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PathWay #11 - Text 21/2/07 3:56 PM Page 1
Contents ADVISORY BOARD Dr Debra Graves (Chairman) Chief Executive, RCPA
Dr Bev Rowbotham Vice President, RCPA
Associate Professor Jane Dahlstrom Representative, Committee of Deans of Australian Medical Schools PATHWAY Dr Tamsin Waterhouse Autumn 2007 Deputy CEO, RCPA Issue #11 Wayne Tregaskis S2i Communications
PUBLISHER Wayne Tregaskis
EXECUTIVE EDITOR Dr Debra Graves COVER STORY EDITOR Kellie Bisset Bodies of evidence: 8 Protecting our pathology museums – a precious medical resource ART DIRECTOR Jodi Webster FEATURES ADVERTISING SALES DIRECTOR Bronwyn Sartori Movers and shakers 14
PUBLISHING CO-ORDINATOR Populate or perish: WA and Qld pathologists are getting Andrea Plawutsky impressive results in reversing the workforce shortage
In profile 17
PathWay is published quarterly for the Royal College A magnificent obsession: why Professor David Weedon doesn’t of Pathologists of Australasia (ABN 52 000 173 231) have time for holidays by S2i Communications, Suite 1201, Level 12, 4 O’Connell St Sydney 2000 Hot topics 21 Tel (02) 9235 2555 Fax (02) 9235 2455 Testing times: how the new HPV vaccine will affect the future of PrintPOST approved PP60630100114 cytology
Spotlight on disease 26 Clearing the way: a cure for cystic fibrosis still eludes us
Foreign correspondence 30
The Royal College of Pathologists of Australasia Mission, possible: Dr Richard Davey is relishing the challenge of Tel: (02) 8356 5858 his Papua New Guinea locum posting Email: [email protected] Disciplines in depth 33 S2i Communications Pty Ltd Tel: (02) 9235 2555 Getting back to basics: current standards of pathology teaching in Email: [email protected] Australia’s medical schools are far from uniform
PathWay Email: [email protected] At the cutting edge 39 http://pathway.rcpa.edu.au The philadelphia experiment: Adelaide researchers are leading the way on chronic myeloid leukaemia
Testing, testing 42 A tale of two microbes: pathology’s role in rubella and pertussis FOR FURTHER INFORMATION ON THE ROYAL COLLEGE OF PATHOLOGISTS OF AUSTRALASIA OR ANY OF THE FEATURES IN THIS ISSUE OF PATHWAY CHECK OUT THE WEBSITE Cover Professor Robin Cooke, a published expert on pathology museums, www.rcpa.edu.au examines some interesting specimens. PHOTO: GIULIO SAGGIN
PATHWAY_1 PathWay #11 - Text 21/2/07 3:56 PM Page 2 7 0 4 & $ - 2 9 0 '
IGDE>86A B:9>8>C: 6K>6I>DC B:9>8>C: JC9:GL6I:G B:9>8>C: I=6IÀH DJG >9:6 D; 6AI:GC6I>K: I=:G6EN# 9OUVE WORKED HARD TO BECOME A $OCTOR 3O YOU OWE IT TO YOURSELF TO CHECK OUT ALL THE CAREER OPTIONS OPEN TO YOU !S A $OCTOR IN THE .AVY !RMY OR !IR &ORCE THERE ARE MANY OPTIONS NOT AVAILABLE IN CIVILIAN PRACTICE #HALLENGING OPTIONS THAT WILL ADD BREADTH TO YOUR CAREER 7ITH A LIKE MINDED TEAM OF DEDICATED PROFESSIONALS YOU COULD BE ASSISTING IN NATIONAL EMERGENCIES 0LUS THERES THE POTENTIAL TO BE INVOLVED IN 5NITED .ATIONS PEACEKEEPING OPERATIONS OVERSEAS 0RACTICING IN STATE OF THE ART FACILITIES YOU COULD SPECIALISE IN FIELDS AS VARIED AS s 4ROPICAL MEDICINE s 5NDERWATER MEDICINE s 3PORTS MEDICINE s 0UBLIC HEALTH MEDICINE s /CCUPATIONAL MEDICINE !CROSS THESE FIELDS YOU WILL RECEIVE TRAINING OPPORTUNITIES TO KEEP YOU UP TO DATE WITH THE LATEST MEDICAL ADVANCEMENTS AND BE GIVEN MANAGEMENT AND LEADERSHIP OPPORTUNITIES .OT TO MENTION YOUR ABILITY TO WORK UNDER PRESSURE WILL BE SECOND TO NONE 0LUS IF YOURE A 'RADUATE OR ABOUT TO GRADUATE YOULL BE STARTING WITH A VERY HEALTHY SALARY OF PA 0ART TIME OPPORTUNITIES ALSO EXIST IN THE .AVAL !RMY AND !IR &ORCE 2ESERVES WHERE YOULL RECEIVE TAX FREE PAY 7ANT TO FIND OUT MORE ABOUT A FAST MOVING MEDICAL CAREER #ALL OR VISIT WWWDEFENCEJOBSGOVAUDOCTOR PathWay #11 - Text 21/2/07 3:56 PM Page 3
REGULARS REARVIEW From the CEO 4 PAGE 64 Welcome from RCPA CEO Dr Debra Graves
Under the microscope 6 News + views
The GP view 20 All in the balance: Dr Linda Calabresi LIFESTYLE reflects on the youth of today Travel 46 Conference calendar 67 A happenang thang: Malaysia has even more to offer this year Postscript 68 as it celebrates its 50th anniversary of independence
Cutting it fine: an early forensic Private passions 50 pathology pioneer left some room for improvement. Sax appeal: Dr Richard Steele takes some time off pathology to indulge his musical side
Travel doc 52 Aegean pearls: Dr Michael Harrison is already dreaming of his next trip to the Greek Islands
Working holiday 55 Maltese moments: Dr Jane Dahlstrom won’t forget the magical A HAPPENANG THANG islands of Malta PAGE 48 Recipe for success 57 A class of his own: Tony Bilson reflects on the state of Australian fine dining
The good grape 60 Give us this day our daily red: Ben Canaider wonders if you can get too much of a good thing
Dining out 61 Good morning: Pathway explores some favourite breakfast haunts
Rearview 64 On fertile ground: early pregnancy tests aren’t what they used to be
PATHWAY_3 PathWay #11 - Text 21/2/07 3:56 PM Page 4
from the CEO
Welcome to the first Edition of PathWay for 2007
or those of you who may be reading it students and the general public. In fact on been driving these changes and plans to Ffor the first time, PathWay is a unique Saturday 3 March, 2007, there will be an establish a Centre of Excellence in magazine in Australian publishing. Now Open Day at the Museum for the general Pathology to help address some of the into its eleventh edition, Pathway is a public. Please see page 7 for details. problems caused by the workforce crisis. publication of the Royal College of There has been considerable In Queensland, Professor Sunil Pathologists of Australasia (RCPA) in discussion in the general media in recent Lakhani is rebuilding the University of association with S2i Communications, times about medical school curricula and Queensland’s Pathology Department. and is provided to over 30,000 doctors, concerns over the paucity of pathology Being a Queensland graduate myself, it medical students, health administrators, and anatomy teaching in some medical has been disappointing to see the once politicians and the general public courses in Australasia. In our ‘discipline in excellent department struggling to survive. throughout Australasia. The purpose of depth’ section, the article “Getting back It is really great to see things improving. the magazine is to promote an to basics” looks into this issue. We speak Speaking of academic pathology and understanding of what pathology is and with a number of academic pathologists Queensland, we profile Professor David what pathologists actually do. about their concerns and explore some Weedon, who was a very inspirational Most people are unaware that solutions to try and address them. pathologist at the University of pathologists are the doctors who Academic medicine in general needs Queensland for medical students (me diagnose every detected cancer in the more support to ensure that there are included!) in the seventies and eighties. world and that they are involved in the robust departments in universities to Now a senior pathologist at Sullivan and diagnosis and monitoring of all acute and provide high quality teaching and Nicolaides in Brisbane, his passion for chronic illnesses, such as diabetes, blood research that is so important in assuring disorders and infections. Even less well teaching pathology continues at Bond good medical care. Having such known is that pathologists are also University. Indeed as a testament to his departments will also hopefully intimately involved in the management of dedication the University’s Pathology encourage young doctors to consider a these often life threatening conditions. Museum bears his name and in 2006 he career in academia. This is even more was awarded the Bond University Student The RCPA is committed to enhancing pertinent for pathology, where lack of Council’s Award for Academic Excellence. the medical and general communities’ support from some universities has understanding of pathology and hopefully, meant that pathology departments have There are many other articles in the at the same time, entertaining you with “a been decimated. As a consequence, the edition which we hope you will find good read”. amount of pathology taught in many informative and entertaining. Enjoy! We hope you enjoy this edition of medical courses has been inadequate. PathWay, which explores several important In our ‘movers and shakers’ section, topics, including pathology education. we highlight two areas where attempts are Our cover story, “Bodies of evidence” being made to improve academic looks at the important part pathology pathology departments. The University of museums play in teaching medical Western Australia has, in principle, agreed students about the pathological basis of to reverse a decision made about seven Dr Debra Graves disease. We also highlight that museums years ago to amalgamate the CEO, RCPA can be used to teach the general public departments of pathology and surgery. about the origins of disease. The And the professor of pathology position, University of NSW has an innovative which had lapsed, is to be reinstated. Dr program opening the museum to school Peter Flett, Director of PathWest, has
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under the microscope: news + views
Prenatal test taking guesswork out of foetal abnormalities
biochemical prenatal screening test PAPP-A test] pregnancies that may fail,” developed in Australia is slowly Dr Sinosich told PathWay. A R E H
changing attitudes towards early G
“The biochemistry looks at the A L L detection of foetal abnormalities. placenta; ultrasound looks at the baby – A G N
The pregnancy-associated plasma sometimes you get a discordancy. The O M A E
protein-A (PAPP-A) test has been used reality is you can have a placenta without : T I D E
clinically around the world since 2000 a baby, but you can’t have a baby without R C O
and, when used in combination with a placenta, and people are becoming T O H
nuchal translucency screening at 10 to 13 more attuned to this.” P weeks’ gestation, can improve Down Dr Sinosich said more women were syndrome detection rates by 10–15%. learning about the test, and while it was But according to the test’s developer well known to specialists, many general and RCPA associate member Dr Michael practitioners were unaware of it. Sinosich, it is also useful in determining a “In reality only about 30% of all problems. It can make an emotional pregnancy’s future viability. pregnancies are screened [using the test], difference, but also potentially it could Scientific Director of Prenatal Testing Dr Sinosich said. “It is available more in save someone their reproductive function at the Sonic Clinical Institute, Dr Sinosich urban teaching centres and not so much if they were at risk of losing their fallopian said the institute was taking the test one in rural areas.” tubes.” step further than Down syndrome However, he said the potential Dr Sinosich and the Northern Sydney detection, where it was most commonly benefits of early diagnosis were important. and Central Coast Area Health Service used. “Because a fair proportion of early have taken out a patent on the test, which W “Even in the presence of normal pregnancies fail, if women have this was licensed by biomedical testing ultrasound, you can still identify [with the marker available it could save them manufacturer Beckman Coulter.
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Screening helps babies with Clarification In the article ‘What is Immunopathology’ rare metabolic disease on page 42 of our last issue it has been suggested that some of the information on training may need ustralian researchers have A study published in The Lancet clarification. Ashown that neonatal screening (2007;339:37–42) suggested the There are three categories of by tandem mass spectrometry screening was effective since early immunopathologists/clinical diagnosis reduced deaths and severe dramatically improves outcomes for immunologists: children with medium-chain acyl- adverse events from the disorder in • those primarily responsible for CoA dehydrogenase (MCAD) children up to age four. providing laboratory services (for deficiency – a genetic disorder that Honorary RCPA Fellow Professor this you’d generally train as a affects the body’s capacity to break Bridget Wilcken* and colleagues pathologist, but may also choose to down fats. studied nearly 2.5 million patients, a train as an internal medicine third of whom underwent neonatal specialist) screening for MCAD deficiency. • those who provide both patient Comment by UK and US care and laboratory services MUSEUM OF researchers published in the same (generally you’d train as both a HUMAN DISEASE issue of the journal said the study was pathologist and an internal important new evidence that showed medicine specialist) newborn screening seemed to prevent • those primarily responsible for OPEN DAY death in 10% of children diagnosed patient care (generally you’d train On Saturday March 3, 2007 the with MCAD deficiency. They said as an internal medicine specialist, Museum of Human Disease at the similar research was needed for other but may also train as a pathologist). University of New South Wales will disorders diagnosed by tandem mass Those electing to train in both open its doors to the public. The spectrometry. pathology and internal medicine Museum contains more than 2,700 * Professor Wilcken is the Clinical generally undertake training that is specimens and exhibits. The Director of NSW Biochemical Genetics supervised and accredited by the collection features rare disease and Newborn Screening at The Joint Specialist Advisory Committee of specimens such as diphtheria, and Children’s Hospital at Westmead. the RCPA and RACP. specimens showing the effect of more common ailments such as heart disease, stroke, and cancer. Pathologists recognised in Visitors will be able to view specimens and exhibits and attend Australia Day honours presentations highlighting specific conditions. he Fellowship of the college congratulates the following Fellows who received NOTE: Some individuals, children and Tawards in the honours list, Australia Day 2007. cultural groups may experience Order of Australia Companion (AC) in the general division sensitivity due to the nature of the museum specimens and suitability of Dr John Robin Warren, Northbridge WA. For service to medicine and medical this material should be considered research, notably the discovery of the Helicobacter pylori bacterium and its role in gastritis and peptic ulcer disease. when planning a visit. Member (AM) in the general division
Saturday 3 March 2007 Professor Clive Gordon Harper, Sydney NSW. For service to medicine in 10:00am – 4:00pm neuroscience, chiefly research into the neuropathological consequences of alcohol- Museum of Human Disease related brain damage and for input into public health policy. Ground Floor, Samuels Building Dr Svante Rikard Orell, Adelaide, SA. For service to medicine in diagnostic The University of New South Wales pathology, chiefly the introduction of fine needle aspiration biopsy, and to medical Bookings are Essential training. For further information please call Medal (OAM) in the general division 9385 1522 or visit Professor Donald Murray Walker, Dorset, Britain. For service to oral pathology www.hallofhealth.med.unsw.edu.au and oral medicine as an academic and clinician, and to public health through research and diagnostic services relating to oral and maxillofacial pathology.
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cover story
Bodies of evidence
AUSTRALIA’S PATHOLOGY MUSEUMS MUST BE PRESERVED TO PROTECT OUR PRECIOUS MEDICAL HISTORY FOR FUTURE GENERATIONS OF DOCTORS AND PATIENTS. DAVE HOSKIN REPORTS.
n a way, I'm looking at a murderer. The Allen Museum of Anatomy and Pathology, I Ivictim has been dead a long time, can't help feeling he's onto something. expiring approximately 60 years ago. Unlike most museums, these We know their death was quick, but collections are as much about the present the perpetrator of the crime is still present as the past. When a pathology museum at at the scene. It sits there like a massive the university was first proposed in 1859, its chief aim was not simply preserving the shadow cast over the right-hand side of historical record, but to illustrate the victim's brain – a perfect example of morphology. Specimens were gathered to intracerebral haemorrhage. demonstrate body structure, to illustrate Around me are thousands of other disease and to chart the way its patterns deadly killers, all neatly labelled. Behind change over time. The result was that me, the tiny body of a child floats in museums such as this became an essential yellow preserving solution, the top of its aid in teaching doctors about disease. head ruined by anencephalus. A few They have also kept pace with steps onward is a heart, its surface blown technology. A visitor to the Museum of outwards by cardiac infarction. Human Disease at the University of New As I lean closer to the glass, I'm South Wales would never know that once upon a time most of its specimens were reminded of an interview in which film simply stored in jars of alcohol. Today director David Cronenberg talked about digital microscopes and virtual his fascination with the body's interior. microscopy provide a far closer view on Arguing that there's just as much beauty disease than ever before, and computers under the skin as there is on the surface, are ubiquitous. at one point Cronenberg even suggested Every exhibit has been completely there should be a beauty contest for our photographed and digitised; every image internal organs. has been linked to its histology, radiology It's an odd idea, but standing here in the and clinical history; every student has University of Melbourne’s Harry Brookes been given a copy of this resource on CD. > 8_PATHWAY PathWay #11 - Text 21/2/07 3:56 PM Page 9 E K R A L C
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Professor Denis Wakefield among some pathology specimens at the Museum of Human Disease, University of New South Wales. PathWay #11 - Text 21/2/07 3:56 PM Page 10 E K R A L C
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Professor Robin Cooke: many factors have played a part in pathology museums’ decline as a teaching tool.
Modern obstacle course The number of specimens obtained A major shortage of anatomical during surgery, for example, has been pathologists in Australia’s teaching Despite these efforts to move with the significantly reduced. hospitals also hasn’t helped matters. times, these days many pathology “It's all done by keyhole surgery,” However, Professor Monagle doubts that museums are under threat. Professor Wakefield says. the decrease in autopsies can be One of the principal reasons is attributed to work practices alone. “You can't bring out a big specimen obvious: running a museum is an that way. You break it all up and suck it “I think the major issue is that our expensive exercise. A successful through tubes and you end up with clinical colleagues often just don't wish to collection requires considerable storage nothing to show anybody.” ask for autopsies anymore,” he says. facilities, specialised expertise in Similarly, because of the demand for “Part of that may be because they preparing and maintaining specimens, and more detailed pathological analysis, more believe they already know why their many man-hours of hard work to host incisions are being made in specimens patients are dying, and part of that may quality exhibitions. than was previously the case. The result is be because that, in this day and age, we “There's less and less funds available that even if large surgical specimens are have to get full informed consent. within medical schools and universities to retrieved intact, they may be too damaged “Many people, when faced with the do these types of things,” explains to be worth displaying. prospect of going and asking people 'can Professor Denis Wakefield, head of the The other traditional source for we take the specimen for a pathology Museum of Human Disease and the specimens was autopsies, but museum?' find that rather daunting and School of Medical Sciences at the unfortunately, for many reasons the don't wish to do that.” University of New South Wales. autopsy rate has dropped to almost zero “Often medical schools look around in some hospitals. In the public interest and say 'where can we cut the cost?', “Pathology departments are being and one of the obvious places is to get pushed,” says Professor Paul Monagle, This delicate process of obtaining patient rid of museums.” head of the Department of Pathology at consent is another hurdle for pathology Just as serious is the increasing difficulty the University of Melbourne. museums to overcome. in obtaining tissue specimens. There are a “Autopsies are an awful lot of work, “Probably one of the biggest things number of reasons for their scarcity, but one and unfunded work. There is no Medicare you can do in life is to donate something of the most obvious is simply a change in benefit for an autopsy outside of the of yours,” says Rita Hardiman, curator of accepted medical practice. perinatal period.” the Harry Brookes Allen Museum. > 10_PATHWAY PathWay #11 - Text 21/2/07 3:56 PM Page 11
“There's nothing better than to be able to actually see disease to appreciate how it works.”
Our pathology museums: a selection
INTERACTIVE CENTRE FOR HUMAN DISEASES, UNIVERSITY OF SYDNEY One of the most intriguing items in an Australian pathology museum is an unopened flask of beef broth. The last of 12 such flasks sent to Australia by Louis Pasteur, the broth was intended to culture a chicken cholera virus for the extermination of rabbits.
