what they are.”
Dr Dodd, who is also a keen pistolshooter, says that only a few years ago he
“literally had just a handful of little unusual
surgical instruments and a few old
microscopes”.
“But it’s ballooned out of all control
over the last five years – it’s gone from
very meagre to quite impressive in a
relatively short time span.”
Today, the collection focuses on
surgical instruments as well as laboratory
and diagnostic equipment.
“I’ve got pharmaceutical and quacktype instruments, too,” he says.
“The arbitrary cut-off point is about
1950, so anything earlier than that is fair
game.”
Dangerously beautiful
A favourite item, sourced on a trip to
London, dates back to the mid-1800s.
“One of the nicest things I have in the
collection is an old post-mortem kit –
obviously it has a direct relationship to
forensic pathology.
He’s also paid “largish amounts” for
particularly desirable objects.
“But with the vast majority of things,
unless you’ve had the training you
wouldn’t know what they were.”
Dr Dodd blames his hospital training –
which exposed to him to “lots of really
neat instruments in my early formative
years” – for his collecting bug. He started
his career as a medical laboratory
technologist, but soon realised he wanted
to study medicine. The only problem was
that he never matriculated from high
school.
He applied to both Monash and
Melbourne universities but didn’t get in to
either institution.
“It’s in a beautiful mahogany brassbound box with instruments in mint
condition.”
“The second year I applied [to the
University of Melbourne again] and I didn’t
tell my wife about it,” Dr Dodd says.
Dr Dodd is particularly drawn to
surgical instruments that have “gone into
extinction”. Some are so unusual that he
“We went to Tasmania for a holiday
and came back to about 10 days’ worth
of unopened letters. There was one from
Melbourne Uni and I opened it up and
went as pale as a sheet. My wife said,
‘what’s the problem?’
“I said, ‘I didn’t tell you but I actually
applied for medicine.’
“She said, ‘what does it say?’
“It says, ‘You got in, you start
tomorrow’.”
Boys’ own adventures
Post-medical studies, Dr Dodd spent two
years at Box Hill Hospital as an intern and
resident before setting up a general
practice in Melbourne’s outer-east. After
eight years, and disliking the changes
brought about by bulk-billing, he decided
to pursue what he’d always wanted to do
– forensic pathology.
Dr Dodd has now been with the
Victorian Institute of Forensic Medicine for
a decade. As well as dealing with a whole
spectrum of unexpected deaths in his
day-to-day working life in Melbourne, he’s
in demand for tough overseas
assignments such as investigating war
crimes. He reels off a list of destinations –
Kosovo, the Solomon Islands, Timor,
post-tsunami Thailand – that sounds like a
tourist’s worst nightmare.
“I’m one of those rare individuals who
thrives in Third World countries,” Dr Dodd
says matter-of-factly.
“You just have to rough it – I live off
army rations and sleep under mosquito
nets.”
Besides the unusual cases he sees in
these far-flung places – such as machete
attacks – and carrying out exhumations
under trying conditions, there are also
thrills such as flying in helicopters.
“It’s boys’ own stuff. I just find the
challenges fantastic.”
All that is easier, it seems, than trying
to figure out a long-term future for his
collection.
“I put that in the too-hard basket,” Dr
Dodd says, when asked where he’d like to
see his collection end up.
“Whatever happens to it happens
to it.”
PATHWAY_57
recipe for success
West side story
PERTH CHEF CHRIS TAYLOR’S GOLDEN RULES ARE KEEP IT SIMPLE, KEEP IT FRESH,
WRITES BRONWYN MCNULTY.
py an office worker strolling up St
George’s Terrace, Perth, towards the
city’s famous Kings Park and you can bet
they’re going to stretch out on a patch of
green to enjoy their sandwiches and the
breathtaking views over Perth and the
Swan River.
S
Spot one with an extra spring in their
step and they could well be about to turn
off into Fraser Avenue to dine at what is
arguably one of Perth’s best eateries –
Fraser’s Restaurant.
Perched high on the outer rim of this
remarkable 400-hectare park, Fraser’s is
regarded as an institution in Perth, both
for its splendid outlook and its top-rate
food, service and ambience.
There has been a restaurant on the
site for the past 40 years. And in late
1992, what had mostly operated as tea
rooms came into the hands of a former
Victorian, Wangaratta boy Chris Taylor.
“I was 24 and thought, if I screw it up,
I will just move to Sydney and no-one will
ever know,” Taylor, now 48, says.” If he
did screw it up, he was right – no-one
ever knew. After four years at the
International, Taylor moved on to
Observation City, a five-star hotel on the
beach in Perth’s popular Scarborough.