HARRY BROOKES ALLEN MUSEUM OF ANATOMY AND PATHOLOGY, UNIVERSITY OF MELBOURNE One of the largest repositories of historical specimens in Australia, notable exhibits include injuries suffered in World War I and the death masks of bushrangers Ned Kelly and ‘Mad Dog’ Morgan.
RA RODDA PATHOLOGY MUSEUM, UNIVERSITY OF TASMANIA Many collections reflect the interests of their founders, and this is no exception. Influenced by Roland Arnold Rodda's fascination with brain disease, the museum has a notable selection of specimens such as tumours, stroke and Huntington's disease.
MUSEUM OF HUMAN DISEASE, UNIVERSITY OF NSW As Australia's oldest surviving collection of medical specimens, some of the most intriguing exhibits are those all but eradicated by modern medicine. A perfect example is the museum's brain and bone samples of tuberculosis – specimens now impossible to acquire.
HADLEY PATHOLOGY MUSEUM, UNIVERSITY OF WESTERN AUSTRALIA Another collection distinguished by the interests of a major donor, in this case that of Rolf EJ ten Seldam. His donations stem from his work in countries such as Indonesia and Papua New Guinea; the specimens include many advanced malignancies and examples of rare tropical disease.
PATHOLOGY MUSEUM, UNIVERSITY OF ADELAIDE The museum contains approximately 1300 specimens (some nearly 100 years old) that demonstrate a wide range of common and important diseases. Updated catalogues include clinical information, a description and diagnosis of each specimen.
JAMES VINCENT DUHIG MUSEUM OF PATHOLOGY AND THE MARKS-HIRSCHFELD MUSEUM OF MEDICAL HISTORY, UNIVERSITY OF QUEENSLAND The museum contains about 3500 specimens, covering the full spectrum of common disease. Both museums are currently in the process of relocation, refurbishment and modernisation within the Royal Brisbane Hospital site.
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“Patients take up the opportunity to donate their tissue with great gusto. About 96% of all patients we have contacted have consented.”
The good news is that communities that suffer most from this although doctors may be reluctant trend, perhaps because they have more to broach the subject, patients money available for ancillary testing. are often very keen to become “You cannot do without ancillary tissue donors. testing,” he stresses, “and it's been a Professor Jane Dahlstrom has wonderful advance in the diagnosis of established a Surgical Specimens disease. But I think – and I guess I'm not Teaching Museum at the Australian alone in this, at least among pathologists National University Medical School. – that the pendulum has swung too far in Having decided to concentrate solely favour of relying totally on ancillary on tissue that remains after pathological investigations during life for making a final assessment, she reports an astonishing diagnosis.” rate of success. The chief casualty of this trend is medical “I think the reason is that generally students’ ability to think about disease in people are very giving and see that if the three dimensions. Textbooks and photos tissue is of no use to them but is of use are all very well, but they can’t replace the to somebody else, then that's great,” immediacy of real specimens. she says. “There's nothing better than to be able “Patients take up the opportunity to to actually see disease to appreciate how donate their tissue with great gusto. it works,” Professor Wakefield says. “For E
K About 96% of all patients we have example, if it's a malignancy, how it R A L
C contacted have consented.” spreads, how it causes problems in
N E
R adjacent organs and tissues, and then to
R Professor Robin Cooke, a published A W
relate this to the physical findings that you : expert on pathology museums, also T I D
E find in an individual who happens to suffer
R reports little difficulty in obtaining consent C
O from that disease.”
T for retaining organs for demonstration in O H P teaching museums. Professor Dahlstrom also points out He says recent unfavourable press that this interest in specimens is not
Head of femur showing signs of osteoporosis given to the retention of human tissue and confined to those in the medical and pin to reinforce fracture a shift in the attitudes of medical profession. educators have played a part in the After writing to patients to ask if decline of pathology museums as a they'd be willing to become tissue donors, “It's very important to treat that with teaching tool. a certain number will ring her to ask the utmost respect.” questions. Some simply want to know Consequently, in considering the ethics Seeing is believing what she plans to do with the tissue, but others have a deeper motivation. of displaying human tissue, pathology “In the second half of the twentieth museums err on the side of caution. century the philosophy of the medical “Often when they ring, I know it's Legally, only the donor can veto how teachers has changed,” he contends, because they really would like to see the their body is exhibited, but if their family “placing less and less emphasis on the specimen themselves,” she says. has a strong objection the museum staff use of three-dimensional pathology “Often when something's inside of will do their best to respect their wishes. specimens in teaching medical students you, you can't really visualise what it’s In the same vein, as technology plays a about diseases.” like. Maybe if it's a broken leg you can greater part in how people experience the He notes that this is not a uniquely see that, but if it's, say, a problem with exhibits (for instance, placing Australian problem, with most overseas your gall bladder, all you can do is photographs of specimens online), those museums grappling with similar imagine what it must look like. So patients responsible for the museum need to difficulties. actually come along and see their own consider whether this wider distribution is However, Professor Cooke believes specimens. And when they do, it often ethically appropriate. that it is the advanced Western gives them a bit of closure.”
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This rare opportunity to get a glimpse of what lies under our skin may ultimately prove to be pathology museums' salvation. Professor Wakefield is quick to highlight the public's keen fascination in medicine and pathology, and believes that tapping into this interest can be of E
enormous mutual benefit. K R A L C “There are a number of strategies that N E R
people could put into place,” he explains. R A W
Volunteer Dr Victoria Velens : T “One of them is to make museums I D
at the UNSW Museum of E R
open to the public. Also, turn them into a C Human Disease with manager O
Robert Lansdown. T profitably run business unit, and this can O H be done basically by putting on P exhibitions, putting on education programs. Not just for the medical VOLUNTEERING: profession, but for the general public. That's what we've done and that's been quite successful.” vitally rewarding The result of Professor Wakefield’s t was an advertisement in the paper that attracted Victor Wong Doo's strategy is a true repositioning of the Iattention: the Museum of Human Disease was looking for volunteers to help Museum of Human Disease, moving it run its new community outreach program. beyond the realms of elite academia and “I'm a retired medico, so I thought I could be of some use to the museum,” into the community at large. says Dr Wong Doo. “I thought it'd be something interesting to do.” The museum staff talk enthusiastically Launched in 1996, the outreach program was intended to raise the of queues stretching for hundreds of museum's profile in the wider community, focusing particularly on HSC biology yards at each open day, not to mention students. the thousands of students that visit every As the visitors explore the exhibits, the volunteers stand ready to help out. year as part of their HSC biology studies. “We explain all the ins and outs of the disease process and answer any Most rewarding of all is that there questions they might have,” Dr Wong Doo says. often seems to be a student that is Most of the volunteers are retired, but they come from a variety of changed by what they see. backgrounds. Dr Wong Doo was a radiologist before he retired, and fellow They begin to ask more searching volunteer Dr Victoria Velens was a GP. questions, begin to make connections, Some enjoy the social aspect of being part of the team, while others find it and as they do a career in medicine a good opportunity to enthuse young people about medicine. suddenly becomes tangible, interesting, “I like students,” Dr Velens says. “I like their enquiring minds, and they want something to aspire to. In this way, as to know things in depth which is rather nice.” they walk out the door with heads full of ambitions, these high-school students She also feels that the museum can give the students a unique perspective become the most important thing a on disease. “They have all looked at books, they have all looked at the museum can produce. computer. They're quite surprised when they see it in three dimensions. It doesn't look the same.” Of course the bones of the past are Museum manager Robert Lansdown is delighted with the success of the important, as is the study of disease in outreach program. the present. “It's incredibly satisfying,” he says. “And without the volunteers it just But it’s the doctors of the future that wouldn’t be possible.” are the most precious things of all.
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movers and shakers
Populate or perish TWO DEDICATED PATHOLOGISTS FROM OPPOSITE SIDES OF THE CONTINENT ARE GETTING IMPRESSIVE RESULTS IN THEIR BID TO REVERSE THE PATHOLOGY WORKFORCE SHORTAGE. CATHY SAUNDERS REPORTS.
hen he took on the task of their rates competitive with those offered School of Pathology and Laboratory Wconducting a detailed analysis of the by the private sector. Medicine that will train not only medical pathology workforce in Western Australia, Another drawcard for the profession is but also science students. Dr Peter Flett got something of a shock. some newly established Fellowships – All of these strategies add up, Dr Flett “I realised that within 10 years, 40% of funded by PathWest – enabling says, to a plan to establish a WA Centre of the current pathologists will have either pathologists to spend three or six months Excellence in Pathology which will lure retired or died,” he says. overseas on further training in areas such pathologists from all over the world to Dr Flett was given the challenging task as cancer diagnosis and genetic testing. work with highly skilled colleagues in 18 months ago of merging all the WA state-of-the-art applied research public pathology services into one body laboratories that are being developed for he now heads, called PathWest. Early success each of the sub-specialties. The strategies appear to be working, and This he will take one step further. And already he is making substantial medical graduates are now waiting in the progress in shoring up the workforce loss. wings to take up training places. “You have to not only develop a Centre of Excellence, but become the employer of The number of new registrar places “We did a pretty big sell last year and choice,” he says. increased by three last year, and this will we were over-subscribed in all the sub- jump to 10 extra this year, making a total specialties,” Dr Flett says, pointing out that “That is being able to be flexible with of 40 registrars in training. advertisements for the training places what you can offer prospective employees “The plan is for the next five years to attracted more than double that number of – if female pathologists only want to work continue to expand as much as possible applicants. part time, that is fine by me. And we need to ensure we have adequacy of the As the workforce shortage is to, sooner or later, be prepared to take on pathologists’ workforce for the future,” particularly dire in country areas, part-time training of registrars too.” he says. consideration is also being given to Dr Flett is also prepared to pay now to But more needs to be done, so Dr Flett following the lead of the mining industry ensure he has a workforce in the future has focused on the all-important attraction and offering fly-in, fly-out work. and is in discussions with Curtin University and retention rates. Dr Flett has been doing a lot of talking about initiating cadetships for science He’s doing the hard sell to potential – not only to governments and pathology students in pathology. trainees about the big choice of pathology groups, but also to academics. PathWest will pay their HECS fees for sub-specialties, predictable working hours As a result, the position of professor of four years and in return, once graduated, and the opportunity to be jointly qualified pathology at the University of WA, which they would be expected to work for the as a physician and a pathologist, ensuring had lapsed, is to be re-established and organisation, possibly for three years and clinical skills are not lost. applicants are now being called for. potentially in rural areas. The hip-pocket nerve has also been Moreover, the university has agreed in To keep his current workforce, Dr Flett targeted. This year, WA public pathologists principle to split the School of Surgery and has no hesitation in hassling any will enjoy a pay rise of about 25%, making Pathology and create a stand-alone pathologist he talks to.
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“You have to not only develop a Centre of Excellence, but become the employer of choice.” - Dr Peter Flett H G U O N O D C M
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“The message I say to everybody – all initiatives – which include the strategies to – came from the UK to new horizons in the clinicians – is ‘you can’t retire, you attract, train and retain pathologists – will Australia. have to keep working’,” adding that he is significantly impact on the pathology His clinical work as a breast cancer happy to be very flexible with their work workforce. pathologist for QHPS at the Royal conditions. Brisbane and Women’s Hospital means he “The point about all this is we haven’t has “a foot in each place”. got much time. If we sit on our hands we Meanwhile, back in Qld… The first task was to build up the are going to be caught. The clock is On the other side of the country, University university department. of Queensland pathology professor Sunil ticking on this one. “The academic department was pretty Lakhani is working to ‘hardwire’ the “I think it is up to us in each of the much down to one senior person when I states to be far more vocal than we have relationships between the university’s came,” he says. pathology department, the Queensland been in pathology and take it to the feet of “It had been struggling – as have all Institute of Medical Research (QIMR) and the ministers who matter and make them academic departments around the world – the statewide Queensland Health realise that if they don’t do something, chiefly due to an inability to recruit staff. they won’t have a pathology service in 10 Pathology Service (QHPS), which are This is due to a shortage of trained years time.” independent but which he believes can academics with a strong research help each other on various levels. WA Minister for Health Jim McGinty background and the huge differential in says the WA Government sees the Professor Lakhani arrived in Brisbane income, which has fallen way behind provision of pathology services as a in late 2004 to head the university’s compared to that of clinical pathologists. priority and is confident that the academic department. He and his “Until the government addresses these government-funded health reform research group – now based at the QIMR issues, it will continue to be so.” > PATHWAY_15 PathWay #11 - Text 21/2/07 3:56 PM Page 16 N I G G A S
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Talks are underway with the Queensland state government to improve academic pay rates, but at present the problems of recruitment continue. Nevertheless, Professor Lakhani is pushing on in rebuilding the department. A French pathologist has been appointed senior lecturer, an associate professor who is a non-clinical researcher Professor Lakhani has also established and these are for newly funded specialist heads a laboratory, and there is funding for a link with a medical education unit in the positions. Negotiations to fill the only another senior lecturer or associate School of Medicine so that new clinical professor who is yet to be appointed. regional position are underway. registrars who participate in teaching Recently, Professor Lakhani gained Moreover, according to a spokesman medical students learn strategies for extra funding from the university for an for QHPS, two new registrar training teaching and assessing the students. academic pathology registrar who is positions were approved from last July “This will not only provide valuable teaching and conducting research in the and eight were approved from January. All skills to registrars, but will further enhance university department as well as doing but one have been filled. Six positions had the links between clinical and academic hospital clinical work. also previously been approved in 2005. work,” he says. “This position forms part of the For the first time, three of the positions [pathology] training rotations through the A further line of attack has been made are for general pathologists who, it is possible by his role of running a research hospitals and the university, in order to hoped, will end up working in regional laboratory at the QIMR, which is located further the links between academic and centres, which are always harder to staff. clinical departments and to encourage on the same campus as the medical The QHPS has chalked up further other trainees who are in the full-time school and the Royal Brisbane and success. All but one of last year’s diagnostic training to rotate into the Women’s Hospital. graduates have opted to stay in the public academic department,” he says. “Having a research laboratory on the system, lured largely by a new package of campus means we can get registrars and Each year, a new registrar will be improved conditions introduced in January offered this position. other interested colleagues to come and last year, which include a 7% pay rise and have a look at how it is possible to do “This means that we will slowly expose higher on-call and private practice good clinical work and bring questions the whole pool of registrars to academic allowance rates. into the research laboratory, in the hope activities in the hope that we can that answers can be translated into clinical Professor Lakhani says he is getting demonstrate the role of academic work to management of patients,” he says. good feedback from registrars who are our trainees and also rebuild the academic slowly being exposed to the rewards of infrastructure in Queensland.” “What I am trying to do is to hardwire relationships between these three teaching and research in pathology. Another academic registrar, funded by organisations – teaching, research and the Ludwig Institute for Cancer Research, “What is needed are good role models, has been lured from Brazil on a Fellowship clinical work.” people who are good diagnostic to do his PhD in Professor Lakhani’s While building up academia, Professor pathologists and also good researchers,” research laboratory. Lakhani has also been working as a he says. It is hoped that his lifestyle of clinical specialist breast pathologist with QHPS, “When they see how research affects activity, research, writing papers and where similar expansion and recruitment diagnostic practice and clinical presenting at international conferences will has also happened. management, they are able to grasp the help to change the ethos and be a role There are only a couple of vacancies central role that pathology plays in science model for local registrars. for pathologists in the metropolitan area, and medicine.”
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in profile
A magnificent obsession
TIRELESS ENERGY, DEDICATION TO DETAIL AND AN ABILITY TO JUGGLE A HERCULEAN WORKLOAD HAVE CATAPULTED PROFESSOR DAVID WEEDON TO THE HEIGHT OF HIS PROFESSION. MELISSA SWEET LOOKS AT WHAT LIES BENEATH.
risbane pathologist Professor David BWeedon is famous for many things, including his internationally acclaimed expertise in skin pathology, workaholism and dry sense of humour. His obsessiveness is also legendary; indeed he is almost obsessive about acknowledging this trait, and has the evidence ready for display when we meet in his office at Sullivan Nicolaides Pathology in the leafy Brisbane suburb of Taringa. First exhibit is his bare desk. It is always left spotless, he declares proudly. Years ago, after finishing a stint at the celebrated Mayo Clinic in the United States, he was presented with a miniature dissection board “because I was known for being so obsessive about it always being kept clean”. N I G G
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“I don’t mind being known as When asked if his glass collection deprecating humour could easily obscure obsessive,” he says. “Obsessiveness goes includes vases, he responds drily: “You his achievements. with being a pathologist – one has to be.” don’t ever use the word ‘vase’. It’s ‘tall As one associate notes, he manages a It is a Monday morning but Professor forms’. I have a few tall forms. I try to avoid workload that would normally exhaust tall forms because too many of them look Weedon has already completed a full shift three people – hence the ‘Superman’ cake like vases.” – as usual, he started work the previous colleagues once bought to celebrate his evening, finishing his last pathology report birthday. by 6am. He works through the night so the A life less ordinary But computers are one domain days can be devoted to other projects, Professor Weedon has not mastered – his Last Christmas, Professor Weedon loyal secretary of 20 years, Pam Kent, runs whether teaching, writing or chairing received a copy of an autobiography, his email program – so he may not realise committees – and it also means a speedy Morbid: A Pathologist’s Life, from Dr the multitude of glowing reviews revealed response for referring doctors and their Alastair Burry, who was Director of by a Google search for the second edition patients. Pathology when the young Weedon was of his landmark text, Skin Pathology. Most days he grabs no more than four training at Royal Brisbane Hospital in the hours sleep, and it is not unusual for 24 1960s. It is inscribed: “To my best pupil. “The author, who is a well hours to pass without a snooze. Didn’t he do well!” acknowledged, world known expert in this field has to be commended for having “I do feel tired all the time,” he says, Dr Burry writes in the book of the painstakingly undertaken this gigantic task trainee setting a standard that “his fellows admitting a tendency towards irritability. of not only updating his previous edition struggled to emulate”. “I am sure it affects my health.” but who seems to have given his ‘all’ to Professor Weedon has, however, been “His witty and novel paper on acne produce this masterpiece,” says one known to nod off while queuing through convulsed the audience with laughter and review. was followed by loud stamping of the night to purchase newly released The third edition, now in development, approval,” he adds. banknotes. An avid collector, he has sold will be even more extensive, citing at least most of his coin and banknote collections Asked why he chose to specialise in 30,000 references, while Professor but continues to amass glassworks, pathology, Professor Weedon is quick to Weedon’s book on the pathology of the paintings and watches. reply: “Because I hate people.” gall bladder is also much cited. He stopped stockpiling elephants This is only partly a joke – he then Other career highlights include taking admits to finding clinical medicine because “people start giving you cheap the first photograph of apoptosis in a skin “demanding emotionally” – but it suggests ones for Christmas so you are burdened cell in 1978, and becoming one of a that Professor Weedon’s dry, self- by variants you don’t want”. handful of non-Americans to be made an honorary member of the College of American Pathologists, as well as a regular CV in brief on the international lecture circuit. A vision splendid
PROFESSOR DAVID DE VAUX WEEDON, AO Apart from his many medical (OFFICER OF THE ORDER OF AUSTRALIA) commitments, Professor Weedon has also been politically active. He was prominent in 1964 BMedSc (Pathology) student politics at the University of Queensland and later joined the Liberal 1966 MBBS (First-class Honours) Party (which once considered him for a Senate vacancy), until resigning his 1983–1984 President, Queensland branch, Australian Medical membership in 1983, when he became Association Queensland president of the AMA. 1995–1996 President, Australian Medical Association He remains close to a former AMA colleague, Federal Minister for Defence Dr 1996– Member, Professional Standards Review Panel Brendan Nelson, who last year appointed him to chair a national inquiry into medical 1998–2001 Chair, Medicare Services Advisory Committee education. But Professor Weedon is not easy to 2001–2003 President, Royal College of Pathologists of Australasia pigeonhole politically. 2004– Chair, Prostheses and Devices Committee He hated being federal president of the AMA, largely because of the intrusive 2005– Chair, Steering Committee for the Medical Education Study media demands. “I am not particularly good at thinking 2006 Bond University Student Council Award for Academic on my feet,” he says. “I think of all the right Excellence things (to say) after the event.”