Then in 1992, Taylor joined forces with
Melbourne food and beverage operators,
the O’Brien family, to create Fraser’s
Restaurant.
“I named it after Fraser Avenue, the
main road that runs through Kings Park,”
Taylor says. “We wanted a name that was
relevant.”
His aim was to turn the newly
renovated site into a “top-notch”
restaurant.
“It’s a major development, quite an
imposing building, and probably the best
park in the country,” he says.
“As a kid I always helped in the
kitchen,” he says. “I was one of four boys
and everyone used to get in and give a
hand.”
“We are a package – we have function
rooms, private dining rooms, a restaurant
that seats 110 inside and 80 outside on
the terrace.”
At 16, Taylor moved to the big smoke
of Melbourne to do his cooking
apprenticeship at St Kilda’s Beverly Crest
– a four-star hotel/restaurant/bar.
A fresh change
In 1984 he cut his apron strings
completely and moved west to take up an
executive chef position at the five-star
Ansett International hotel.
58_PATHWAY
and great local meats,” he says. “Because
it’s a pretty mild climate, we tend to stick
to grills, seafood and healthy, clean food.
“We serve 150–180 people every day,
so we have a consistent turnover which
gives us the ability to have fresh produce
all the time – we buy our fish daily,
because we can.”
Taylor’s catchcry is to “respect what
you put on the plate”.
He predicts restaurant food will be
pared back to good, basic dishes without
the fluff and tricks.
“I am not saying that we [restaurants]
haven’t been cooking well, but we have
been guilty of tricking things up a bit and I
think that will change.
“The public is much more discerning
now and they don’t want to wait; they
don’t want to dress up; they like things
more relaxed. I am about giving the
punters what they want and to do that
you need seriously good produce and
seriously smart, uncomplicated dishes.”
With all this emphasis on the quality of
local produce, it comes as no surprise
Since day one Fraser’s Restaurant has
lived up to expectations. Taylor sees the
success as a reflection of both the quality
of the food and the dining experience.
that Taylor is also employed by private
“We serve modern, produce-driven
food, using good West Australian seafood
organic and biodynamic ingredients where
companies and the state government to
promote West Australian produce. He is a
big believer in small suppliers and using
possible.
>
“The public is much more
discerning now and they don’t want
to wait; they don’t want to dress up;
they like things more relaxed”
PHOTO CREDIT: TONY MCDONOUGH
– Chris Taylor
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PHOTO CREDIT: TONY MCDONOUGH
“The flavours of this type of produce
are fantastic, and it’s good to see small
suppliers doing well,” he says.
In his produce-promoting role Taylor
has travelled to Bali, Mauritius, Japan,
Singapore, South Africa, Phuket, Jakarta,
Zimbabwe, London, Ireland and
throughout Australia, hosting cooking
classes and events to spread the good
word about West Australian produce.
“I get out of here to go overseas at
least five times a year. And sometimes my
wife Julie and the kids come too.”
Taylor has fond memories of
Melbourne.
“I think of going back to Melbourne
regularly. There’s good food, and culturally
I like it because it’s got football – I’m a
Geelong supporter, and we’re having a
good year. But I love it here, and the sun
comes out and that’s great.”
Taylor also regularly hosts cooking
classes and special events at Fraser’s
Restaurant.
All this fits into a six-day, 60- to 70hour week.
“I like the lifestyle, the kitchen
atmosphere, the close-knit community
and the adrenaline,” he says.
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50_PATHWAY
And on Sundays, just when you’d
expect to find him in a crumpled heap on
the couch, this energetic father-of-three
invites a few mates round for a feed.
“Only half a dozen or 10 people,”
he says.
“It’s a bit different when you are cooking
with a glass of wine in your hand…”
GETTING THE MOST FROM
YOUR PRODUCE
• Build a good relationship with your suppliers.
“Ask their advice about what’s good and the best way to
put stuff together,” Taylor says. “They will tell you.
And for fish, go to the fish market. You will be surprised at
how what you get starts to improve.”
• Cook food simply.
“Use nice garnishes and side dishes, whether vegetables
or salad, and have the protein as the hero of your dish. Try
not to mask the flavour of the food with heavy sauces.”
• Respect your raw ingredients.
“Store your food correctly, and handle it with respect.
Use it when it is at its prime. Try to buy seasonally.”
diningout
Cross country
IT’S A BIG COUNTRY, BUT AWAY FROM THE BIG CITIES THERE’S SOME CAPITAL DINING TO BE HAD.