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Making a difference: In his uni days Professor Weedon was active in student politics, later joining the Liberal Party before heading the AMA.
He has been a greenie since “before it “The last major holiday was to write the Professor Weedon is known for being was fashionable”, and believes it may be last edition of the [Skin Pathology] book,” generous with both his time – including difficult for the Howard Government to win he says. “I can’t recall ever having more tutoring individual students – and his purse. the next election because of its slowness than one week’s holiday of relaxation.” Many have benefited from his largesse. to embrace environmental issues. Ms Kent, who has worked for him for “I think the future is absolutely dismal,” Just your regular superguy almost 20 years, says he is liked and he says. “This generation has used millions respected by staff because of his On Friday mornings, after another night’s of years worth of the earth’s basic biologic willingness to help and his lack of products. The current generation, from work, Professor Weedon grabs a grandstanding. about 1950 on, has just been profligate.” McDonald’s hamburger for breakfast. He “The side that impresses staff the most Professor Weedon also feels eats it, tea towel across lap, while driving is that he will get in and do the most passionately about the “immorality” of to Bond University at the Gold Coast. menial of tasks,” she says. banks allowing customers to accrue huge There he gives lectures, tutorials or works credit-card debts, the limitations of on the pathology museum, named in his “When we had a flood and water problem-based learning in medical honour, that he has set up. coming inside the building, the first person out there in the rain, clearing the drain with schools, and the need for national Last year, he won the Bond University his hands, was Dr Weedon.” healthcare reform. Student Council Award for Academic “I am a very strong believer that the Excellence and, according to Professor Professor Weedon once bought a states exist to name football teams only,” Chris Del Mar, Dean of the Faculty of hamburger shop on the Gold Coast to help he says. “The states promote non- Health Sciences and Medicine, is set up a friend; when the arrangement cohesiveness in a nation.” extremely popular with students, not least didn’t work out, he was known to lend a In an ideal world, he says, Australia because he pays for their colour hand in the kitchen after finishing his would be divided into 10 different regions photocopies of his handouts to ensure they pathology shift. responsible for healthcare delivery, with have the best possible materials. It’s a safe bet that he also took the local representation on regional boards Professor Weedon’s work at Bond opportunity to indulge his sweet tooth – he working to national policies. University is honorary. is not remotely health conscious, despite Not that he expects such changes in having type 2 diabetes (“like the rest of the “I don’t take any money so they can’t his lifetime. At 65, Professor Weedon is world”) and having had open heart surgery. control me,” he says, in what seems obliged to retire as a Sullivan Nicolaides Professor Weedon feigns horror when partner at the end of June, but no-one another half-joke. But it doesn’t obscure asked if he exercises. expects him to retire from his many other another of his well-known traits. careers – pathologist, writer, teacher, “The most defining characteristic of “Heavens no,” comes the quick reply, “I committee chair – anytime soon. David is his enormous generosity,” says a run down people and leap to conclusions.” No-one, least of all the man himself, Sullivan Nicolaides colleague, Dr Richard No wonder so many colleagues can even imagine him taking a long Williamson, who was taught by Professor call it a pleasure to work with someone holiday. He recently cashed out 13 weeks Weedon at the University of Queensland in they affectionately tease as a “grumpy of vacation leave. the 1980s. old man”.
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the GP view
Reality check
MAYBE TODAY’S YOUNG DOCTORS COULD TEACH THE REST OF THE PROFESSION A THING OR TWO, WRITES DR LINDA CALABRESI.
ou know you’re getting old when you from teaching or working for a division, to Yfind yourself whingeing about the research or assisting in surgery. ‘youth of today’. Others pursue interests outside That’s exactly what I was in the throes medicine. Some simply opt to reduce their of doing at a recent lunch with similarly consultation hours and work part time. aged friends. But generally speaking it appears We were united in our bemoaning of variety is the goal, rather than seeking an how Generation Y has, almost by alternative career or better remuneration. definition, a strong sense of entitlement, It’s that variety that appears to create despite having yet to prove their worth or a better work–life balance. And perhaps demonstrate their commitment to a job or our more mature new breed of doctors a profession. already know that. From the perspective of the medical By the time medical students world I quoted examples of young doctors complete the prerequisite university time, who weren’t interested in working long hospital time and GP training course, they hours or doing after hours, who appeared are more likely to be in their 30s (rather to put their commitment to their family Dr Calabresi is a practising GP and Editor of Medical Observer than their mid 20s, as was the case a few before ensuring their patients were decades ago). medically looked after around the clock. Ten years more life experience must We were certainly on a roll… make a difference to a person’s priorities, On reflection, however, I believe the especially when those 10 years may have reality is – as always – not so black No matter how rewarding general included finding a life partner and maybe and white. practice can be, seeing large numbers of starting a family. patients all day, every day, five or six days Recent statistics from an Australian They will be entering general practice a week, is emotionally exhausting for Institute of Health and Welfare report on at a point at which those of us who most people. the medical labour force showed the started younger didn’t arrive until much number of full-time equivalent GPs fell Trying to meet each patient’s later, after many years working in the from 102 per 100,000 people in 2000 to expectations, be attentive to their profession. 98 in 2004. complaints and vigilant for any hidden If we admire the maturity and pathology or any opportunity for This is despite an increase in the experience in the newest members of our preventive care is challenging. Especially actual number of GPs, and directly relates profession then, to a certain extent, we when the process needs to be repeated to GPs choosing to work fewer hours. have to expect that those qualities will and recorded with the same enthusiasm Attributing this trend solely to young and attention to detail every 15 minutes also be employed when they are looking doctors preferring to work part time would over 30 times a day. at their work schedules and entitlements. be simplistic at best, and unlikely to be It’s those qualities that will have borne out on further analysis, just as I know there are GPs out there who do them seeking variety in their work from laying the blame on that other common this, many of whom have been doing it for the outset, and making work–life balance lament – the feminisation of the workforce years. They genuinely have my unqualified a priority. – has been shown not to be the single respect and admiration. culprit in the trend toward fewer However, for the majority of GPs I Whether this is better or worse, who consulting hours. have met over the years, such a schedule can say? It would seem this trend is more a would be considered too gruelling and a But the statistics support the premise reflection on society as a whole. ‘Work–life recipe for burnout at the very least. that the ‘youth of today’, at least in balance’ is the new catch-cry. And By necessity, luck or design, the medicine, have the same ideals as the considering the nature of the work, it is majority of GPs I know vary their working rest of us. not surprising this phenomenon has week by including elements other than So maybe I need a new topic of lunch become evident in general practice. face-to-face consultations. These range conversation.
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hot topics TestingTesting timestimes R E H G A L L A G
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The Pap smear process of course “Secondly, the vaccine only protects WHAT WILL THE NEW HPV involves the role of scientists working as against 70% of the strains that cause VACCINE MEAN FOR THE cytology screeners, as well as cervical cancer, so even in a vaccinated cytopathologists trained in anatomical population, screening will still be needed.” pathology. FUTURE OF CYTOLOGY? But while the workload will remain When a sample is taken from the constant – the same number of Pap KATE WOODS REPORTS. cervix and placed on a slide, the cells smears will still cross the desk – Professor here is no denying it. are viewed by cytology screeners, who Frazer says that the chances a smear will The advent of the prophylactic human detect any abnormalities and refer them T be abnormal will be significantly reduced. papillomavirus (HPV) vaccine has been on to the cytopathologist for review and a final diagnosis. In fact, he predicts that over the next one of the most exciting recent 8–10 years there will be a 75% drop in the developments in medicine. An existing shortage of cytopathologists however, could be number of abnormal smears, and 50% of It promises to prevent more than 90% compounded in this new landscape, these will be high-grade abnormalities. of genital warts, eliminate at least 70% of according to one of the vaccine’s As a consequence, the National cervical cancers and save the lives of up developers Professor Ian Frazer. Pathology Accreditation Advisory to 300 Australian women each year. A weakening of expertise among Council’s performance measures – which And with the vaccine now part of the established cytopathologists and cytology outline the number of abnormalities screeners and the potential for laboratory National Immunisation Program Schedule laboratories and pathologists are required performance measures to become and therefore more affordable for a to see over a set period of time – will outdated once the vaccine’s impact starts significant number of women, these need to be revised, he says. to be felt, are other hurdles to be cleared, predictions could become reality before he says. Dr Marion Saville, director of the too long. Victorian Cytology Service, agrees. She But while there are undoubted Same work, just says full-time screeners currently see national advantages to an HPV vaccine, different about 200 Pap tests each week, of which it’s not all good news for cytology. If the one is generally a high-grade abnormality. “The vaccine won’t alter the screening mood among cytopathologists is a little But if the prevalence of high-grade program for cervical cancer because abnormalities falls by 50%, she says this more reserved, it’s because this latest firstly, most of the people vaccinated will figure would drop to one a fortnight. development has thrown up some tricky be young women and the screening issues regarding the future of their program is aimed at women aged over 20 “There will also be a reduction in the discipline. years,” Professor Frazer says. positive predictive value of these high- > PATHWAY_21 PathWay #11 - Text 21/2/07 3:56 PM Page 22
Dr Gabriele Medley: “There are many pieces that need to be fitted into this complex jigsaw.” R E H G A L L A G
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grade reports purely on the basis of and a member of the RCPA Cytopathology around the country performing reduced prevalence,” she adds. Advisory Committee, says whether the gynaecological cytopathology. Dr Gabriele Medley, head of standards need to be revised will depend “If we end up having fewer cytopathology at Melbourne Pathology on whether there are eventually fewer labs laboratories doing more smears because of the cost of the machines and the shortage of cytopathologists and cytoscreeners, the current [NPAAC Prophylactic vaccines: measures] would be fine,” she says. “But if the current laboratory structure a profile is to persist then yes, they may need to be revised.” p to three-quarters of all sexually active people acquire the human Dr Saville warns a drop in papillomavirus (HPV) at least once during their life, making it the most common U abnormalities could lead to further sexually transmitted viral infection in the world. workforce shortages, with lecturers But with two HPV prophylactic vaccines – one already approved for use, the already seeing some reluctance from other on its way – experts are hoping this could soon change. science students to choose cytology as a The first vaccine, Gardasil, is a quadrivalent vaccine made up of highly purified major area of study. ‘virus-like’ particles based on the recombinant capsid protein L1. These particles “Informally we believe this is due to the induce a strong humoral immune response to protect people against HPV types 16 publicity about the vaccine and students’ and 18 – which cause 70% of cervical cancers – and types 6 and 11, which account belief that this skill will not be relevant for for about 90% of genital warts. the entirety of their working lives.” While the vaccine has been shown to be almost 100% effective, duration of protection beyond five years is still unknown. As a result, it’s possible we could see a decline in the capacity to report Pap The second is a bivalent vaccine known as Cervarix. It has not yet been tests before there is a decline in demand. approved for use but manufacturer GlaxoSmithKline says it is hoping for some positive news soon. To further complicate matters, anatomical pathologist Dr Nick Mulvany While the two vaccines work in a similar manner, Cervarix’s L1 capsid protein was produced using a recombinant baculovirus propagated in insect cells, while believes it will become increasingly Gardasil’s was produced using transgenic yeast. difficult for established anatomical pathologists to maintain their expertise in Cervarix targets HPV types 16 and 18, but may also protect against HPV types cytopathology over the coming years. 31 and 45, which are responsible for up to 10% of all cervical cancers. If approved, GSK is hoping it will be indicated for women aged 10–55 years. “People need to see a certain volume A number of therapeutic vaccines have also been developed, but most are still of material to become and stay good at undergoing early-phase trials. diagnosing abnormalities. With fewer abnormal cases coming through, I strongly
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suspect it will become more difficult for be financial 'trade-offs' because these cytologists to pick them up.” Dr Nick Mulvany: additions won’t be cheap. maintaining expertise. Then there is the issue of training. “It may well be that we will need to “This is a highly subjective field – it’s have a two-tiered screening system where more subjective than histology and those who have been vaccinated are certainly more difficult and more subtle screened every five years and those who in its interpretations,” says Dr Mulvany, haven't are screened every three years,” senior anatomical specialist pathologist Dr Medley suggests. at the Austin and Mercy Hospital in “There are many pieces that need to Melbourne. be fitted into this complex jigsaw, and I “Trying to get consistency from one cannot stress too strongly the importance institution to another is and will become of dealing with the Cervical Cancer an increasing problem.” Screening Program as a whole, and not in a piecemeal way.” Technological boost In contrast, Dr Saville believes it will
Dr Mulvany suggests the solution may be far too complex to introduce two be to introduce liquid-based cytology different screening programs. and automated screening. Instead, she suggests it may be R ThinPrep and SurePath are the two E worthwhile moving the age at which all H G A
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D screening tool and cytology as a follow-up tests are easier and quicker to examine E R C for those who are HPV positive. O
because they produce slides containing T O H
cells that are evenly distributed in a P This method is currently being trialled concentrated area, without obscuring overseas. “The main drawback of this agents such as blood and mucus. strategy in the current environment is that looks for evidence of the viruses that at 25 years of age about 20% of women A computer-assisted primary cause the abnormal changes. can be expected to test positive for screening system has also been produced The federal government’s Medical high-risk HPV. for use in association with the tests. Services Advisory Committee is expected Currently being trialled in a number of to review a proposal to fund liquid-based “However, if almost all women had Australian laboratories, this system cytology in combination with DNA testing been vaccinated, then the proportion of locates and displays potential abnormal later this year. women testing positive to high-risk HPV cells for cytologists to view. could be expected to dramatically decline. Dr Paul Shield, chief scientist at Vaccine not the whole This will improve the specificity of HPV as Sullivan Nicolaides Pathology, says answer a primary screening test.” preliminary trial results suggest the Whatever happens though, with a While it’s still uncertain whether these automated device provides at least an number of new technologies available at a tests will become standard practice, Dr equivalent level of sensitivity to manual time when vaccination is also to be Medley says the assumption that cervical screening, but higher productivity. introduced, all decisions must be cancer – and therefore cervical screening evidence-based, Dr Saville argues. If it does prove successful, it could – will disappear with the vaccine is a very help reduce the problems associated with simplistic view of the situation. “We should be anticipating the maintaining expertise and staff shortages. The vaccine's duration of protection evidence that would be needed to support “This would be a good way to use the remains uncertain, and the community change and be proactive about trying to technology – use the machines to do the has not yet fully accepted the need to get the evidence if it is not already searching and the trained scientists or immunise all children, she says. available.” pathologists to do the interpretation.” Also, many unvaccinated women Dr Medley agrees all changes and Dr Medley says liquid-based cytology remain at risk of developing cervical introductions need to be evidence based, has the added advantage of being able to cancer. but says good evidence favouring the new be used for high-risk (HR) HPV DNA testing. However, if we do move to a system in technology is available. Unlike the Pap smear (designed to which cells are assessed using HR HPV “So far, the reason it has not been pick up abnormal cell changes in a DNA testing and are then prescreened by taken up is because of the costs, not woman’s cervix), HR HPV DNA testing automated technology, there will need to evidence.”
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inview
24_PATHWAY PathWay #11 - Text 21/2/07 3:57 PM Page 25
Coloured scanning electron micrograph of melanoma cells, the most serious of human skin cancers.
Melanoma is a tumour of melanocyte cells that produce the melanin pigment in skin.
Here, large rapidly dividing (malignant) cancer cells are seen with tiny projections which enable the cells to be motile and to spread.
Melanoma is able to spread from the skin through the blood, lymph, or across a body cavity to other parts of the body.
This cancer is most common in people exposed to strong sunlight for a number of years.