TarraWarra Estate Winebar
TarraWarra Estate has been growing grapes and turning them
into superb wines for decades but it wasn’t until the vineyard’s
owners, philanthropists Marc and Eva Besen, decided to open
a private museum on the estate that Melburnians really started
to sit up and take notice.
Architecturally extraordinary, with a superb collection of
contemporary Australian art and in the most stunning country
setting only an hour from central Melbourne, the museum and
winery quickly became one of Victoria’s ‘must see’ destinations
when it opened in 2003.
The vision for TarraWarra naturally included an intimate
winebar/restaurant, and although it’s hard to compete with a
collection of the best contemporary Australian art from the last
half century, TarraWarra Winebar holds its own. Echoing the
design of the museum, the restaurant also has stunning views
over the rolling hills of the Yarra Valley, but in winter its cosy
open fire makes it a less intimidating space than the nearby
museum.
The limited but clever menu was designed by Melbourne chef
Michael Lambie to complement the wide selection of
TarraWarra wines. Offering just four entrees, five mains, two
desserts and a cheese course, the menu even manages to
squeeze in one or two vegetarian options.
We started with a quail and chicken liver terrine that matched
the recommended pinot rosé perfectly. Dense and rich, the
terrine was studded with hazelnuts and served with fine slices
of toast, caper berries and rhubarb compote. Roasted blue eye
fillet with a fresh rocket and tomato salad followed and was
satisfyingly rich, thanks to a creamy chilli mayonnaise.
But the roasted saddle of lamb with pureed white beans and
turnips was easily the winner – on a cold September Sunday
with rain clouds threatening, the comfort of a warm, rich, meaty
dish with a TarraWarra shiraz was hard to beat.
A plate of imported cheeses (strange considering the location
in the heart of cheese-making country), biscuits and fruit
chutney helped us finish off the last of the wine. We chose our
own bottles, but wine flights are offered to match each course
if desired – a good option if you want to taste a variety of wines
or you’re driving to Melbourne the same day.
The Yarra Valley is the home of some of Victoria’s premier
wineries and there’s no shortage of lovely restaurants with
views over the valley to choose from, but TarraWarra has
something special. The intimacy of the restaurant, the quality of
the food and wine and the double pleasure of combining both
with a stunning art experience should make a visit to this
winery top of your list of things to do in Victoria.
– Justine Costigan
TarraWarra Estate Winebar
311 Healesville-Yarra Glen Road, Yarra Glen, Vic
Ph: (03) 5962 3311
Web: www.tarrawarra.com.au
Open daily 11am–5pm
Set menu on weekends, $50 per person for 2 courses, $60 person for 3
courses (including tea and coffee; drinks extra)
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>
diningout
Stewart’s
When you’ve left Perth city behind and arrive at Stewart’s at
Brookleigh (pictured right), 40 minutes away in the Swan Valley,
you feel as though you’ve been given a package deal without
asking for one.
The 30-hectare Brookleigh Estate has its own vineyard, which is
not surprising in a valley renowned for its wines, but you hardly
expect to find a world-class equestrian centre, chateau, lake
and ‘bunkhouse’ accommodation on the same patch as the
restaurant.
The fact that the restaurant exists in its current form is largely
due to managing director Neil Reveler, who quit the cold climes
of Canada for the sunny Swan Valley to help his step-sister and
estate owner Nikki Brooks.
But he did so on the condition that her planned venture should
be a restaurant, and not simply a café to complement the
equestrian centre.
The restaurant, which has a French influence thanks to Nikki’s
childhood in Jersey in the Channel Islands, was built alongside
the vineyard in 2003. The following year it won the Best
Restaurant in a Winery award from the Restaurant and Catering
Industry Association.
Although the cuisine is modern Australian of an international
standard and the service worthy of a fine-dining establishment,
the restaurant has achieved its aim of not being starchy but
rather, relaxed and slightly rustic.
It was built with plenty of natural materials including wood and
stone and is surrounded by a luxuriant garden.
When we dined there, we were starving and leapt straight into a
bottle of wine and the estate-baked bread ($8.50), served with
WA olive oil and a tomato salsa.
The entrees proved to be delightful delicacies. The herb-crusted
goat’s cheese ($16) came with a cake of slow-roasted tomato
and olives crowned with green beans, and the salt and pepper
prawns ($17) appeared with a lime and chilli dipping sauce plus
a twist of lime.
After a digestion-friendly interval, the main courses were also
worthy of an award-winning restaurant. My partner had the
market-fresh fish of the day (market price $32) – a delicious and
tender fillet of swordfish served with pumpkin and a tangy
sauce – while I opted for the lamb Wellington ($32), which sat
atop a dark jus of rosemary and tarragon.
Even the side dishes were exceptional. The grilled asparagus
($9.50) we chose had a gribiche sauce – which includes hardboiled eggs, mustard, capers and tarragon – and the roasted
potatoes ($9) were infused with the flavour of garlic and
rosemary.
If you think you have hit on a package deal now, this feeling will
only amplify in the next few years, as a wine bar, hotel and
wellness centre are planned for the estate.
– Cathy Saunders
Stewart’s at Brookleigh
1235 Great Northern Highway, Upper Swan, WA
Ph: (08) 9296 6966
Open for lunch and dinner Wed–Sun
Licensed
About $160 for a three-course meal for two, including drinks
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Appellation
The last few years has seen the Barossa Valley grow in stature
as one of Australia’s leading food regions, noted almost as
much for its produce as its wines.
Providores, restaurateurs, cafe owners and hospitality workers
have become part of an evolving landscape with new
restaurants and cafes, a food culture now supported by the
Food Barossa brand and the local Slow Food chapter, a thriving
farmer’s market and new areas of industry such as
cheesemaking.
It’s taken chef Mark McNamara some years to finally have the
opportunity to fully display his talents, during which time he had
his own restaurant, Pear Tree Cottage at nearby Greenock. But
at Appellation he has excelled himself, plating up the very best
produce the Barossa has to offer.
Surrounded by the small but sumptuous lodgings of Peppers
The Louise, which has set new standards (and prices) for the
Barossa, Appellation is tastefully kitted out in chocolate and
cream, with some tables tucked into semi-private booths.
McNamara’s menu is unusual in that it doesn’t distinguish
between entrée and main courses – simply a listing of a dozen
or so dishes that can be taken two, three or four dishes at a
sitting, with varying prices to match.
The focus is very regional, with dishes such as thin slices of
Barossa corn-fed chicken with lachschinken, garlic and sage;
loin of Hutton Vale lamb with broad beans, braised baby leeks
and sticky thyme glaze; or a duck tasting plate of rillettes, gumsmoked breast and liver parfait. All very wine-friendly cooking,
with an excellent wine list to match.
The tasting menu includes interesting wines not well known
outside the Barossa, such as Milhinch Wines Seize The Day
Rosé, David Franz Stonewell Hill Semillon, and Two Hands For
Love or Money Cane Cut Semillon. In all, a definitive Barossa
experience.
– Nigel Hopkins
Appellation
Peppers The Louise
Seppeltsfield Road, Marananga, Barossa Valley
Ph: (08) 8562 2722
Dinner seven days.
Licensed.
Two courses $57, three courses $79, four courses $97 plus drinks.
Tasting $90 including wine
Watermark
Townsville, the cultural capital of North Queensland, has seen a
population explosion and housing boom in recent years. Its
tropical climate and proximity to the Coral Sea attracts residents
and visitors who like a big modern city combined with easy
access to the ocean, bush and mountains.
I opted for Queensland steamed prawns on avocado, lemon and
chive bavarois with citrus salsa and watercress ($19). It was
delicious.
My main course was honey beer-battered red emperor with
chips, tartare, watermelon and cucumber salad ($23). This
upmarket version of fish and chips went down well with a bottle
of Cascade Premium.
It is also a world-class mecca for fishermen, boaties and
yachtsmen. It boasts the main campus for James Cook
University as well as the brand new Townsville Hospital.
My wife chose a glass of champagne to accompany her slowroasted cherry tomatoes, zucchini, pine nuts with semi-sundried
tomato purée, tossed angel hair pasta and goat’s cheese ($22).
As befits an expanding city, the range and number of bars and
restaurants have multiplied.
The Watermark does have a wide range of desserts, but we were
well and truly satisfied with just two courses. However Aaron, our
extremely able waiter, was pleased to indulge our request for
after-dinner coffee, prior to presenting us with the reasonable bill
of less than $100.
One of my personal favourites is the Watermark halfway along
The Strand, facing the ocean.
The Strand is an area of the Townsville seafront that faces
Magnetic Island and is a popular walking area for those who like
to ventilate their lungs with fresh sea air. It extends from the
saltwater rockpool at one end to the marina at the other end.
Tables at Watermark are available either outdoor or indoor, the
latter having comfortable and stylish white leather seating.
On a recent visit to celebrate our anniversary, my wife enjoyed a
starter of baked zucchini dome filled with roast pumpkin,
spinach and Yarra Valley Persian feta, served on a creamy
eggplant sauce ($14).