PHOTO CREDIT: NATIONAL CANCER INSTITUTE / SCIENCE PHOTO LIBRARY
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spotlight on disease
Clearing the way
ADVANCES IN OUR UNDERSTANDING OF CYSTIC FIBROSIS HAVE SEEN GREAT LEAPS IN OUTCOMES FOR PATIENTS, BUT A CURE REMAINS ELUSIVE. MATT JOHNSON REPORTS.
mbedded in the walls of nearly every conditions. Indeed, life expectancy has The protein was eventually identified Ecell in your body are small pumps. more than doubled in the past 40 years to and named the cystic fibrosis Made of protein, they are constantly a median age of 37. transmembrane conductance regulator working to maintain the delicate But there is still no cure. While one (CFTR). It’s found in membranes of cells chemical balance required for cells to school of research has discovered how a that line the lungs, liver, pancreas and function normally. faulty protein causes the disease and reproductive tract. Depending on the protein and cell tested a number of potential cures, the In patients with CF, the dysfunctional they inhabit, they can permit, assist or improvements in morbidity and mortality (or absent) CFTR protein causes the lungs reject the passage of sodium, chloride, have come from another camp of to produce a thick, extremely viscous potassium and a host of other researchers, which has been working to mucus. Unable to clear this mucus, the electrolytes. identify the disease as early as possible, CF lung is susceptible to chronic infection with pathogens such as Staphylococcus Suffer a mutation of the gene that isolate the pathogens that accelerate its aureus and Pseudomonas aeruginosa that instructs these pumps and, for the sake of progression, and develop better nutrition are nearly impossible to eradicate once a few electrolytes, your lungs can become and physical therapy. The latter group has established. Inflammation from the congested and inflamed, your pancreas will improved the length and quality of life of dysfunctional CFTR and chronic infections struggle to provide the enzymes necessary people with CF, but with the knowledge create a cycle of tissue destruction and to digest your meals, your liver can fail, their patients will ultimately succumb to and your life expectancy plummets. the disease. airway obstruction that, over a long period of exacerbations and partial recovery, Cystic fibrosis (CF) occupies an eventually leads to respiratory failure. uncomfortable place in modern medicine. The genetic component The genetic cause of the disease was In the pancreas, the large quantities of established as early as 1949, when The CF gene lies on the long arm of thick, viscous mucus block the flow of researchers investigating the disease’s chromosome 7 and produces a protein digestive enzymes through the ducts, pattern of inheritance suggested it was that determines a cell’s ability to move food cannot be properly absorbed and produced by a single defective gene. It chloride and other ions across the cell weight gain is limited. Eventually the took another 35 years to localise that membrane. Early attempts to identify this blockages can cause cysts and scar gene, and during that time sufferers would protein found high levels of salt in the tissue to develop that ultimately may rarely reach adolescence before their sweat of CF patients, whose glands, it was cause diabetes. lungs failed. discovered, are impermeable to chloride. Mucus can also block the bile ducts, With knowledge comes hope, Subsequent studies of epithelial cells and 98% of men with CF are infertile however, and identification of the gene from the airways of these patients also because of blocked seminal vesicles. sequence in 1989 offered the possibility of provided evidence of a chloride The discovery of elevated serum levels of curing one of medicine’s more cruel permeability defect in the lungs. immunoreactive trypsinogen (IRT) in
26_PATHWAY PathWay #11 - Text 21/2/07 3:57 PM Page 27 T H G I R W
L U A P
: T I D E R C
O T O H P
“The expectations for patients with CF are so much better today, and probably the main reason is because we have much more coordinated care.” - Professor Peter van Asperen
infants with CF resulted in the first Screening struggle there is a benefit in early diagnosis of CF: community-wide newborn screening there’s a lot of data that children Professor Bridget Wilcken is the Clinical programs for the condition in NSW in diagnosed at birth don’t get as sick early Director of NSW Biochemical Genetics and 1981. Since then, all Australian states in life, they spend less time in hospital, Newborn Screening at The Children’s have introduced newborn screening. they get better nutrition earlier and there Hospital at Westmead in Sydney and an are fewer childhood deaths. The initial screening programs Honorary Fellow of the RCPA. “There have also been some studies conducted an IRT test on day four, with a “Different parts of the world have linking late diagnosis to poor nutrition and second test at six to eight weeks for responded differently to newborn subsequent poor intellectual infants who returned a positive result on screening, with some more enthusiastic development,” she adds. the first test. A second positive result than others,” she says. “You get improved lung function with would prompt a sweat test, in which the “In some places it’s been a struggle.” early diagnosis – and while it’s a big amount of sodium in the child’s sweat Here, she is referring to an ad hoc shock for most parents, you have to was analysed. committee of North American remember the alternative is a prolonged The discovery of the gene responsible paediatricians who suggested that the period of various illnesses while they for CF added genetic analysis to the testing wouldn’t be sensitive enough to search for a diagnosis.” screening program, and all states in pick up pancreatic insufficiency and that While genetic analysis has made Australia now use a combined IRT/DNA- identification would stigmatise the child testing for CF more accurate, the nature based screening regime. An IRT is now and interrupt mother/child bonding. of the mutation means not every newborn performed between 48 and 72 hours after Professor Wilcken struggles to with the disease is identified. birth, and infants with an elevated IRT understand this continued reluctance. “The common deltaF508 mutation have a CFTR gene mutation analysis “The test has proved both accurate represents 75% of all mutations,” performed from the same blood sample. and sensitive, and it’s now quite clear Professor Wilcken explains, “and as > PATHWAY_27 PathWay #11 - Text 21/2/07 3:57 PM Page 28
Identification of the gene sequence in 1989 offered the possibility of curing one of medicine’s more cruel conditions. Indeed, life expectancy has more than doubled in the past 40 years to a median age of 37.
94–95% of babies who have CF will have subsequent pregnancies, with studies Department of Respiratory Medicine at at least one copy of this mutation, we only showing about two-thirds of parents The Children's Hospital at Westmead. test for that common mutation in NSW.” would alter their reproductive activity if “The expectations for patients with CF Funding at present doesn’t allow they were aware of their genetic status. are so much better today, and probably Professor Wilcken’s service to routinely the main reason is because we have test for the other mutations, a process Ensuring access much more coordinated care,” he says. that would require an extra $34,000 a year “Sure, we don’t have a cure, but to identify just one extra case. “It’s not an aim of newborn screening to we’re developing better treatments and identify carriers but can be useful for “But mutation testing will become we’re delivering those treatments much parents, and we need to ensure they have easier as technology develops, and if we more effectively.” were able to test for six or seven access to the counselling they need,” The thick mucus produced in the mutations we could cover half the babies Professor Wilcken says. lungs of CF sufferers obstructs airflow, but we don’t find at the moment. We’re And while the move towards prenatal also allows viruses and bacteria to constantly considering it and it will be testing is probably unavoidable, it colonise the lungs. These infective included eventually.” shouldn’t be at the cost of newborn exacerbations and the inflammation they While the genetic component of the test screening, she argues. cause accelerate the respiratory failure. has added a degree of certainty to the Despite advances in screening, But they also offer a potential avenue for diagnosis, it has also raised issues for children with CF will still be born and, until therapeutic control. parents. Part of Professor Wilcken’s a cure is discovered, their quality and “While there was a lot of expectation program directs parents to genetic counselling.This includes parents of length of life will depend on treatment of when the gene was discovered, there children with the disease, as well as those the disease. unfortunately hasn’t been a lot of progress who are carriers. Once identified, many of these – and until there’s a cure, treatment is really aimed at slowing the progression of Counselling includes advice on children will find themselves patients of the disease,” Professor van Asperen says. prenatal testing for parents prior to Professor Peter van Asperen, head of the “The principles are basically: mobilise the thick secretions and reduce the infections. The most recent area to emerge is using new therapies to treat the CF: incidence and inheritance inflammation.” Oral steroids have been shown to improve CF is one of the most common life-threatening autosomal outcomes in CF, but they also carry recessive conditions affecting Caucasians. The incidence is significant side effects. The search for 1/2500 to 1/90,000, depending on the population. It is uncommon better anti-inflammatory drugs has in Asians and Africans. recently uncovered azithromycin: an Individuals who become symptomatic will have two copies of a antibiotic that also appears to have anti- mutated CFTR gene, one from each parent. inflammatory properties. Carriers will have one normal and one mutated CFTR gene and “The control trials have been good in their health will not be affected. However, carriers have the patients with advancing lung disease, potential to pass on the gene to their offspring. Brothers and but there are also promising results sisters of affected individuals are at increased risk (one in four) coming from trials in patients with early of having CF because both parents will be carriers. lung disease.” If two carriers of the mutated CFTR gene have children, there is a: The other area of focus is the removal of secretions and there are several • one in four chance their baby will have CF therapies Professor van Asperen says can be effective. • one in four chance their baby will not have CF or carry a “Inhaled hypertonic saline softens the CFTR mutated gene mucus and makes it easier to clear and, • two in four chance the baby will not have CF, but will carry given with a bronchodilator, it’s an one CFTR mutated gene. inexpensive, safe and effective therapy. We’re currently also assessing mannitol to see if it has a similar effect.”
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Perhaps the most significant recent breakthrough occurred when researchers at the University of Queensland (UQ) discovered that common bacterial pathogens in CF, Pseudomonas aeruginosa, glued themselves together with a ‘biofilm’ to protect themselves from antibiotics. T
Until then, experts had thought a sugar H G I R W
called alginate thickened the secretions, L U A
but when UQ researchers analysed the P
: T I D
substance they found far more DNA than E R C
alginate. This has led to the development O T O
of a new type of drug that breaks down H P the DNA in the film, reducing the tenacity of the mucus and allowing antibiotics to attack the pathogen. “There’s a lot of data that children diagnosed at birth don’t get as Controlling the colonisation of P. aeruginosa is a major focus for Professor sick early in life, they spend less time in hospital, they get better van Asperen as studies show that eradicating early infections dramatically nutrition earlier and there are fewer childhood deaths.” slows the disease. - Professor Bridget Wilcken “We’re trying to learn more about the organism, more about its colonisation, about the possibility of vaccination – but we’re also taking a very different approach patients with end-stage disease to a genetically modified viruses, others have to infection control,” he says. lung transplant. used lipid capsules, and others are trying Within his hospital, CF patients with “Outcomes from transplants are to get naked DNA into the cells. Pseudomonas (and other common improving all the time and they are now a “They all have their positives and infections) are segregated from those who serious option for end-stage patients. negatives, but the major issue is the remain unexposed to the organism. Until we find a cure, they are our only consistency and efficiency of the delivery.” “The practicality varies with different opportunity to improve the eventual Far from being despondent, Professor hospitals, but we’ve set up age-based outcome of the disease.” Christodoulou (who recently became an clinics where preschool-age patients start RCPA fellow) is confident the techniques and remain until they are colonised with Towards a cure will eventually be found, and until then, Pseudomonas. We then have school-age learning more about the hundreds of gene and adolescent clinics, where the majority Nearby, clinical geneticist and genetic mutations that contribute to CF will allow of patients have Pseudomonas.” pathologist Professor John Christodoulou, researchers to provide a more accurate Another change has been to develop Director of the Western Sydney Genetics prognosis and effectively treat the disease. chest physiotherapies and breathing Program, will not put a time frame on a “Since we’ve discovered the mutation techniques to assist lung function that can cure, but he is confident it will one day we’ve identified a much wider spectrum of be performed by the patient without emerge. CF, and we now find patients with milder needing to visit a clinic. “Understanding of the genetic basis of forms of the disease, like men presenting “It not only allows patients to be more CF has improved our understanding of the at infertility clinics. It’s these people that independent, but it leads to later disease and how other treatments could may give us a better understanding of colonisation.” be effective, but despite a lot of work and how to treat – and then ultimately, cure – And when the treatments are no hype, gene therapy is struggling to the disease.” longer effective, Professor van Asperen provide a cure,” he notes. now has the option of using bi-level “The problem for gene therapy is positive airway pressure and continuous GPs NOTE: This article is available for positive airway pressure – devices to delivering the corrected gene to the target patients at http://pathway.rcpa.edu.au assist with breathing - that can bridge tissue. Some researchers have tried using
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foreign correspondence
Mission, possible Y E V A D
D R A H C I R
R D
: T I D E R C
O T O H P
A LOCUM POSTING IN PAPUA NEW GUINEA HAS SEEN CHEMICAL PATHOLOGIST DR RICHARD DAVEY TACKLE EVERYTHING FROM OTITIS MEDIA TO THE THREAT OF BIRD FLU. KIM COTTON REPORTS.:
n the surface, Dr Richard Davey’s Dr Davey is the medical counsellor at Organization in the Indonesian province of Opractice appears to be as typical as the Australian High Commission in Papua West Irian Jaya (West Papua), and it is only that of any other physician. New Guinea (PNG). a matter of time before it presents in PNG. “Every other week there is someone His 400 patients comprise the “Avian influenza is a matter I had with a middle-ear infection. There are kids Australian diplomatic, AusAID, Australian always bursting, busting, breaking or Federal Police and Australian Defence thought a little about before coming here slicing open themselves and have to be Force community employed by the and rapidly had to research more sown back up,” he says. Australian government to work at the intensively, and now keep a very close But it soon becomes apparent that Dr mission, along with their families. handle on,” Dr Davey says. Davey’s workday presents challenges not Aside from tending to bladder faced by most doctors practising from the infections, the odd pulmonary embolism “The border between West Papua and relative comfort of Australia. and “a lot of respiratory-related infections PNG is just a line on a map and the birds The looming threat of avian flu, for one. because the air in the dry season gets and the virus are not going to respect the absolutely foul”, the Melbourne-born “Our clinic male and female external line. Once the thing turns to human-to- toilets you can hardly get into because of chemical pathologist also advises the Head human transmissibility, the aim would be the boxes of masks and gowns,” he says. of Mission on public health issues such as to keep the mission open as long as “There are parts of my consulting room the potential risk of avian influenza. that I can hardly move in because there Cases of the virus in domestic birds possible to help the Australians who can are boxes of the anti-influenza drugs.” have been reported by the World Health go home, go home.”
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Dr Richard Davey is keen to help raise pathology standards in PNG. Left: Port Moresby, PNG. A I
Charting new territory R A H A V I Dr Davey arrived in PNG in May 2006, E O J
:
having decided to spend his two years’ T I D E
long service leave as a locum abroad. R C
O T
He officially retires from his post as O H chemical pathologist at Royal Melbourne P Hospital in December next year. While he’d considered working with an During his time in PNG, Dr Davey is international aid organisation, he first not interested in popular challenges such Five things as trekking the Kokoda Track: “I have approached the Department of Foreign seen the countryside and have read the Affairs and Trade (DFAT) and within a you didn’t know books and can mentally put the two week was touching down at Jacksons together,” he laughs. International Airport in the PNG capital, about PNG Port Moresby. However, he is keen to see pathology standards raised in the • There are more than 800 Two months turned to four months postcolonial country. indigenous languages spoken and now Dr Davey will stay until “Pathology does need to be better November before looking at other DFAT in the country. regulated up here because some of the locums in Burma, Laos, Indonesia, East results coming out of the laboratories are • The world’s largest butterfly, Timor or Cambodia. physiologically untenable. They couldn’t the Queen Alexandra This is his third visit to PNG – once as be the results from a live human.” Birdwing Butterfly, with a a student and twice in his current role. Having met another two pathologists wingspan of up to a foot is And while he’s familiar with the territory, in PNG who have the RCPA Fellowship - found only in Oro Province, he still finds the pathology standards a bacteriologist and a haematologist – as Papua New Guinea. difficult to accept. well as a histopathologist who trained in “The pathology availability in the town the UK, the possibility of developing • Portuguese explorer Don is roughly like what you would have found national standards is taking shape. Jorge de Meneses is credited in Australia in 1960,” he says. with naming the principal “There is modern technology to do the Making inroads island "Papua" - a Malay assaying, but the range of assays word meaning frizzy hair. Discussions are currently underway with available is extraordinarily limited – you the Royal College of Pathologists of can’t even get thyroid function tests. They • Papua New Guinea is one of Australasia and the National Association have to be sent to Cairns.” only three places on earth of Testing Authorities. To compensate, he has had to be with snow capped tropical It is a delicate project Dr Davey more clinically alert than would otherwise mountains. believes will occur over a decade, with be demanded in conditions where its viability dependent upon • Life expectancy is 55.7 years. pathology is advanced. But he believes collaboration with the local authorities Tuberculosis prevalence is his training in general pathology in the and medical fraternity. 448 cases to every 100,000 1980s has given him an edge. “If in one year, one could set people. “People like myself who trained as something in train that over the next five general pathologists back then are getting to 10 years could lift the game of the Sources: thinner on the ground. practice here bit by bit, that would be Ethnologue: Languages of the World, Fifteenth “What you did then was two to three something useful,” he says. edition years of histopathology and one year “The key to success is convincing the AusAID Department of Foreign Affairs and Trade each in chemistry, haematology and local people that they have done it World Wildlife Fund microbiology. It was almost like doing themselves and indeed, if they haven’t United Nations Development Programme Human your medical degree all over again from done it themselves, then it won’t Development Report 2006 the point of view of aetiology.” succeed.”
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disciplines in depth
Getting back to basics
HOW DO CURRENT STANDARDS OF PATHOLOGY TEACHING IN AUSTRALIA’S MEDICAL SCHOOLS STACK UP? PAM WILSON INVESTIGATES.
ike a pilot learning to fly without an ad hoc fashion and that students are At the universities where pathology is Lknowing the workings of a plane, simply not being taught enough histology, not taught extensively, students are medical students emerging as doctors anatomy and pathology. emerging with a reduced knowledge in the without a solid understanding of the first first principles of medicine, she says. It is also worrying that many university principles of medicine is risky business. lecturers teaching pathology are not The decreased exposure to pathology Twenty years ago, medical schools specialists in the field, she says. also means fewer are choosing it as a were renowned for producing doctors specialty. “We are noticing that, “It was a pretty dramatic change when who could pick an enlarged liver in particularly from the universities where we they started restructuring the curriculum seconds, but had little idea how to break know there isn’t much pathology taught, 10 or 15 years ago. In relation to the the news to a patient. the number of graduates wanting to do amount of pathology in the courses, it Now there is concern medical schools pathology is much lower,” she adds. was a total change of philosophy as to have gone too far the other way and are This is bleak news given there is what medical students should get taught.” marginalising the disciplines of pathology already a serious shortage of pathologists and anatomy. Dr Graves concedes that universities across Australia. The country has lost 70 If there is one thing pathologists, have difficulty employing specialists pathology positions over the past doctors, medical educators and because most academics are poorly decade, and faces an uphill battle to get students agree on it’s that pathology is remunerated and a workforce shortage funded training positions from the basis of all medicine and is vital to means many pathologists simply don’t governments to replace the rapidly medical education. have time to teach as they are coping with ageing pathology population. However, it can be difficult to find huge diagnostic workload demands. A lack of teaching around how enough pathologists to teach the growing But she feels that if universities put pathology integrates with the clinical number of students. And there are pathology higher on their agenda, this would process also means many young concerns that pathology has a low profile go some way to attracting specialists. doctors will not know what pathology among policymakers who control the tests to order, what they mean and how they relate to the clinical process, Dr funds required to put it higher on the Rules of attraction agenda in medical schools. Graves says. Dr Debra Graves, CEO of the Royal The RCPA developed a core pathology “If you don’t know what you’re College of Pathologists of Australasia curriculum in 2002, but uptake has been ordering or what you’re looking for, you’re (RCPA), feels the increasing emphasis on slow. Dr Graves says it has only been probably going to order inappropriate integrated curriculum and problem- adopted by ‘passionate pathologists’ pathology tests and not use the resources based learning are factors contributing eager to boost pathology within their as wisely.” to the downgrade of pathology in curriculum, and adds that those Dr Graves is hopeful the federal medical education. universities teaching pathology well all government’s Medical Education Study She is concerned that the basic have dedicated academic pathologists at into undergraduate-level medical principles of medicine are being taught in the helm. education in Australia will go some way to > PATHWAY_33 PathWay #11 - Text 21/2/07 3:57 PM Page 34
Dr Angela Barbour, head of the Department of Pathology at the University of Adelaide, believes the increased focus on integrated assessments in many medical schools means students are not forced to become competent in pathology. “They can pass without reaching a certain standard of knowledge in pathology and other subjects such as anatomy.” She also believes the change to non- graded passes in some schools reduces the incentive for students to improve and excel.
From the ground up
Eminent general practice educator Professor John Murtagh agrees most medical students are graduating without sufficient knowledge in the basic medical sciences including anatomy, pharmacology and pathology. But he’s not sure how big a problem this will be long-term for the nation’s GPs. Doctors truly begin to learn their trade when they graduate and begin work as interns under supervision, he says. “So the doctors will learn because R E H they simply have to, but they may not be G A L L so efficient or discriminate in their A G
N ordering of pathology tests and other O M A
E investigations such as imaging.”