– Professor David J Williams (Department of Pathology,
The Townsville Hospital)
Watermark
72–74 The Strand, Townsville
Ph: (07) 4724 4281
Open for lunch 7 days 11am–3pm, dinner Sun-Thurs 6–9pm and Fri–Sat
6–9.30pm or later
Licensed
About $100 for two plus drinks
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the good grape
Red HOT reds
THERE IS A SOLUTION FOR RED
WINE LOVERS WHO DON’T
WANT TO RESORT TO ROSÉ
DURING SUMMER, WRITES BEN
CANAIDER..
his is my quandary: over winter I tend
to drink a fairly large volume of
Australian red wine – mostly cabernet,
mostly shiraz, and some of it carrying a
little bit of bottle age.
T
These are wines that suit the food I
like eating during winter: roasted meats,
stews, pasta with a rich ragu.
The quandary? When spring is sprung
and the warmer weather descends, these
foods don’t seem to call my name so
fondly, nor do the associated wines of
winter. With warmer weather about, shiraz
can start to taste porty and the cabernet
too angular and tannic.
Yes, I know that come summer I could
do what young people do and talk
gushingly about how fabulously rosé suits
our Mediterranean lifestyle and climate
and cuisine. I know I could sip glasses of
refined pinot noir from such wonderful
pinot regions like Tasmania, but I don’t
want to do that every day until next
Easter. I don’t want to give up my red
wine hits.
The solution? Imported reds.
Italian, French, Spanish – more and
more of these wines are coming into
Australia. They have a number of features
and benefits. Quality is nowadays much
better. Smarter winemaking practices,
smarter wine-buying decisions by
importers, and smarter shipping (in
climate-controlled containers) means
better wine gets here in better condition.
Price is another factor. With grape
oversupply in Europe, prices are good
for buyers of finished wine. European
winemakers are also actively looking for
overseas markets as their own
country’s wine consumption is on a
downward trend.
64_PATHWAY
The local availability of imported wines
has also improved – no longer do you
necessarily have to make a special trip to
a geographically challenging fine wine
store to buy your imported wine. Even the
supermarket liquor stores now carry a
quite reasonable range of imported wines.
Most importantly, however, many of
these imported reds are wines that tend
more towards a beverage than a fruitbomb. They are lighter-bodied and often
more savoury in flavour – as opposed to
the heavier and more fruity Australian
reds.
The sorts of imported red wines I like
have good texture and good acid; they’ve
also got some length and that savoury
flavour profile I just mentioned.
They are red wines that are very easy
to drink; they’re not aperitif wines by any
stretch of the imagination, but when
coupled with barbecued meats or cold
cuts they really sing. Everything from a
plate of sliced prosciutto through to a
slowly barbecued pork chop will bring out
the best in these wines – and vice versa.
Such wines even find friends with
vegetable dishes like ratatouille, or a good
chickpea stew.
Here are some affordable and very
drinkable imported reds for you to
experiment with over the coming months.
LZ RIOJA 2005, $28
Forget any old-school thoughts you might
have about dank and dirty Rioja – this LZ is
part of the new generation of wine and
winemaking in Spain. Made by Telmo
Rodriguez, the emphasis here is on the fruit
of the vine and the land it comes from. Get
the grapes right and the wine virtually
makes itself, or so the story goes. This is a
tempranillo blend with drying cherry and
blackberry tastes. It’s an attractive red that
has strong aromatics, a shiraz-like spice,
and cabernet-like structure.
GUIGAL CÔTES DU RHÔNE 2004,
$20
An ever-reliable and more-ish Rhône blend
of predominantly grenache and shiraz.
This vintage has plenty of velvety berry
fruit, with those spicy, peppery flavours to
the fore. It just might be the world’s best
barbecue wine, with good gripping tannins
and some balancing acidity.
CASTIGLIONI CHIANTI 2005, $22
From the Frescobaldi stable of Tuscan
wines, this Chianti is a real winner with
lighter veal, chicken or pork dishes. All the
deliciously savoury Chianti notes are
struck in this red: earth, spice, leather, and
the cherry-pip flavour that makes Tuscan
reds not too sweet and yet not too dry.
CHIVITE GRAN FEUDO CRIANZA
2002, $21
From Navarra and from one of Spain’s
best-known wine families, this red is 70%
tempranillo, 25% grenache (or garnacha)
and 5% cabernet. It makes for a smooth,
bottle-aged amalgam of spice, berried
fruits and tobacco notes, and a faint
overlay of toasty oak. Round, but in no
way structureless. Good with a pork chop,
or spare rib.