: T
I Professor Paul Monagle with med students Kah D
E Lok Chan and Helen McDougall: “Students learn Professor Murtagh, Adjunct Professor R C things off by heart, but we don’t get them to O of General Practice at Monash University, T
O that core basic knowledge”. H
P argues that the quality of medical graduates in Australia remains superb and that the relative lack of training in the basic sciences does not put patients at highlighting these problems and make Sydney, former Director of Forensic any increased risk. recommendations to help rectify the Medicine at Westmead Hospital and now “The risk comes from poor clinical and situation. The study’s supervising works as a regional forensic pathologist communication skills, which still remains committee will meet again in June before with Queensland Health Scientific the core focus of undergraduate it can produce its report. Services. education,” he says. However, she insists the responsibility He agrees that the amount of didactic Ask students their opinion and they largely lies with medical schools and their teaching has dropped dramatically in are happy with the status quo. When the commitment to ensuring students are well recent years. Australian Medical Students Association educated in the most important “I’ve had students observe autopsies (AMSA) conducted its Medical Education disciplines. “There needs to be an and … for a large number of them it was Survey last year, the verdict from more underpinning in the first couple of years of the first time they had seen the inside of a than 600 reviewed responses was that the amount of pathology taught was [student] training where they get body,” he says. ‘just right’. dedicated pathology training by “It’s a concern when you have But AMSA President Rob Mitchell pathologists. someone who is within 12 months … says medical schools can’t rest on their “In the latter stages of the course, going to be prodding around people’s laurels. “Medical education is constantly there needs to be involvement with abdomens hoping to find an enlarged liver evolving and in a climate where student pathologists who are in practice.” and they have never seen one before.” numbers are increasing exponentially it’s Dr Peter Ellis is a former senior Inadequate assessment of pathology important that in new models of curricula lecturer in pathology at the University of is also a concern. we maintain a balance … and don’t forget
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that an emphasis needs to be placed on “This has never been the responsibility electronic format followed by didactic, pathology,” Mr Mitchell says. of the RCPA,” she says. small-group teaching sessions to discuss He adds that the survey also found “We are a member-based organisation the lecture. Professor Lakhani feels that students valued problem-based with responsibility for post medical degree pathology teaching at the school is strong learning, but felt it only worked if they first pathology education and while we try to and may even improve after teaching had a scientific basis to work from. influence pre medical degree education methods are reviewed. And while they were happy with some Further, he feels the university has a strong teaching team. self-directed learning, they felt it shouldn’t replace traditional teaching styles “We’re lucky in Brisbane as we have delivered by trained doctors. support from public hospital colleagues – at a consultant and training level – as well as from pathologists in the private Resource issues sector who help with the teaching Proponents of problem-based learning program”. and integrated learning feel the problem is One university acknowledged as not with the style of curriculum or how it making great inroads in pathology is applied. education is the University of New South They blame a lack of teaching Wales (UNSW). resources in the clinical years, increased student numbers, increased student Cutting through workloads and a lack of authority by the medical fraternity over policymakers. In the past six years, its Department of N I Pathology has won an unprecedented G
The University of Sydney was one of G A nine faculty- and university-level awards S
the first medical schools to move to a O I
L for pathology teaching. U I
graduate course 10 years ago and is now G
T I “This is quite a remarkable D
conducting a major review of its E R
C achievement given the present situation,
curriculum. O T
O with the dramatic changes that have H
Professor Nick King, head of the P occurred in medical education,” explains Department of Pathology, says that while Dr Peter Ellis: worried students have Professor Denis Wakefield, head of the the curriculum is integrated, he thinks insufficient anatomy knowledge. university’s School of Medical Sciences. pathology is well represented in the first The department’s success is partly two years. due to Professor Wakefield’s approach to But he does agree pathology needs a via developing generic curriculae and building a strong teaching team of higher profile and more teaching encouraging pathologists to teach, we academic pathologists. resources throughout Australia. have no direct role in delivering university He has created openings not only for courses. This is a funding responsibility of “The way to address the problem … pathologists who have a primary interest the universities themselves.” is by increasing the number of teachers in teaching pathology, but for those or the College committing more of its involved in clinical research who have own resources to doing this in a more Leading by example teaching skills they can offer and for those formal environment.” The University of Queensland is also available for part-time fractional Professor King feels it’s time the reviewing the way it teaches pathology to appointments. RCPA, educators and practising accommodate increasing numbers of UNSW Faculty of Medicine Director of specialists came together to discuss medical students. Academic Projects Professor Rakesh creative ways to solve the problem and Sunil Lakhani, Professor of Molecular Kumar says the department can also persuade policymakers to boost the and Cellular Pathology, says the increase attribute its success to the fact that profile of pathology. in student places from 320 to 400 has pathology was well represented on every “If the College took the lead, they made it necessary for electronic and curriculum committee when the medical would be in a better position to dictate digital technology to supplement program underwent a restructuring what the government changed, rather traditional didactic teaching. process from 2002. than the government dictating to them.” Although first-year students will still “We made sure it was seen not just as Dr Graves says the college would have a lecture-based program, the a basic science, but as a clinical science, welcome the opportunity to sit at the table teaching for year two is under review as and we worked hard to ensure it was not and discuss with universities ways of the school simply doesn’t have enough diluted and lost,” he says. addressing this critical issue. lecture theatres to accommodate 400 The University of Melbourne’s School But she points out that it’s not the students. of Medicine is also driving hard to put college’s role to commit resources to From 2008, second-year students more pathology back into its curriculum. university education. may receive some lectures in an Professor Paul Monagle, head of the > PATHWAY_35 PathWay #11 - Text 21/2/07 3:57 PM Page 36
Department of Pathology, says despite reverse the trend the school has “They … have represented pathology students getting more than 102 hours of appointed a clinical pathologist who at all levels of governance and planning in dedicated pathology and additional works part time in hospital to bring that the ANUMS, from early in its gestation to integrated problem-based learning ‘cutting, real-life edge’ of pathology into its delivery.” teaching in the first five semesters, it’s still the curriculum. The shift in medical education has not enough. Meanwhile, the Australian National been rapid and all encompassing, but it “[Students] learn things off by heart, University Medical School (ANUMS) is seems many academics are now but we don’t get them to that core basic ensuring clinical and anatomical pathology conscious of the need to slow the knowledge where they can think about a are very well represented. There are about process and consider the impact disease process and work from first 345 hours of face-to-face teaching for various external pressures have on principles about what the likely anatomical pathology per year, and at medical education. pathological process is.” least another 100 for clinical pathology. Professor Monagle, who is also With this awareness and the call for director of haematology at the Royal “ANUMS has a high-profile team of greater communication within the Children’s Hospital, adds that much of pathologists, [and a] high profile in the pathology sector, perhaps we are on the what is taught is the pathological basis of school and the local medical community,” cusp of a new shift that will eventually see disease and not the use of a pathology explains Dr Julia Potter, Professor of first principles put high on the agenda service in the real world. In a bid to Pathology at the school. once more.
Pathology: UNIVERSITY OF SYDNEY - graduate entry Student numbers Intake of 284 for 2007
Face-to-face Pure pathology includes 26 hours of lectures, 60 what’s on offer teaching hours of practicals and 72 hours of self-directed learning topics in Years 1 and 2. There are also additional sessions integrated with other disciplines In Years 3 and 4 it is delivered off-campus in nsw hospitals UNIVERSITY OF NEW SOUTH WALES - undergraduate entry Staff 7 academic staff
Student numbers 270 per year of the six-year course (from 2007) Delivery PBL, CBL, practicals, lectures
Face-to-face Academic staff heavily involved in face-to-face Assessment Integrated. Case-based, modified essay questions, teaching teaching in Phase 1 and 2 (Years 1 to 4). Exact single best-answer questions similar to MCQs hours difficult to estimate due to integrated curriculum, but Phase 2 has at least 40 lectures and 170 hours of practical class teaching per year UNIVERSITY OF WOLLONGONG - graduate entry Conjoint academic staff in hospitals teach through Student numbers 80 per year in each of the four years Phase 3
Staff 7 academic staff; plus additional sessional Face-to-face N/A (fully integrated). But there are defined pathologists and doctors teaching pathology outcomes and competencies and it’s considered an essential element of the course Delivery Experiential learning (scenario-based) with lectures, scenario group sessions, practicals (including Staff N/A as teaching is too heavily integrated. School integrated histology/histopathology practicals) and has numerous staff and honorary commissions tutorials Delivery Integrated. This is a new-style clinically driven and Assessment Integrated. Short answer, MCQ, extended matching, outcomes-based course. Lectures, CBL (no PBL), OSCE practicals, tutorials, specimens
Assessment Integrated. Multi-station examinations similar to UNIVERSITY OF WESTERN SYDNEY - undergraduate entry OSCEs, extended matching, written questions and assignments, short answer Student numbers 115 to 120 per year
Face-to-face Largely integrated so difficult to be exact; in Years 1 UNIVERSITY OF NEWCASTLE - undergraduate entry teaching and 2 there are at least 2–3 hours of pathology per week Student numbers 120 per year
Staff From 2007 a senior pathologist will be Adjunct Face-to-face About 50 hours for the course Professor, with further university staff appointed in teaching due course Staff No on-campus staff. Pathology teaching is Delivery Uses University of Melbourne curriculum for Years delivered by the Hunter Area Pathology Service as 1 and 2, which is integrated. PBL, CBL, CD-ROM required by the university interactive, lectures, practical classes, tutorials and videos of autopsies Delivery Fixed resource sessions, clinical pathological conferences (CPCs). The uni is working on Assessment Integrated. Pathology and its links to clinical introducing a web-based pathology curriculum medicine are a part of all exams. MCQ, short answer, OSCE Assessment Integrated. OSCE
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Key CBL case-based learning PBL problem-based learning MCQ multiple-choice questionnaire OSCE objective structured clinical examination qld BOND UNIVERSITY - undergraduate entry act Student numbers Intake of 84, plus 149 in Years 2 and 3 (2007) Face-to-face Integrated. In 2006, 18 hours in Year 1, and 60–80 THE AUSTRALIAN NATIONAL UNIVERSITY - graduate entry teaching hours per year from Year 2; plus incorporated into PBL Student numbers Total of 250 in 2006 Staff 4 academic staff, plus additional sessional Face-to-face Integrated curriculum. Pathology introduced as a pathologists and doctors teaching discipline from Week 1 of Year 1. Minimum of 345 hours per year of anatomical pathology, plus a Delivery Lectures, tutorials. No PBL minimum of 100 hours of clinical pathology Assessment Stand-alone. MCQ, pathology pots, short answer Staff 6 pathologists, 3 registrars for anatomical pathology; 12 pathologists and 3 registrars for clinical pathology. Plus additional sessional GRIFFITH UNIVERSITY - graduate entry pathologists and doctors for both Student numbers Intake of 150 for 2007 Delivery PBL, practicals, lectures (Years 1 and 2) CBL, practicals, laboratory, lectures, autopsies, Face-to-face 4 hours per week web-based (Years 3 and 4) teaching
Assessment Integrated and stand-alone. Mini-case, MCQ, Staff 2 academic pathologists extended matching, essay, OSCE Delivery Lectures, PBL, practicals, web-based vic Assessment Integrated. MCQ, short answer and mini-case MONASH UNIVERSITY - undergraduate at Melbourne and Malaysia JAMES COOK UNIVERSITY - undergraduate entry campuses; graduate entry at Warrigal campus (opening in 2008) Student numbers About 100 in Years 1 to 3, and 71 in Year 4 (150 per Student numbers Intake of 220 at Monash Melbourne; 50 at Monash year from 2008) Malaysia in 2007, expanding to 100 in 2008 In 2008, the Warrigal campus is opening with an Face-to-face Approximately 14 hours per week in Years 1, 2 and 3 intake of at least 130 teaching About 10 hours plus clinics in Year 4
Face-to-face Year 1 has 36 hours, Year 2 about 60 hours, Year 3 Staff 10–14 tutors for each year, teaching tutorial groups teaching about 120 hours of 10 students. Most large classroom teaching is Year 4 still to be developed, Year 5 has 6 hours done by in-house medical specialists and visiting clinicians Staff About 30, plus 6 trainees Delivery Tutorials, PBL, lectures, lab sessions with web Delivery Lectures and practicals (Years 1 and 2), tutorials resources and internet CBL (Year 3), patient-based (Years 5 and 6) Assessment Integrated. End of year exam has written papers consisting of MCQ, key features paper. Practicals Assessment Integrated. MCQ (Years 1 and 2), extended consist of OSCEs matching and OSCE (Year 3), assessment by case supervisors (Years 5 and 6) UNIVERSITY OF QUEENSLAND - undergraduate and graduate entry UNIVERSITY OF MELBOURNE - undergraduate and graduate entry Student numbers Increasing from 320 to 400 per year
Student numbers Intake of 330 for each year Face-to-face Year 1 has 15 hours of lectures teaching Year 2 has 35 hours of lectures, 12 hours of Face-to-face 102 hours of lectures, seminars and practical practical tutorial classes and 3 hours of teaching classes in first 5 semesters. Pathology also autopsy/coronial symposium and an autopsy incorporated into PBL. More pathology covered in observation session semesters 8 and 9 through tutorials in hospitals and Year 3 and 4 is dependent on clinical firms CD-based interactive learning
Staff 15–16 staff Staff 3 full-time academic appointments (plus 1 vacant) and 25–30 sessional lecturers, hospital consultants Delivery PBL, CBL, CD-ROM interactive, lectures, practical and registrars classes, tutorials, videos of autopsies. Semesters 6 and 7 are an elective research year Delivery Small group tutorials, PBL, practicals, tutorials, autopsies. Some lectures may be replaced by a Assessment Integrated. In practical exams, there are some web-based program from 2008 dedicated path questions. MCQ, short answer, OSCE Assessment Integrated. MCA, short answer, OSCE, mini-case > PATHWAY_37 PathWay #11 - Text 21/2/07 3:57 PM Page 38
sa UNIVERSITY OF ADELAIDE - undergraduate entry Student numbers 130 per year; intake of 144 for 2007
Face-to-face More than 22 hours for Years 1 to 3, plus teaching incorporated into PBL. About 13 hours in Years 4, 5 and 6 tas Staff 3, plus sessional input from other pathologists UNIVERSITY OF TASMANIA - undergraduate entry
Delivery Lectures, practicals, PBL, question and answer, Student numbers 120 per year tutorials Face-to-face Approximately 10 hours per week in Years 1 to 3. Assessment Integrated. MCQ, short answer, practicals, OSCE teaching Integrated, but still highly represented
Staff 6 university pathology staff, plus about 10 sessional FLINDERS UNIVERSITY - graduate entry pathologists in the public sector
Student numbers 120 in 2007, 135 in 2008 Delivery Lectures, practicals, integrated tutorials and CBLs. As many face-to-face small groups as possible Face-to-face Integrated, so difficult to estimate exact hours. For teaching Years 1 and 2, there are 1–4 hours per week Assessment Integrated. Mini-case, MCQ, short answer, extended In Year 3 there are flexible delivery options, but less matching. Clinical case scenarios face-to-face than Years 1 to 2
Staff At least 6 staff delivering the anatomical pathology course, some of whom are sessional
Delivery PBL, CBL, lectures, practicals, tutorials, web-based, autopsy, electives new zealand Assessment Integrated. MCQ, short answer, mini-case, extended matching, OSCE UNIVERSITY OF OTAGO - undergraduate entry Student numbers Intake of 220–240 students into the Dunedin campus. For Years 4 to 6, the cohort splits, with some students going to the Christchurch and Wellington campuses wa Face-to-face Year 2 has 41 hours of case-based sessions and teaching lectures NOTRE DAME UNIVERSITY - graduate entry Year 3 has 38 hours of case-based sessions Student numbers 80 each in Years 1 and 2, plus an intake of 100 for Years 4 and 5 have 50 hours per year 2007 Staff 35 Year 4 still being developed
Face-to-face At least 54 hours in Year 1, 94 hours in Year 2, 100 Delivery CBL, web, practicals, lectures, autopsies, tutorials teaching hours in Year 3 Complemented by micro/path components and Assessment Stand-alone and integrated. Format varies autopsy teaching (introduced in 2007 for Year 3) according to year; short answer, EMCQ, OSCE
Staff 2 (Year 1), 7 (Year 2), 3 (Year 3) UNIVERSITY OF AUCKLAND - undergraduate entry Plus additional clinical academics Student numbers About 150 in each of the 6 years Delivery PBL course, plus lectures, practicals, tutorials and Also offer undergraduate and postgraduate CBL pathology papers to science students with Assessment Integrated. Case-based scenarios, short answer, enrolments of 20–25 for postgrad papers and OSCE 50–250 for undergrad papers Face-to-face Year 2 has about 63 hours teaching UNIVERSITY OF WESTERN AUSTRALIA - undergraduate entry Year 3 has about 60 hours plus, incorporated into integrated learning and four to six pathology Student numbers 216 each for Years 3 and 4 (pathology only taught in lectures in each year these years) About 10 hours of tutorials and CBL in Years 4 and 5
Face-to-face Four hours a week in Year 3, and about 1.5 hours in Staff 15, plus hospital staff delivering laboratory teaching Year 4 medicine tutorial program
Staff 16–20 (includes sessional lecturers) Delivery Lectures, practicals, CBL, web, self-assessment, combined anatomy and pathology museum Delivery Lectures, tutorials, web-based Assessment Stand-alone and integrated. MCQ, short and essay Assessment Stand-alone. MCQ and short answer written questions, OSCEs in Year 5 assessment
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at the cutting edge
The Philadelphia experiment
AN ADELAIDE RESEARCH INSTITUTE HAS BEEN QUIETLY LEADING THE FIELD IN CHRONIC MYELOID LEUKAEMIA, HELPING TRANSFORM IT FROM A TERMINAL INTO A CHRONIC ILLNESS. LOUISA DEASEY REPORTS.