CARPINETO DOGAJOLO 2005,
$14
I drink this Tuscan blended red whenever I
don’t want to have to think too hard about
the wine in front of me. It’s my effortless,
default drink. To this Chianti’s sangiovese
some cabernet has been added, which
helps the wine’s length and structure.
Otherwise this is a charmingly bucolic
wine wearing its Sunday best. Perfect
with good sausages.
MICHEL LYNCH BORDEAUX
ROUGE 2005, $10
The winemaking team at Chateau Lynch
Bages put this ‘entry-level’ Bordeaux red
together. It’s a blend of cabernet and
merlot with remarkable consistency, not to
mention quality. Berries and blackcurrants
dominate a slightly dusty aroma and
palate. It’s a fairly firm wine, but the
tannins are rounded and the fruit weight
helps carry everything to a well-balanced
conclusion. Excellent for the price.
2007
Conference Calendar
NOVEMBER 2007
MARCH 2008
17
5
5th Annual Infectious Diseases and
Microbiology Trainee Weekend
17 - 18 November
Sydney, Australia
13th Ottawa International Conference
on Clinical Competence
5 - 8 March
Melbourne, Australia
Andie.s.lee@gmail.com
JUNE 2008
22
American Academy of Oral
Maxillofacial Pathology
22 – 26 June
California, USA
www.iaop.com
14
JANUARY 2008
17
Australian Postgraduate
Neuropathology Course
17 - 19 January
Sydney, Australia
Pathology Update
14 - 16 March
Sydney, Australia
OCTOBER 2008
www.rcpa.edu.au/pathologyupdate
The 19th International Symposium on
the Forensic Sciences
6 - 9 October
Melbourne, Australia
17
www.pathology.usyd.edu.au/Neuropathology
_Courses/Neuropath_Index.html
29
Fourteenth Annual Practical Pathology
at Whistler
29 Jan – 1 Feb
Whistler, Canada
Focus Cytology Tutorial for
Pathologists
17 - 19 March
Sydney, Australia
Joanne.clarke@symbionhealth.com
MAY 2008
6
www.anzfss2008.org.au
29
The National Forum on Safety and
Quality in Health Care
29 – 31 October
www.achs.org.au/nationalfiorum08
www.pathology.ubc.ca/cme
30
FEBRUARY 2008
29
Cytopathology Course Singapore
30 May – 1 June
Singapore
MARCH 2009
www.med.nus.edu.sg/path/teach/cytopath2008.htm
The XXV WASPaLM Congress in
conjunction with Pathology Update
13 - 15 March
Sydney, Australia
Real-Time Molecular Diagnostics for
Infectious Diseases
29 February - 1 March
Sydney, Australia
13
www.rcpa.edu.au/pathologyupdate
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PATHWAY_65
rearview
IN COLD BLOOD
DR GEORGE BIRO EXAMINES HISTORY’S LOVE AFFAIR WITH BLOODLETTING AS A POPULAR
MEDICAL REMEDY.
e find blood fascinating. It has been
called the circulatory computer tape
with coded orders to our organs.
W
And it has wound its way inextricably
into our lexicon. We say ‘blood is thicker
than water’ and ‘blood will have blood’. In
1940, Winston Churchill told his
countrymen, “I have nothing to offer but
blood, toil, tears and sweat.”
This preoccupation with blood has a
long history, based largely on ignorance of
the functions of the heart and circulatory
system.
For example, the Ebers Papyrus
(around 1500 B.C.E) suggested the heart
turns our food into blood. The arteries
were thought to contain air, while the
veins carried the blood.
By the time of Hippocrates in about
400 B.C.E, the Greeks believed the body
had four important humours. They
thought four elements (water, air, fire and
earth), each with its specific element
(respectively moist, dry, hot and cold),
comprised the whole external universe.
By analogy, the human body had four key
fluids: blood (warm and moist), phlegm
(cold and moist), yellow bile (warm and
dry) and black bile (cold and dry).
Consequently, for good health, it was
thought pairs of opposites must remain in
balance. So fever, for example, meant a
surplus of blood and called not only for
bleeding but also for a cold remedy like
cucumber seeds. Hence we say ‘cool as
a cucumber’.
66_PATHWAY
By the Middle Ages, the Greek
concept of the four humours (or
‘complexions’) were said to account for
psychological and social as well as
physical characteristics.
So the cold and moist ‘complexion’ of
women explained their timidity as well as
their menstruation!