PHOTO CREDIT: EAMON GALLAGHER
rofessor Timothy Hughes has long of chromosomes 9 and 22, called the Both were unsatisfactory treatments Pheld a fascination with chronic Philadelphia chromosome. compared to a breakthrough discovery myeloid leukaemia (CML). The fusion of chromosomes 9 and 22 in 1998. In 1989 as a leukaemia research fellow causes two important genes to come The development of the tyrosine at London’s Hammersmith Hospital, the together, producing a fused gene, kinase inhibitor Glivec (imatinib mesylate) Director of Haematology Research at BCR–ABL. This new gene produces the sparked an exciting time in CML research. Adelaide’s Institute of Medical and BCR–ABL protein that is responsible for The drug, manufactured by Novartis, Veterinary Science (IMVS) was given the driving abnormal growth of this mutated worked by blocking the tyrosine kinase opportunity to work with the world leader cell, which rapidly divides to produce protein that drove the disease, and was in CML research, John Goldman. billions of copies of itself. All of the one of the first ‘kinase inhibitor’ agents Eighteen years later, Professor Hughes abnormal behaviour of these leukaemic found to be effective in cancer therapy. and his team at the Institute are cells can be attributed to the BCR–ABL This discovery saw many new areas of considered world leaders themselves, at protein. This protein is an overactive CML investigation open up, and Glivec the forefront of groundbreaking research tyrosine kinase enzyme that signals the turned out to be all the researchers had into treatment of the disease. cells to keep dividing. hoped, offering a 90% success rate in In Australia, CML currently afflicts CML treatment in the 1990s involved blocking disease progression. about 200 new patients per year. It is a interferon therapy (which left patients Five years after the first group of cancer of the bone marrow, caused by a feeling like they permanently had the flu) patients started taking it, 90% of them mutation within a single bone marrow cell. or bone marrow transplants, which can were still alive. The challenge now is to This mutation is an unusual rearrangement cure some patients but are high risk. increase the response rate closer to 100%. > PATHWAY_39 PathWay #11 - Text 21/2/07 3:57 PM Page 40
“A physician in New York recently told me that a patient in New York could not get a BCR–ABL assay for CML. In Australia, virtually every patient is being monitored using the PCR assay.” E B M O C R A L
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Professor Timothy Hughes and senior research scientist Deborah White have developed a predictive assay that assesses a patient’s sensitivity to Glivec. PathWay #11 - Text 21/2/07 3:57 PM Page 41
The Institute’s molecular Knowing that resistance to Glivec is “The first thing I look at when I see a mainly due to mutations of the BCR–ABL patient is their PCR result. Without PCR breakthroughs gene has led the researchers to theorise monitoring, we only know the patient is in Because of his previous work on CML, that second- and third-generation kinase trouble when resistance is already quite Professor Hughes had been busy forming inhibitors currently under development advanced.” a team to focus on molecular research might be able to specifically target these Though it may be a year or two off into the disease. So when patients in mutations and offer an even more from standardising the assay Australia and around the globe began successful treatment option for patients. internationally, the Institute is currently taking Glivec in 1999, the Institute had Most patients in Australia enrolled in standardising 16 other laboratories already started diagnostic research into clinical trials of the newer kinase inhibitors around Australia. monitoring treatment response and for CML are monitored by Professor These are exciting times for the predicting drug resistance and relapse. Hughes and his team using the assays Institute and for CML research in general It was a case of perfect timing. they have developed. As well as as we teeter on the brink of even more The Institute’s CML laboratory was Australian patients, the Institute oversees dramatic developments in leukaemia specialised and set up so that as soon as CML patients undergoing clinical trials research. patients started taking the new drug, the from Asia, South Africa and North and “Some patients have had dramatic team was monitoring exactly how it South America. responses to Glivec where we can’t worked, when it didn’t, and how this detect any leukaemia in their blood or could translate into predicting patient Achievements honoured bone marrow for several years,” Professor outcomes on the drug. Hughes says. Since starting at the Institute, Professor In 1997, Dr Susan Branford (PhD) had “The question then becomes, do they formed the Institute’s CML molecular Hughes and his team have produced a actually need to take Glivec anymore? laboratory, to work on developing a highly number of internationally published We’re now conducting a study in Australia accurate and sensitive molecular assay, papers on their work. Their laboratory was where patients who have had negative which tested the levels of the BCR–ABL one of only three in the world to conduct PCR assays on every single occasion for gene using polymerase chain reaction a study monitoring the impact of Glivec two years and who want to be part of the (PCR) tests and thus monitored a patient’s on newly diagnosed CML (N Engl J Med study, stop the drug and then we follow response to treatment. 2003;349:1423–32), which proved the them closely with PCR tests.” drug’s effectiveness in reducing BCR–ABL Over two years, Dr Branford worked To have reached this point after the levels for those with CML, compared to with Professor Hughes (an RCPA fellow), drug has only been available in Australia interferon therapy. developing this sensitive PCR assay, for seven years is very much due to the which is now at the forefront of global The Institute's laboratory testing, work of Professor Hughes and his team. CML monitoring and research. analysis and quantitative research into But he says haematologists from all Senior research scientist Deborah CMLwas also recognised last year, with around Australia have contributed to the White, who has worked at the Institute for Professor Hughes receiving the Eric research effort, through the Australasian 25 years, manages the CML research Susman award for the most outstanding Leukaemia and Lymphoma Group. laboratory. With Professor Hughes she contribution to the knowledge of any Associate Professor Andrew Grigg, developed a predictive assay that branch of internal medicine by a fellow of deputy head of the Royal Melbourne assesses an individual patient’s sensitivity the Royal Australasian College of Hospital haematology department, says: to Glivec therapy. Physicians. “The IMVS is a world-class centre She explains the mechanism of action But there is still more work to be conducting groundbreaking research for this predictive assay: done. The Institute’s PCR assay to which has been published in a number of front-line journals. On a global level, “In cases of CML there is a measure serum levels of BCR–ABL is still they’re up there with the best of them.” phosphorated form of a protein called not a standardised test across the world. CRKL. By then giving the drug to the cells In an effort to make this happen, Perhaps the most exciting aspect in a test tube, we look at changes in the Professor Hughes and his team recently about our new knowledge of CML is the level of phosphorated CRKL with drug published a paper on the accuracy and long-term benefit for patients, Professor exposure. benefits of BCR–ABL testing in Blood Hughes says. (2006;108:28–37). “It essentially means at diagnosis we “Those of us working in CML have can predict, with a reasonable degree of “America has been very slow to adopt been riding a wave of exciting progress certainty, how a patient is going to PCR monitoring for patients,” Professor that has turned a terminal illness into a respond and whether they’ll need a dose Hughes says. chronic one, and provides hope that a cure based on drug therapy alone may be increase, or whether they’d be better on a “A physician in New York recently told around the corner.” different drug.” me that a patient in New York could not To a patient, this knowledge can mean get a BCR–ABL assay for CML. They are receiving the most appropriate therapy still relying on an assay developed 50 Declaration of interest: Professor Hughes and his team receive research funding support right from the start, rather than waiting for years ago to monitor their patients. In from the Leukaemia Foundation of Australia, a poor response to standard therapy Australia, virtually every patient is being the Cancer Council of Australia, the NHMRC, and several pharmaceutical manufacturers before making a change. monitored using the PCR assay. including Novartis.
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testing testing ARTS + CULTURE
A tale of two microbes
RUBELLA IS ON ITS WAY OUT, BUT PERTUSSIS REMAINS A SIGNIFICANT PUBLIC HEALTH CHALLENGE. TONY JAMES REPORTS ON PATHOLOGY’S ROLE IN CONTROLLING THESE INFECTIOUS DISEASES.
wo diseases, two vaccines, and two persistent cough. Some experience Tvery different stories. more serious disease, with Vaccination against pertussis complications such as pneumonia (whooping cough) and rubella (German and problems from sustained, forceful measles) has been routine for many years, coughing, ranging from urinary but there’s little similarity in the recent incontinence to inguinal hernia and history of these diseases. pneumothorax. About 7000–10,000 cases a year are notified in Australia, While pertussis persists as a common with distinct epidemics occurring in respiratory disease in adults and continues addition to a stable background level to challenge the medical profession, of infection. rubella is close to being eliminated. Although some immunity is provided from the mother at birth, this Pertussis at large wanes quickly, so a first vaccination as Pertussis, caused by the bacterium soon as possible after two months is Bordetella pertussis, is highly infectious. essential. Pertussis vaccination has also a factor. In the first year after a primary Between 70% and 100% of non-immune long been included in routine childhood course of three injections there is virtually people living in the same household as vaccination schedules, in combination with 100% protection against fatal or severe an infected person are likely to develop diphtheria and tetanus (DTP). disease, but only 90% protection against the illness. However, pertussis remains a public typical disease and 70% against mild In babies and young children, it health challenge worldwide due to the disease. Immunity after vaccination has typically causes a persistent and continuing high rate of disruptive been estimated at 4–12 years, compared distressing cough and can lead to severe respiratory disease beyond childhood, the to up to 20 years after natural infection. complications including pneumonia, failure of vaccination to provide sustained Adults are an important source of seizures and brain damage. The infection protection, and a risk of complacency infection for vulnerable infants, so a number causes about 250,000 deaths a year in about routine childhood vaccination. of countries have recommended boosters developing countries, but vaccination Despite widespread vaccination, after childhood. The NHMRC suggests a programs have made fatalities a rarity in pertussis has never been eliminated from booster can be given at any age from eight developed countries, with Australian any population. In fact, increased infection years onwards, and recommends that it be authorities usually recording only one or rates have been described in some considered in adolescents aged 15 to 17, two deaths each year. developed countries, but the reason for for both partners planning a pregnancy, for Pertussis causes much less severe this is far from certain. Better diagnosis adults working with young children in disease in older children, adolescents and might account for part of the rise, and healthcare or child care, and in any adult adults, who might have just a simple but incomplete protection from vaccination is expressing an interest.
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Pertussis remains a public health challenge due to the continuing high rate of disruptive respiratory disease beyond childhood... and a risk of complacency about routine childhood vaccination. T H G I R W
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Above: Dr David Mitchell: “Much of the data on the epidemiology of pertussis is unreliable.” Left: Scanning electron micrograph of Bordatella pertussis infection (green).
Pertussis in the path lab in very small samples, are now the Early treatment with erythromycin or method of choice for identifying pertussis other macrolide antibiotics can reduce the Pathology tests for pertussis are designed during the first few weeks of infection. severity of symptoms and can help to diagnose current infection or to confirm a prevent infection of close contacts. recent infection. Dr David Mitchell, an Aspirating fluid from the nasopharynx But decisions about excluding a staff infectious diseases physician and is the optimal method of obtaining member from work, monitoring others for microbiologist at Sydney’s Westmead specimens, but the procedure is infection, and possibly treating others to Hospital, says the organism is fastidious uncomfortable and disliked by adults, in prevent infection can have serious and very difficult to culture in the laboratory. whom throat swabs are usually adequate. implications and therefore require good “Growing the organism is the ideal “PCR has limitations too,” Dr Mitchell evidence that the infection exists. way to make a diagnosis, and it also says. “For example, it detects dead Serology – testing for antibodies to allows us to study the bacterium, its organisms as well as living ones, so it pertussis – can help confirm that the sensitivity to antibiotics and the way that it can’t be used to monitor the success of infection has occurred in people who might be changing over time, but in most treatment.” have experienced typical symptoms, but cases this is not an option,” he says. Diagnosing a current infection has the is not particularly reliable. “Only a few specialised paediatric greatest benefit where the patient might “The tests available for routine laboratories have the facilities for culture.” pose a threat to others, for example a laboratory use are neither sensitive nor Polymerase chain reaction (PCR) tests staff member working in a neonatal specific for pertussis and can lead to for fragments of bacterial DNA, detectable intensive care unit, Dr Mitchell says. over-diagnosis,” Dr Mitchell says. > PATHWAY_43 PathWay #11 - Text 21/2/07 3:57 PM Page 44
Rubella infections have continued to decline and now number fewer than 200 a year, compared to about 3000 annually in the early 1990s.
“This can be a problem when we are Only 10–20% of babies are affected factors such as vaccination history, attempting to control an outbreak or if the mother has rubella after 16 previous antenatal screening tests, and restrict the spread of the disease in a weeks’ gestation. the date and duration of possible contact workplace. It also means that much of Girls were first vaccinated against with other infected people. A sharp rise in the data on the epidemiology of pertussis rubella in the 1960s, and immunisation – IgG antibodies can also be detected is unreliable.” like natural infection – provides long-term within four to five days of symptom onset, protection. Rubella is now combined with but patients are rarely tested at this early Careful interpretation measles and mumps vaccinations (MMR) stage. IgM levels remain elevated for 8–12 in routine immunisations. weeks after infection. Like all pathology tests, the results of A national ‘catch-up’ campaign in Specialised pathology tests can also pertussis serology have to be interpreted 1998 aimed to ensure vaccination of all be used to check for foetal infection if a carefully in light of the patient’s illness. In Australian adolescents, particularly the woman wishes to continue with a a general practice environment, evidence cohort of boys who had missed childhood pregnancy after contracting rubella. Tests that a patient has developed antibodies immunisation. As a result, rubella include IgM levels in foetal blood sampled to pertussis after an episode of typical infections have continued to decline and from the umbilical cord, or testing for viral illness can provide some reassurance now number fewer than 200 a year, genetic material in foetal blood or about the cause and likely course of the compared to about 3000 annually in the chorionic-villus samples. illness, and help rule out other causes of early 1990s. Only one or two cases of persistent cough. The risk of rubella will continue for congenital rubella syndrome are reported some years until there has been a Serology tests are not needed, and in Australia annually. sufficiently high uptake of MMR aren’t helpful, in deciding whether an vaccination by children and adults of both adolescent or adult should be Role of rubella lab tests sexes. The NHMRC recommends revaccinated. vaccination of non-pregnant women Greater success, however, has been The main aim of diagnosing current or lacking antibodies, and female immigrants achieved in controlling rubella. recent rubella infection is to assist a who have entered Australia after the age pregnant woman to make an informed This virus usually causes a self-limiting decision about the risk to her developing of routine vaccination – especially those disease in adults. Inhalation typically leads baby and whether the pregnancy should from Asia, where natural infection rates to multiplication in the upper respiratory be terminated. Serological tests for and levels of immunity are low. tract, then fever, a skin rash and spread of antibodies are required in any pregnant Screening for rubella antibodies is the virus to organs including the placenta woman who is thought to have rubella or now a standard part of antenatal care. of pregnant women. who has been in contact with others who In 1941 an Australian ophthalmologist, have the disease, regardless of their Norman Gregg, first made the link vaccination history. GPs NOTE: This article is available for between rubella and birth defects. A number of other rash-causing viral patients at http://pathway.rcpa.edu.au He observed that some babies were illnesses – including measles, parvovirus born with congenital cataract – some also B19, human herpesvirus 6 and enterovirus Further reading with congenital heart disease – after their – can closely resemble rubella and cannot Crowcroft NS, Pebody RG. Recent mothers had rubella during pregnancy. be distinguished clinically, so laboratory developments in pertussis. Lancet It’s now known that maternal infection confirmation is essential to make the 2006;367:1926–36. in the first 8–10 weeks of pregnancy is diagnosis. very likely to lead to foetal damage, with The presence of rubella-specific IgM Banatvala JE, Brown DW. Rubella. Lancet long-term consequences such as strongly indicates current or recent 2004;363:1127–37. blindness, deafness, mental handicap and infection, but the result must be NHMRC, The Australian Immunisation cardiac abnormalities. interpreted by a specialist in light of Handbook, 8th edition, 2003.
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lifestylePathWay lifestyle
travel 46 private passions 50 travel doc 52 working holiday 55 rrecipeecipe for success 57 the good grape 60 dining out 61 rearview 64 conferconferenceence calendar 67 postscript 68
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travel
a happenang thang
PENANG HAS ALWAYS BEEN A RICH MIXING POT OF CULTURES AND CUISINES, BUT THIS YEAR THE TINY ISLAND STATE PROMISES TO BE EXTRA FESTIVE, WRITES JUSTINE COSTIGAN.
here’s a certain romance about most interesting way of exploring places that invites – no, demands – Tapproaching a new country by sea Malaysia’s wonderful western coastline. wandering by foot. that puts all other forms of transportation Just one caveat: the day I took the to shame, no matter how comfortable, ferry from Langkawi to Penang, an A gorgeous time in fast and modern they may be. unseasonal downpour transformed the Georgetown As land looms in the distance and your calm emerald seas into angry grey waves With its English history evident in the boat gradually brings the coastline into and lashed the ferry’s windows with rain architecture of almost every street, it’s focus, the slow discovery of the land’s and seaspray. easy to get lost in a Somerset Maugham- shape and form – its mountains, natural Penang emerged from the sea through esque fantasy of English colonial life. forest and beaches, small towns and mist and rain and my arrival, though just finally, the distant outline of a city skyline – And there’s no better place to catch a as interesting as I’d hoped, was a little is always one of excited anticipation. And glimpse of the past than at the imposing while the feeling is probably intensified if more Melbourne in winter than island Eastern & Oriental Hotel – the first hotel you’re travelling in style on a luxury yacht, paradise in summer. opened by the Armenian Sarkies brothers, a humble ferry can be just as wonderful a Luckily, then, Penang is more than just who later established Raffles in travelling experience. a beautiful beach destination. This little Singapore. Afternoon tea continues to be For many travellers exploring the Straits island has a rich and fascinating history one of the lovely traditions upheld by the of Malacca or taking the slow meandering that is most evident in its capital, hotel, which looks polished and beautiful route from Thailand down the coast to Georgetown, one of the most accessible since its renovation a few years ago. Malaysia, the ferry is the only form of and visitor-friendly cities in South East A round of scones with jam and transport. But it’s also the most reliable Asia. Just big enough to be called a city, cream, delicate smoked salmon and efficient form, and one that offers the Georgetown is one of those wonderful sandwiches and little cakes accompanied
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by tea in a silver teapot soothes the soul, nineteenth century has been recreated, Cause célèbre even if it does serious damage to the illustrating the lifestyle of the family of a credit card. wealthy Chinese businessman. In fact, any visitor to Malaysia this year will find it hard to avoid learning While its British history might be one From the kitchen with its dozens of of the dominant features of the tiffin containers to the half-dozen cabinets something about the country’s history. Georgetown architectural landscape, filled with delicate Chinese porcelain, the Celebrating the 50th anniversary of Penang has its own distinct personality museum is filled with the work of expert independence on August 31, Malaysia is that draws on many cultures. craftsmen. Intricate wood carving, painted gearing up for a year of non-stop events. As a crucial port in the development glass doors, and the embroidery on bed It’s an unashamed and deserved year of the spice routes, Georgetown quickly linen and clothing are all to be admired. of congratulation, and one that’s also became an important trading city with Newly opened, the museum is being used to encourage visitors to the strong Chinese and Indian communities country and its surrounding islands. As as well as its ethnic Malay population. privately owned and was conceived to preserve a part of the city’s history that part of the celebrations, Penang will host Although the island was eventually the community is fiercely proud of. several of its own big events including a overtaken by Malacca in importance, major music festival, dragon boat racing Georgetown remained a bustling and You could spend days in prosperous city. The confluence of cultures Georgetown’s museums taking in the and the annual Lantern Festival. – Chinese, Indian, Malay and British – history of the island from indigenous This is one event I’d love to see. continues to guarantee a rich tapestry. arrival (only shortly before the British in Already filled with light, colour and people In the Peranakan Mansion, a the seventeenth century) to its trading at night, the city’s month-long festival fascinating museum in the heart of past, World War II history and subsequent must be truly spectacular. Wandering Georgetown, a home from the turn of the independence. through the streets of Georgetown, the > PATHWAY_47 PathWay #11 - Text 21/2/07 3:57 PM Page 48
Perhaps the strongest and most spectacular symbol of ‘Visit Malaysia Year 2007’ is the giant ‘Eye on Malaysia’ wheel, pictured here against the backdrop of the world’s largest towers, Petronas Twin Towers, Kuala Lumpur
The night markets draw crowds of both locals and tourists to enjoy one of Penang’s most highly regarded attractions: its food.
city already seems to have a permanent Staying in Batu Ferringhi, the stunning festival atmosphere. stretch of beach a 15-minute drive north of The night markets draw crowds of the city, I caught a daily glimpse of the both locals and tourists to enjoy one of Malaysian personality in every driver and Penang’s most highly regarded every journey to Georgetown and around attractions: its food. From the island’s the island. Every driver was keen to make famous char kway teow, a delicious dish sure my stay was enjoyable, offering of noodles and pork, to the delights of advice about food or a brief history lesson. freshly barbecued satay, cane sugar juice With daily tips and commentary in with lime and salted prunes, coconut the newspapers about welcoming pancakes or curry mee, the food here is visitors to Malaysia in this spicy, delicious, fresh and inventive. commemorative year, keeping tourists And everyone has an opinion about it happy seems to be a national challenge – especially the island’s well-informed, everyone is taking seriously. articulate and friendly taxi drivers. Ask one for a restaurant recommendation and With national pride at stake on this you’re likely to get a lively discourse on important anniversary of independence, the merits of Peranakan versus Malay or there’s probably never been a better Indian cuisine. time to go.
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VISIT MALAYSIA 2007
n this special year-long celebration of PENANG INTERNATIONAL Ieverything Malaysian, the country has DRAGON BOAT FESTIVAL put together an astonishing calendar that includes sporting and cultural events, JUNE 8–10 Colourful dragon boats race to get to the festivals and competitions, exhibitions finishing line accompanied by the and displays – and of course the year’s rhythmic beating of drums and the most important event, a nationwide cheering of the crowds. celebration in August to commemorate 50 years of independence. MALAYSIA MEGA SALE CARNIVAL JUNE 16 TO SEPTEMBER 2 TAMAN NEGARA ECO-CHALLENGE Amazing discounts and bargains are on MARCH 24–25 offer throughout Malaysia during this Malaysia’s world-famous national park is festival devoted to shopping. the location for this extreme sporting challenge, open to anyone interested in mountain running. KUALA LUMPUR FESTIVAL JULY 1–31 The country’s premier celebration of MALAYSIA GRAND PRIX CITY Malaysian arts and culture. FESTIVAL
APRIL 1–8 WORLD MUSIC FESTIVAL To coincide with the F1 Grand Prix, Kuala Lumpur will host a festival of entertainment JULY 20–22 and Grand Prix-related events. The beautiful surroundings of the Penang Botanical Gardens come alive to the sound of music and performances from NATIONAL WATER FESTIVAL around the world. APRIL 6 TO MAY 6 Water sports and activities are the focus 50 YEARS OF NATIONHOOD PENANG INTERNATIONAL of this festival in Langkawi which will LANTERN FESTIVAL AUGUST include the Labuan International Sea Throughout August, Malaysia will be SEPTEMBER 15 TO OCTOBER 14 Challenge, the Rolex IGFA International Celebrated in the eighth month of the devoted to the commemoration and Game Fishing Tournament, the Cross Chinese Lunar New Year, Penang lights celebration of 50 years of nationhood. up at night in a spectacular and colourful Channel Swimming Challenge, Round Events include performances by World display of lanterns big and small. Island Kayak Challenge and a grand Lion Dance troupes, the Malaysia closing ceremony. International Fireworks Competition, a grand parade attended by the King and KUALA LUMPUR FASHION WEEK JOHOR INTERNATIONAL ORCHID Queen of Malaysia and a Merdeka OCTOBER 27–31 SHOW (Independence Day, August 31) Eve Local designers compete for top awards concert, among many other local and and recognition as the best of Malaysian MAY 25–27 national celebrations. fashion grabs the spotlight. Showcasing orchids from all over the world, as well as Malaysia’s own WASPALM CONFERENCE MALAYSIA INTERNATIONAL exquisite varieties. GOURMET FESTIVAL 20-24 AUGUST The XXIVth World Conference of NOVEMBER 2–29 Malaysian and international chefs tempt COLOURS OF MALAYSIA Pathology and Laboratory Medicine will gourmands around the country with be held in Kuala Lumpur this year. The MAY 26 TO JUNE 10 special menus, demonstrations and Kuala Lumpur is the host of this festival theme is Meeting the Challenges of celebrations of all things culinary. devoted to Malaysian culture, featuring a Globalisation and Miniaturisation. For colourful line-up of food festivals, more information visit * For a full listing of Visit Malaysia 2007 events, parades, performances and exhibitions. www.waspalm2007.org visit www.tourismmalaysia.gov.my
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private passions
Sax appeal
BY DAY HE’S AN IMMUNOPATHOLOGIST, BUT N A W E C M WHEN EVENING FALLS DR RICHARD STEELE F F E J
: T I
LIKES TO IMAGINE HIMSELF AMONG THE D E R C
O
SMOKY JAZZ JOINTS OF 1950S NEW YORK. T O H KATRINA LOBLEY REPORTS. P
should probably have been born pre- president of the RCPA devotes time each considered one of the most influential “Iwar,” says jazz aficionado Dr Richard day to his lifelong passion. tenor saxophonists of all time. Steele. “But I would have had to be born “Playing the saxophone makes me Others to rate a mention are Charlie in the States and I probably would have to feel, on one level, more human as I can ‘Bird’ Parker of the 1940s, and John have been African-American to make it interact on a level outside the normal Coltrane, Ornette Coleman and Art work, I think. Or a heroin addict. professional interactions I have during my Pepper, who made names for themselves “Those are the two things that seem daily work,” he says. “On another level I in the 1950s and 60s. to make the best saxophonist.” feel more than human as it extends my It’s an impressive list, but not quite Despite suffering the indignity of being ability to communicate beyond language, complete. born in the swinging sixties and skipping voice and gesture.” the perils of drug addiction, Dr Steele is “I missed one of my favourites – Eric managing just fine. Dr Steele’s list of musical heroes is Dolphy,” he says. “He was also a bass While he’s currently without a band to long. One saxophonist who made a huge clarinet player. He was just amazing but display his musical talents, the impression on him is Lester ‘Pres’ Young, died very young. He died a few months immunopathologist and New Zealand vice a giant of the 1930s jazz scene who is still before I was born, actually.
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“Playing the saxophone makes me feel, on one level, more human”
“He was an African-American who also played in Europe – he played with John Coltrane and also with a guy called Charlie Mingus. He was an incredible sax player.” Dr Steele can trace his passion for music back to childhood. He started playing piano at six. Although he continued learning until the age of 16, he made the decision at 13 that the saxophone would be his instrument of choice. Did that change of heart have anything to do with girls? “No, no … I might be lying,” Dr Steele says, laughing. “I just really liked the sound of it at that particular point in time. I was a bit frustrated with pop music. The following
year, me and my parents went off to the N A W United States and we bought a second- E C M
F
hand saxophone in New York. Then I had F E J
: T
to paint their house for the next two years I D E
to pay them back.” R C
O T
Although he was strongly drawn to O H music and had grown up in Wellington, a P hotbed of jazz in New Zealand, the budding saxophonist moved to Dunedin – “very much a rock town” – to study medicine at Otago University. Prince Alfred hospitals in Sydney. It was Despite this hectic schedule, Dr “I joined a number of bands when I medicine’s turn then, to take control, with Steele puts time aside each day to pursue got to university – I had my own trio,” he music playing second fiddle. his musical passion. says. “It actually got as big as a quintet "What I like about the sound of the at one point. We performed what I would “That’s where music went into the saxophone is that its tone can reflect your call jazz standards but we also background, unfortunately, for a few years mood. It can sound soft and soothing to performed our own compositions – a bit there as I went through my studies and harsh and frenetic to even kitsch,” he says. of avant-garde.” worked and supported my family through “There is a mind–body thing going on, He also joined forces with several that period.” where you get back in touch with your post-punk bands and played in a soul/ He stayed in Sydney for 11 years body in a very creative way, similar to R’n’B covers band, which was often before returning to Wellington in 2003. many other pursuits such as dancing, booked for student balls – including his yoga and even sport." own graduation ball. Today, Dr Steele works as the clinical At home, Dr Steele is also recording After graduating, the allure of music immunopathologist at Wellington Hospital, and producing an album for Dunedin pop saw his medical career take a back seat. where he specialises in allergy-related band The Puddle, in which he played illnesses, autoimmune diseases, HIV and “Basically, I just played music for a many years ago. And he just might join a year,” he says. primary immunodeficiency conditions. band again one day. “We used to tour around the South “About 80% of my time is spent in the “I perform to the neighbours at the Island. That was great fun, actually. It was hospital and 20% is spent in the moment,” he says. a really great year.” community – there’s a laboratory in the “They haven’t called the police around community,” he says. He returned to medicine in Dunedin yet or the noise control officer, so I guess then emigrated to Australia, where he “I’m a sole practitioner and my referral that’s a good sign. I don’t squawk too trained in pathology at Liverpool and base is about a million, so it is busy.” badly.”
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travel doc
A tentacular sight at the markets in Naxos; inset: outside the lace shop in Kritsa, Crete.
PHOTOS COURTESY OF MICHAEL HARRISON AEGEAN PEARLS
DR MICHAEL HARRISON WAS SWEPT OFF HIS FEET BY THE ENDURING CHARM OF THE GREEK ISLANDS.
hen a Greek Islands guidebook Our best memories of Athens? At Piraeus, where we caught the ferry Wappeared in our house a few years Breakfast at the St George Lycabettus to the island of Crete, we were confronted ago it was inevitable we would head in Hotel with the panorama of central with another: Greek ferry-terminal that direction. So last June we set off, Athens, the Acropolis and the etiquette. No facilities, no queues, just a with sole child Princess Sally, 14, and basic concrete wharf with unloading and Mediterranean stretching out in front of niece of same age, Victoria, on a boarding in an uncoordinated frenzy of us; the Central Market; and the National Singapore Airlines flight to Athens pushing, blowing of whistles and beeping Archaeological Museum with its (something Qantas can’t offer). of horns, as pedestrians and vehicles Mycenaean gold and classical bronzes We were charmed by Athens: hot, compete for ramp space. recovered from the sea bed. windy and glary, but with friendly locals We were quite taken aback the first and ancient glories such as the Acropolis, Some of the quirks of Greece – the time but on the next seven occasions we the Temple of Zeus and the Agora all never finished building projects and got into the swing of things and just within walking distance. littering – we also saw in Athens. joined in.
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“Our advice to first-timers: don’t arrive at night by hire car, without a map, while staying in a hotel with pedestrian-only access”
Dr Michael Harrison, daughter Sally (right) and niece Victoria enjoy traipsing around Santorini.
Crete appeared in a soft cloudless Highlights of Crete included the ruins more significant after reading The Fall of sunset – mountains plunging down to the of the Minoan palaces of Phaistos Crete by Alan Clark. sea and arid olive-dotted hillsides. Our (Festos); Matala on the southern coast There was also Kritsa, a mountain first stop was our base for exploring with its Roman cave tombs; the Phaistos village that specialises in lace and western Crete, the charming old harbour disc in the Irakleion (Herakleion) embroidery, where purchases were made town of Chania. It’s also known as Xania, Archaeological Museum (probably the from the very lady who appeared in the Canea and Khania, with all four different guidebook. On hearing that niece oldest example of writing yet discovered); names appearing on road signs at Victoria was buying for her Grandma, and surprisingly, the Commonwealth War various times. she cluck-clucked with approval and Cemetery near Chania. Our advice to first-timers: don’t threw in a few extras. arrive at night by hire car, without a Unlike other public places in Greece, I went snorkeling at Chania and every map, while staying in a hotel with this was immaculately maintained and its subsequent destination – the clear blue pedestrian-only access... poignantly inscribed headstones even water was surprisingly cool despite air > PATHWAY_53 PathWay #11 - Text 21/2/07 3:57 PM Page 54
Going to extremes: soaking up the Agean view; squashing aboard the ferry at Piraeus.
temperatures of 30ºC plus. The range of spectacle of Santorini – thousand-foot we were atypical Greek Island tourists, fish and other marine life was interesting – black and red cliffs dripping with rejecting the sun lounges and the sea urchins were common, as were whitewashed stone buildings and blue- beaches and instead cruising historic beautiful jellyfish. Unfortunately the litter- domed churches plunging down to sites and museums. strewn land is replicated underwater: the cruise ships on the blue waters of the Finally – with some trepidation as its water is so clear you can easily see the flooded caldera. reputation of over-commercialisation plastic bags on the bottom. The panorama is simply entrancing, preceded it – we made it to Mykonos, and Our base in eastern Crete was but if you can wrench your eyes away found Mykonos town a delight. Elounda near Agios Nikolaos – beautiful from it there are ‘distractions’ such as The Greek Islands were everything we scenery and even better snorkelling. the 68 jewellery shops in Fira or a boat thought they’d be: blue sky, blue sea, blue A north wind blew 30 knots and trip to Nea Kameni. This barren island fishing boats and blue-domed churches; stayed with us for the rest of our time in emerged recently in the caldera formed white houses; wonderful history, relics and the islands. Our next leg – the by the devastating eruption of 1450 BCE. ruins; harbours and ferries. Crete–Santorini route – is long and Sulfur still issues from its fumaroles and unprotected, and the fast ferries were you can swim in a sea warmed by We skimmed the surface and dived cancelled for three days, forcing us onto a volcanic activity. the deep end and know we’ll be back to larger and slower ship-type ferry. The 1000-foot climb up from Fira port see some parts we couldn’t fit in this time. Santorini was worth waiting for. It’s on was made on donkeys by the girls, but we One place we’d always return to is my list of the top 10 places in the world I adults couldn’t subject the poor animals Santorini: it really is something special. have visited. to that and used shank’s pony instead. Next stop was Naxos – a bit like a We arrived in a moonlit Athinios Dr Michael Harrison is the CEO of Sullivan Harbour and next morning awoke to the mini Crete but with better beaches. Here Nicolaides Pathology.
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working holiday
Maltese moments
A WORK TRIP TO THE ISLANDS OF MALTA ALLOWED PROFESSOR JANE DAHLSTROM A BRIEF TASTE OF A COUNTRY WITH A FASCINATING ARCHITECTURE AND HISTORY.
he conference itself was memorable: Marika Fsadni, to show me round the Valletta, the fortified capital built by Tthe world’s experts in breast main island. the Knights of Malta who ruled over the pathology gathered together to honour Extremely picturesque, Malta is a islands from 1530 to 1798, is embellished the contribution of Professor John popular destination for diving and with some of the finest Baroque Azzopardi to the field. yachting enthusiasts. Its waters, caves architecture in the world. Malta’s war Focused and intensive, it was an and rocks, gentle hills and craggy cliffs museum is often a stopping-off point for important opportunity to learn from attract outdoorsy types all year round, pilgrims to Gallipoli. Many soldiers injured colleagues. But when it was over, the even in the cooler winter months. in the fighting in the Mediterranean were chance to relax for a day was welcome. My real interest, however, was in the tended to in the British hospital located Having never been to Malta, I was beautiful towns and villages. Their there during World War I. curious about this tiny group of islands in extraordinary limestone buildings and One of the first things you’ll notice the Mediterranean that joined the vibrant and unique culture have been about Malta is the wonderful golden hue of European Union in May 2004. I was influenced over the ages by various the islands’ limestone, from which so many fortunate that the Maltese High civilisations, from the Romans to the of the older buildings have been built. This Commissioner to Australia, HE Dr Ivan British, who prized Malta’s harbours and golden stone prompted the name ‘Melita’, Fsadni, had organised for his sister, Ms ports as a mid-point in the Mediterranean. which means ‘island of honey’, and it has > PATHWAY_55 PathWay #11 - Text 21/2/07 3:57 PM Page 56
IMAGES COURTESY OFWWW.CHOOSEMALTA.COM
been used for building throughout the Malta’s typically delicious I had just a day to explore the island islands for around 7000 years. Mediterranean cuisine focuses on seafood before returning to Australia but was very This very traditional Catholic country but you’ll also find Middle Eastern, North quickly charmed. I have no doubt I will be spending more time discovering Malta on (98% of the population is Catholic) African and strong Italian influences – and one of my next trips to Europe. naturally has some magnificent churches. the occasional British oddity. The St John’s Co-Cathedral is home As a visitor I felt warmly welcomed Despite the large number of tourists and appreciated. No wonder Malta has a to two masterpieces by Caravaggio, The (there are direct flights from most major reputation as the undiscovered gem of the Beheading of St John the Baptist and European cities) and all its modern Mediterranean. Saint Jerome. And in Mdina, the island’s ancient capital, you’ll find the stunning amenities, Malta remains well preserved. Baroque cathedral dedicated to Saint The islands have maintained their old-world Professor Dahlstrom is an anatomical pathologist and Professor at the Australian Peter and Saint Paul. charm and the locals are very welcoming. National University Medical School.
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recipe for success
class of hisRENOWNED CHEFown TONY BILSON TALKS TO WENDY LEWIS ABOUT HIGH-QUALITY PRODUCE, UP AND COMING CHEFS, AND THE STATE OF AUSTRALIAN FINE DINING. A I L O D N E M A
L E A H C I M
: T I D E R C
O T O H P
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“Great food is driven by generosity – a quality shared by most
Australians, one that we should celebrate more often.”
nyone unaware of Tony Bilson’s For a restaurateur, Bilson is something of We may blithely assume that Uluru, Acontribution to fine food in Australia a raconteur, not averse to taking Port Douglas and other hot spots will may well have been hiding under a entrepreneurial risks. keep overseas visitors flocking to our barrowful of fresh Périgueux truffles for This could be because he sees dining distant shores. But Bilson can quote the the past 40 years. One of Australia’s most not as some peripheral activity at the end figures. And the figures show that skilful chefs, Bilson has established and of a busy day but as a key element in a Australia’s hotel occupancy rates are transformed numerous eating nation’s culture. among the lowest in the world. The hardened urbanites among us may think establishments. Arts, architecture, sport, economics … we live in a thriving metropolis with the Along the way, he has challenged us food and drink? Do Australians see their best of the best on tap; perhaps such an to rethink the whole ethos of food in evening meal and themselves that way? assessment has a hint of self-delusion. Australia: its social aspects, its European And just how does Australia rate for the What about the difficulties in importing versus Asian influences and its place in discerning diner seeking a world-class (relatively small) quantities of exotic the nation’s identity. dining experience? produce? There are two schools of Early in his career, Bilson’s stint at the thought, Bilson says. Albion Hotel in Melbourne’s Carlton Restaurants can go through the brought new taste sensations of the très Room to improve In Bilson’s view, we’re sailing along quite rigmarole of bringing in out-of-season French kind to an eagerly receptive crowd. nicely in terms of mid-range dining. But produce to cater for the international palate. In the early 80s he was behind when it comes to first-class Or they can choose to use local produce or Kinselas, that brazen wine bar, restaurant establishments, it’s not so breezy. imported foods that are easily sourced. and cabaret that hit Sydney’s Oxford Tetsuya’s is a stand-out, he says. But Most establishments in Australia Street with a flourish. as for other international-standard favour the latter approach, using strictly His ambitiously chic restaurant restaurants, we still have room for seasonal produce to create dishes with a Ampersand (now L’Aqua) at Cockle Bay, improvement. Bilson pinpoints two factors local emphasis. It is a ‘brave few’, says holding us back: difficulties associated Darling Harbour was the talk of the town Bilson, who cater for the international with importing high-quality produce, and during the Sydney 2000 Olympics. market by procuring exotic, less readily our small market. available goods. And he is now the driving force behind Australia has a small population. We Bilson’s in the Radisson Plaza Hotel, Bilson suggests there needs to be a have long been constrained by our where one can savour the delights of reassessment of the way Australia is sold location and geography. We can increase internationally – and this applies to our Lasagne of Freshwater Marron Lobster or our market base by encouraging more national image as well as the goods we perhaps succulent Grimaud Duck, cashed-up visitors to our shores. That sell. There are many sorry tales of followed by an exquisite Tart of Pear with seems relatively simple. Australian companies selling themselves Almond Frangipane and Chocolate But consider the recent ‘Where the short through cultural misunderstandings Fondant… Bloody Hell Are You?’ campaign. As or mismanagement. He cites the example Bilson is well known for his penchant Bilson points out, it didn’t exactly attract of Australian beef in Japan: this was a for superb-quality French-influenced the elite – or anyone else for that matter – quality product, branded well, that failed cuisine. He is equally prominent for his even if it was a supposedly clever re- miserably because it was so heavily long-term stance against the so-called invention of Paul Hogan throwing another discounted in Japan that customers ‘fusion’ approach to much Australian shrimp on the barbie as he did ad wrongly perceived it as cheap and nasty cooking today. nauseum in the 80s. and turned away in droves.