An excess of blood, phlegm, yellow
bile or black bile made a person
sanguine, phlegmatic, choleric or
melancholy respectively.
The lesions of cholera, smallpox and
pneumonia were seen as sites for the
discharge of ill humours as diarrhoea,
vesicles and blood phlegm.
This paradigm of the four humours
was to dominate medical thought and
practice for many centuries, though the
maverick Swiss physician Paracelsus
attacked it in the sixteenth century.
The eating of blood is clearly
forbidden in Leviticus. But to take on
some of the courage of their fallen
victims, Roman gladiators did drink their
blood.
blistering and purges – or a cocktail of all
of the above.
They used scalpels, lancets, cupping
vases, bleeding bowls and sometimes
leeches. The use of leeches became
particularly fashionable in the nineteenth
century – in just one year, France is said
to have imported 40 million of them. (Even
now, leeches help some patients after
microsurgery, plastic surgery or grafts.)
The Salerno medical school taught:
“Bleeding soothes rage, bringing joy to
the sad and saves all lovesick swains
from going mad.”
But the ‘English Hippocrates’, Thomas
Sydenham (1624–1689), wrote: “by such
means as these, greater slaughters are
committed … every yeare than … by the
sword of the fiercest and most bloody
tyrant the world ever produced”.
He was not the only critic. A scurrilous
verse about the respected Quaker
physician Dr John Lettsom read:
“When people’s ill, they comes to I,
I physics, bleeds and sweats ’em
Sometimes they live, sometimes they die
When Pope Innocent VIII lay dying,
the story goes, a physician bled three
strapping young men. He then gave the
Pope the blood, probably by mouth.
When the Pope promptly died, the
physician quickly took off.
What’s that to I? I lets ’em.”
To treat illness, barbers, surgeons,
barber–surgeons and shysters used to
drain off excess humours by bleeding,
Despite this, bloodletting remained
widespread until the mid nineteenth
century.
But in 1836, the French physician
Pierre Louis (1787–1872) compiled figures
to prove that in disorders such as
pneumonia, venesection was not only
useless but harmful.
Did George Washington’s
doctors do him in?
“Fever, for example,
meant a surplus of blood
and called not only for
bleeding but also for a
cold remedy like
cucumber seeds”
In 1788, across the English Channel,
poor King George III became manic,
“Had George Washington been a commoner, he would have seen far fewer
consultants and probably would not have been bled to death for his sore throat.”
– David Sackett, Clinical Epidemiology. Boston: Little, Brown & Co, 1985.
On December 12, 1799, there was rain, sleet, snow and wind, but as usual, George
Washington rode about his farm at Mount Vernon.
The next day he had a sore throat and became hoarse. That night he became
breathless and could barely speak.
At dawn he was given molasses, butter and vinegar, which just made him choke.
Washington asked the farm overseer to bleed him. Soon Dr James Craik applied hot
packs of cantharides (Spanish fly) to Washington’s throat and took more blood. A
gargle of vinegar and sage tea nearly suffocated him.
Soon they bled him again. Washington was worse by the time Dr Elisha Dick and Dr
Gustavus Brown arrived. Dr Dick, the most junior of the three doctors, suggested
tracheotomy and opposed further bleeding, but was overruled.
probably from porphyria. He suffered all the
Having drained more blood, they found not “the smallest alleviation of the disease”,
but the blood came “slow and thick”.
usual cures of the time: bleeding, blistering,
No wonder. In all, they drained about half of his total blood volume.
cupping, leeches, emetics and purges.
Remarkably, he did eventually recover
his wits and so averted a national panic.
Oddly enough, had King George lived in
Somehow the poor patient swallowed repeated doses of calomel (mercurous
chloride, a purgative) and tartar (which contains antimony). After a break, they
applied more blisters to the throat and wrapped his legs and feet in poultices of
wheat bran. At 10pm, he became quieter, and at 11.30pm, after an illness of only two
days, the poor man died.
modern times, he may also have been bled.
Even now, there is still a need for bleeding
highly selected patients. Blood banks now
bleed patients with haemochromatosis –
It is easy to be critical of his treatment, but George Washington’s doctors were the
well-trained elite of those times.
Let us not judge them with hindsight.
and even a few with porphyria.
PATHWAY_67
postscript
Gross
anatomy
AN OVERSEAS TRIP
UNEARTHED A NEW KIND OF
PATHOLOGY FOR DR PAM
RACHOOTIN .
went overseas for a short visit recently,
off duty I thought. How was I to know
that I would return to Australia having
discovered a new kind of pathology? This
article is my first public revelation of the
discovery. When it is published, I will no
doubt be knocking back speaking
engagements and tripping over paparazzi
at the front gate.
I
We all know that pathology, like
pathologists, comes in many shapes and
sizes. Putting it more technically, the
morphology varies. The old pathology,
which I suppose will now be known as PP
(pre-Pam), ran the gamut from molecular
to gross. What I have found is beyond this
pedestrian range, beyond what anyone
had imagined possible. I’m out there in
Ultra-Hyper-Mega-land. What I have found
I am going to coin Really Gross Pathology.
I uncovered this pathology
accidentally, while I was visiting my
daughter and her boyfriend in Vancouver.
They live in a noisy, second-floor flat off
Main Street, imbued with a distinct scent
of mould even though they keep all their
windows open.
“We like light and openness, even if it
means everyone can see us,” my
daughter explained.
“Everyone” referred to the patrons of
Duffin’s, a fast-food joint directly opposite
their flat. The establishment did a
booming business, whatever the time of
day, specialising in doughnuts and hot
torta subs. Its customers typically sat
outside and looked across at the
spectacle afforded by open windows and
student life.
“At first I thought it was weird, but I’m
now used to it,” my daughter said, to
encourage my acceptance of her living
arrangements being on perpetual public
display. After all, for the next week, the
voyeurs across the street would have an
additional subject to perve on: me.
68_PATHWAY
I must admit that I looked down at
Duffin’s, literally and figuratively, personally
and professionally. It was not only a
question of the cuisine, although I admit I
never dared try it. The first day I caught
my potential son-in-law devouring one of
their subs. He insisted it was really good,
but on further questioning was unable to
identify what exactly he was eating.
Doughnut diners
The Duffin’s regulars had bellies
cascading over their belts. They wore
sleeveless tank tops, showing off
numerous tattoos. They drank their cokes
and coffees, and smoked their fags. I was
on holiday, but I couldn’t distance myself
from the onslaught of disgusting, Really
Gross Pathology-in-the-making that was
on full view.
With each doughnut diner at Duffin’s, I
envisioned soaring LDL levels contributing
to the formation of atheromatous plaques,
in vessels damaged from hypertension,
smoking and diabetes. I visualised the
cascade mechanism of blood coagulation
creating thrombosis and infarction. It was
painful for me to witness such wilful selfdestruction.
My attention suddenly focused on
something closer to hand. It was a small
drinking glass filled with cigarette butts,
sitting next to the computer. My daughter
was living with a smoker!
That evening I had a chance to speak
with him alone. He told me that he only
smoked outside the flat, and that he was
going to quit. He had even set his ‘quit
date’. I gave my whole-hearted support. He
then went outside on the balcony and lit up.
I started to prepare dinner. He
eventually came back inside and assisted
with the cooking. We were through cutting
up the chicken, onions and mushrooms.
The olive oil was heating up in the frying
pan when I heard shouting. It came from
across the street… the Duffin’s brigade!
“Fire, fire, get out,” they screamed,
pointing at us. I was unable to detect any
sign of a fire. Then I peered out the back
door and saw flames two metres high.
We began frantically filling pots and
buckets with water. Everyone pitched in.
Duffin’s doughnut-dunking diners diverted
disaster: three fire engines, with sirens
blaring, soon arrived.
Those people are now my heroes.
Sometimes it only takes an instant for
sinners in singlets to be transformed.
My potential son-in-law took immediate
responsibility for the blaze. He admitted he
had tossed a burning cigarette butt into the
garden from the balcony. It ignited the
woodchips, along with the fence.
Fortunately, major structural damage to the
flats had been averted.
Admittedly, I tried at first to avert my
gaze out the window and to find
sanctuary in my indoor scene. It wasn’t
easy amid dying pot plants, shredded
linoleum, strewn clothes and cat fur
engulfing the couch.
So, conventional wisdom fails again:
one’s life can be endangered by smoking,
even if one is not exposed to direct or
passive smoke. Fast food saves lives.
Gross pathology is bad, but Really Gross
Pathology is definitely good.
But something miraculous happened,
and my attitude has changed.
Committed to training,
encouraging education
Dade Behring’s commitment to research and development, education and around-theclock support has made us the international leader in integrated diagnostic systems.
We are devoted to forward thinking and innovation at a time when there is a growing
need for highly skilled laboratory professionals. The Emil von Behring scholarship
program is a $1.25 million global commitment to clinical diagnostics education.
The current ANZ scholarship supports a position of pathology registrar.
DADE BEHRING
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Lane Cove NSW 2066
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