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PHOTO CREDIT: MICHAEL AMENDOLIA
But all is not lost. It does well to This insight gives them a brilliant taste for languid al fresco breakfasts is reflect on the positive aspects of headstart in the use of aromatic flavours, nothing new. Australian culture when it comes to fine spices and unusual taste combinations. Long will Australia’s talented chefs dining: our widespread Italian/Southern Even a Francophile like Bilson gently yet deftly shape this nation’s French approach to cooking which is tactfully suggests that the French can be culinary scene. And Bilson will continue to healthy and climatically appropriate; the a little heavy-handed with their use of, create signature dishes – especially duck importance given to the matching of say, Indian spices, simply through their in all its glorious forms – with his wines and food; and the availability of lack of familiarity. inimitable style. In the past he has led fresh foods, especially fruit. How far have we have come as a gastronomic tours in France, fusing travel nation in our attitudes to food? Have we and dining. These days, his energies lie in become more aware of the importance of his restaurant, especially in mentoring emerging talents. Sunny side up presentation, variety and good nutrition? The trend for extended breakfast-cum- Bilson would say that Australians have In his own home, he opts for the brunch is also a good thing: anything that simple pleasures. Roasted and grilled long been aware of these issues, despite creates a leisurely, pleasurable and social meats, the barbie on the balcony, an our past reputation as a nation of bread- dining experience gets the thumbs up abundance of seasonal vegies and loads and-dripping eaters. from Tony Bilson. of fresh fruit, sitting down for an enjoyable He cites Philip E. Muskett’s seminal meal with his wife Amanda and two Also, up and coming young Australian The Art of Living in Australia, first published teenage children. chefs are well-regarded overseas, he in 1893. This book encourages a “Great food is driven by generosity – a says, for their ‘can do’ attitude and Mediterranean-style approach to eating quality shared by most Australians, one that winning approach to creative cookery. We and drinking as it is well suited to our we should celebrate more often,” he says. may be a world away from European climate. It also features handy hints such trends, but young chefs based here have as detailed instructions for the making of a Relaxed social interaction coupled something rather special, having grown up French salad, and expounds on the with simple and delicious foods: this is the in a culture that has long been exposed to possibilities for Australian viticulture and art of good eating. the flavoursome world of Asian cuisine the monotony of the Australian breakfast, If we can get that right, says Tony and its influences. with a plea for something better. Clearly the Bilson, we’re not doing too badly at all.
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the good grape
GIVE US THIS DAY OUR DAILY RED
A new take on the ‘French paradox’ gives a bitter twist to the saying ‘what’s your poison’, writes Ben Canaider. he wine diet. It was only a matter of time, I suppose. want to eat fatty foods lest it makes them, well, fatty. Not to TEvery other area of human endeavour has been so ‘lifestyled’ mention unhealthy. Oh dear. that it’s a wonder wine has stayed below the radar. Except for a This is where Professor Corder’s wine diet idea falls over. He new book: The Wine Diet, written by Roger Corder, a is recommending gruff red wine styles that are not really cardiovascular expert and professor of experimental therapeutics beverages. He thinks the best way to dilate your arteries is to at the University of London’s William Harvey Research Institute. drink some of the most undrinkable reds in the world – and to This is a volume on the positive effects of moderate red wine drink them young, to boot. Take Madiran, for instance – the Biro- consumption, but the idea is not new. Popularised by the 1983 ink red from the south of France. Anyone drinking this young American 60 Minutes report on the so-called ‘French paradox’, would not only be called mad, but also convicted for infanticide. this 17-minute television endorsement sent red wine Corder also uses his platform of wine dieting to overlook consumption – and wine consumption overall – sky-rocketing, what the true role of wine is: to relieve the mundane, irksome helping wine beome the beverage phenomenon that it is today. nature of our day to day. If we spend that day satisfying our The French paradox suggested that despite high tobacco and moronic food dieting needs, what role can wine then properly alcohol consumption, southern French farmers lived longer and play when we get home and try to relax? healthier – all thanks to red wine. Wine is not a diet pill, nor is it an excuse. It is unalloyed relief, This have-your-cake-and-drink-it-too mentality appealed to a which is a point Corder’s book mostly overlooks. lot of Americans. And many others besides. But there are problems at all points of wine’s new dietary, The Wine Diet is the latest generational manifestation of this healthful veneer. Paradox idea. The World Health Organization still recommends three Professor Corder’s thesis – much like the French paradox standard drinks a day for the average human: four for men; two theory – rests on polyphenols. These are the compounds found for women, with two alcohol-free days a week. in red grape skins and seeds – the very same vehicles that give us tannin and astringency in wine and provide red wine with its The sum of the parts is about three 150 mL units of table longevity. Cabernet, for example, has high tannin levels, which is wine every day: a pint for men and a half-pint for the ladies. For part of the reason it needs time to mature in your cellar. the genderless average that’s 450 mL a day, five days a week. Or But back to Corder’s theory. Polyphenols are full of flavonoids. 2.25 litres a week. Or 117 litres a year. That’s about 88 bottles, The best sorts of flavonoids are the procyanidins, which make for give or take the odd bit of spillage, breakage or corked wine. For a drying effect in your mouth when you swallow wine. men, 156 litres per annum; for women, 78. Therefore 117 litres of wine per capita, on average, is in accordance with safe wine- They have a second job, however: they act as antioxidants, drinking guidelines as formulated by the WHO… and help metabolise fat and protect you from the bad LDL cholesterol. The French nowadays drink just less than 60 litres per capita; More importantly Professor Corder likes the way these ditto the Italians – indeed, they are now closer to 50. The USA’s compounds dilate blood vessels, thereby reducing blood proud and free consumers average about nine litres; Her pressure. Apparently this is good if you have heart disease… Majesty’s loyal subjects in the UK quaff about 17, but that’s rising. The Austrians drink 27, which puts Australians to shame; The only problem is the way red wine is now made. Australians – people who grow, make and sell so much of the Corder believes that more polyphenols are found in red wines New World’s wine – only drink about 20 litres per capita. And made very traditionally: hand-picked, basket-pressed, unfiltered that’s been stable for about a decade and a half. sorts of red wines. Red wines, in other words, fit only for heroes. No-one anywhere else in the world comes close to the However, most red wine nowadays is made with an eye to WHO’s recommendations. immediate comfort. Old-fashioned reds need time in the bottle to soften, or they need fatty foods to assuage the tannins in the wine. Maybe then we all need to go on a PlentifulWine Diet? Here we strike another problem: not only do people nowadays not like astringent, manly red wine, but they do not The Wine Diet by Roger Corder is published by Little Brown.
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diningout
Good Morning
The ricotta hot cakes, caramelised bananas, macadamia and Restaurant Lurleen’s praline ice cream and maple syrup are wonderful and on those ost breakfast menus in Australia pay homage to English special days when celebrating are an ideal accompaniment to Mtraditions and Restaurant Lurleen’s, just south-east of the sparkling NV Vineyard Selection Brut Reserve ($7 per glass). Brisbane, is no exception. Grilled WA sardines with semi-dried tomatoes, parsley and Offering old favourites such as eggs Benedict, Lurleen’s basil butter accompanied by thick-cut sourdough toast are a version features toasted English muffins, spinach and robust flavour hit without being overwhelmingly large. The hollandaise sauce, and a choice of leg ham or smoked salmon coffee is superb, service attentive and friendly, and the well- to accompany this well-presented dish. There is also grilled credentialled reputation suggested by the restaurant’s many black pudding with minute steak, fried eggs, tomato, chips and toast. Or superbly subtle English herb and pork sausages in awards is supported by the breakfast experience here. the big breakfast, which also includes bacon, hash browns, Lurleen’s, led by high-profile executive chef Andrew Mirosch, baked beans, corn fritters and Portobello mushrooms. And if overlooks the 240-hectare winery site, most of which is planted you choose, most of these items can be ordered as sides to with grape vines (heavily laden at the time of our visit). satisfy the most committed Anglophile. With distant views over Moreton Bay to Stradbroke Island, this There’s a big focus on fresh produce at this establishment, restaurant has become a destination in its own right. located at Sirromet Wines, between Brisbane and the Gold Coast. Although it’s often heavily booked for lunch and dinner, breakfast is a great way to secure a table here and sample Much of the produce is grown in the winery’s organic kitchen garden on site (including all the eggs), and the best of locally Sirromet’s wares. To my mind, it remains the best-value grown fruit and vegetables also flavours what is on offer first breakfast in and around Brisbane. thing in the morning. - Louise Martin-Chew Restaurant Lurleen’s at Sirromet Wines Our mid-summer breakfast included warm banana bread with 850–938 Mount Cotton Road, Mount Cotton, Qld honey yoghurt, local Redlands strawberries, and roasted Ph: (07) 3206 2999 almonds – a sweet yet piquant quartet for those who don’t Breakfast available Mon–Sat from 9am, Sunday from 8am favour a savoury start to the day. About $40 for two > PATHWAY_61 PathWay #11 - Text 21/2/07 3:57 PM Page 62
Bottom left & left: Urban Bistro, co-owner and chef Bethany Finn Below: Lurleen’s Right: Cafe Xeons
Egg dishes, all free range, start with simple scrambled eggs Urban Bistro with pancetta, asparagus and grilled sourdough, and move ny place that offers you 1990 Krug Champagne at 7.30am through about nine options to a sensational stir-fried blue Aobviously takes breakfast very seriously. swimmer crab omelette. Okay, instead of forking out $500 for a bottle you could opt It’s hardly necessary, but you can bolster these dishes with everything from hollandaise sauce to extra servings of instead for a glass of Barossa Valley moscato at $7.50 or even a asparagus. Bloody Mary, but most people choose something like freshly squeezed organic ruby grapefruit juice or an apricot lassi. Teas and coffees are top class, including jasmine white tea and spiced chai (Indian-style sweet tea with milk), or even a Even sweaty joggers sitting down to breakfast at Urban don’t fortifying corretto (a short black with a dash of grappa). smell quite so sweaty, such is the civilising influence of this There’s also a good list of sparkling wines by the glass for those great breakfast spot overlooking Adelaide’s famed parklands special breakfasts. and the Victoria Park racecourse. - Nigel Hopkins This is the sort of place people go when they can’t be bothered Urban Bistro cooking at home, but don’t want to put on airs and graces, let 160 Fullarton Road, Rose Park, Adelaide Ph: (08) 8331 2400 alone the family pearls. Breakfast available Tues–Sun 7.30–11.30am, weekends 8.30–11.30am In other words, Urban is very much a suburban bistro whose About $50 for two, plus the Krug style is that of a large, modern – even sharp-edged – private dining room. The Green Grocer It’s comfortable and relaxed, with a large communal table for art organic grocery store, deli, bakery and cosy little café, those inclined that way, and is especially popular at breakfast, PThe Green Grocer is a Melbourne inner-city institution with a which is huge here at weekends. dedicated fan base devoted to its organic produce and delicious food. It’s a good early-morning stopping-off point for city-bound business folk during the week, or an early-morning meeting The first fully licensed organic café in Australia, The Green venue for a genteel start to the business day. Grocer quickly gained a reputation for its innovative modern food made with local organic produce and although it may The breakfast menu has to be the best in Adelaide and offers a sound like a relic from the 1970s, this funky little café and great range of options. foodstore has a modern aesthetic and atmosphere that sits very At the simplest – and probably healthiest – end of the menu are comfortably in the noughties, dishes such as bircher muesli with grated apple with toasted The chefs at The Green Grocer pay just as much attention to almonds, or a chilled melon and citrus salad with Cointreau the way food tastes as to how it will affect both the environment syrup and Greek yoghurt – though it’s easy to be tempted by and your body and this is reflected in their delicious breakfast, dishes like the grilled crumpets with caramelised apples and brunch and lunch menu that embraces modern Australian, toasted walnuts. Asian and Meditterranean cuisines.
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Take these breakfast staples for example: two large herb and fetta pancakes topped with the Big Breakfast of fried organic bacon and eggs, or switch herb and fetta pancakes for corn fritters with smoked salmon, relish and sour cream for an even more indulgent start to the day. These are breakfasts that will definitely have you skipping lunch so if you’re not in the mood for such an over-the-top indulgence you’ll also find home-made porridge with loads of nuts and juicy sultanas, fresh fruit salad, sweet and savoury muffins and Cafe Xenos decadent cakes on the menu, as well as smoothies, fruit juices afe Xenos has been a Sydney ‘institution’ for almost four and excellent coffee. Cdecades. Proprietor Peter Xenos recalls working as a young The café and garden courtyard are compact so there isn’t much man in what was then his father’s business back in 1969. elbow room for those who like to spread out the newspaper with Peter’s personal involvement in the day-to-day running of the their breakfast but the limited tables generally mean service is cafe restaurant – with the help of sons Tim and Dennis – is part quick and efficient. of the appeal for the cafe’s loyal following on Sydney’s lower Unfortunately, the popularity of The Green Grocer means North Shore. weekends can be a bit of a crush so if you don’t arrive early you Their Eggs Benedict, one of the best in Sydney, is also part of may have to wait for a table. the reason for their unwavering reputation. Served with either smoked salmon or bacon ($14), its generous serving of While you’re waiting, take the opportunity to re-stock the pantry Hollandaise sauce is a perfect balance of creamy and tangy that with fresh fruit and vegetables, super creamy organic ice-cream brings the dish to life (even if your cardiologist disapproves). and other dairy products, and The Green Grocer’s pre-cooked take-home meals. If Eggs Benedict is not your thing, the menu includes a wide range of options including scrumptious French toast ($7), fresh As with most organic food cafés you’ll pay a premium for fresh ricotta with strawberries and Turkish pide toast ($8), or a rich produce and food but the care with which your food will be smoked salmon omelette with tomatoes, avocado and hash cooked and presented will be worth it. browns ($15). Whether you’re a supporter of organic food or not, you’ll have to Xenos is also open for lunch or dinner, but is best known for its admit there’s something special about the food at this weekend breakfast/brunch fare, making Sunday morning establishment. reservations a must – as those in the know, know. - Justine Costigan - Andrea Plawutsky The Green Grocer Café Xenos 217 St Georges Road, North Fitzroy, Melbourne 7 Burlington Street, Crows Nest, Sydney Ph: (03) 9489 1747 Ph: (02) 9439 1748 Open 7 days 9am-4pm Breakfast available Mon–Sat from 7am, Sunday from 8am About $45 for two for breakfast About $35–40 for two
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rearview X I P S W E N
: T I D E R C
O T O H P
onFROM PEEING fertileON BARLEY TO WARM BATHS FORground TOADS, EARLY-PREGNANCY TESTS HAVE COME A LONG WAY, RECOUNTS DR GEORGE BIRO.
n 1956, Russia invaded Hungary and Sydney Symphony Orchestra after being Nicolaides Pathology (SNP) has an IAustralian troops in Malaya saw their first caught with erotic photographs at Mascot international reputation and employs action. Robert Menzies’ minister for airport. nearly 2000 people. supply Howard Beale assured Parliament That same year, in a basement in the The world has changed exponentially that the nuclear explosion at Maralinga in Brisbane suburb of Wickham Terrace, Dr in the last quarter of a century, but so has South Australia was quite safe. John Sullivan established a small pathology, says the company’s CEO and And world-famous conductor Sir pathology laboratory. Dr Nick Nicolaides managing partner Dr Michael Harrison. Eugene Goossens resigned from the joined a year later, and now Sullivan Lyn Krebs wouldn’t disagree.
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Those were the days: Lyn Krebs would inject female human urine into the lymph sacs of male toads.
When she joined the company as a if not, it was negative. After testing, the abnormal pregnancies will ensure they still young Lyn Rouillon back in 1963, days in toads would be given a break of five play a key role. the laboratory were always interesting, but weeks before being used again. However, they’re just one weapon in the evening work was a little more unusual. All this would come to an end in the the armoury of tests that have become Just as Dr Sullivan had done before 1970s. Antibody-based tests such as the mainstay of modern pathology. Labs her, Mrs Krebs would finish up at the lab latex agglutination and radio receptor such as SNP offer now offer more than and find her way with a torch to a nearby assays eliminated the need for nocturnal creek to hunt male cane toads. 500 tests, some in newer fields like toad hunts and warm toad baths. molecular pathology, immunology and She’d take the toads in a damp sack These days, automated immunoassay cytogenetics. to her mother’s laundry and determine pregnancy tests (using serum rather than their sex. The females she took to the These lead to more precise diagnoses, urine) yield accurate quantitative results, Queensland University physiology lab; and in turn to more specific, tailored Dr Harrison says. Such tests also usually the males to the path lab. For each toad treatment. a bounty was donated to the local Boys’ become positive around day 21 – before It’s little wonder Dr John Sullivan takes Brigade, some of whom would help her the first missed period. pride in the lab he founded 50 years ago. at the creek. But the proliferation of simple and Such was the complicated nature of accurate testing kits used at home or in After 43 years, Lyn Krebs still works pregnancy testing nearly 50 years ago. the GP surgery hasn’t eliminated the need there. She no longer hunts male cane No simple home-based urine tests, but for lab-based pregnancy tests. Dr toads at night with a torch, but there’s a labour-intensive search for male toads, Harrison says their superiority in early or plenty of other work to do. which produce sperm when exposed to human chorionic gonadotrophin (HCG). A pregnant woman’s placenta produces large amounts of this peptide Animal, mineral, vegetable hormone, which passes into the bloodstream and the urine. ver the centuries, men and women have searched for tests to detect early HCG is necessary, especially in the Opregnancy. About 1350 BCE, an Egyptian papyrus asked women to urinate first trimester, for pregnancy to continue. over several days on seeds of wheat and barley. But when given to male toads, it If the barley grew, she would have a boy; wheat growing meant a girl, but if stimulates the testicles to produce sperm neither grew, she wasn’t pregnant at all. and this is the basis of various bioassays, Apparently this method often worked well. including the ‘toad test’. From the Middle Ages to the eighteenth century, ‘piss prophets’ claimed that Try telling this, though, to a suspicious just by looking at urine (or even tasting it) they could diagnose not only pregnancy policeman who finds you rustling around but also various diseases. in the bushes at night. During the 1920s, scientists identified HCG, found in pregnant women. Back at the lab, staff would keep the Ascheim and Zondek described their (A–Z) test for urinary HCG. They injected male toads away from the females for a urine into an immature female rat or mouse; if the animal then went on heat, the week to avoid ‘amphibian amours’ leading test was positive. These tests took at least four days. to false-positive results. Others developed bioassays using toads, rabbits or frogs. In winter, when toads normally But these tests were still slow, insensitive and meant killing animals to assess hibernate, they would give the cold, their response microscopically. sleepy males a warm bath and stretch By the mid-twentieth century, when SNP was formed, scientists were their limbs before starting the test. developing in vitro tests on cells (immunoassays, rather than bioassays) in which Mrs Krebs would take two male toads no animals were killed. and inject a measured volume of female In the twenty-first century, women still want to know as soon as possible human urine into the lymph sacs of each whether they are pregnant. toad’s legs. But some women say they don’t need tests. A friend told us how excited she After at least six hours, she would was about her very first pregnancy. We politely asked when the baby was due: catheterise the toads and check their urine under a microscope. If she saw “Oh, about nine months from last night.” many active sperm, the test was positive;
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2007 Conference Calendar
2 5 Practical Pathology Seminars Dermatopathy 2 - 6 May 2007 5 - 8 June 2007 Cancun, Mexico Las Vegas, USA www.uscap.org 18 3 The Virology Master Class Viruses In May 18 - 29 June 2007 3 - 5 May 2007 Adelaide, Australia Katoomba, Australia www.sapmea.asn.au/virology2007 [email protected] JULY 2007 8 15 XXth International Symposium on Technological Innovations in AACC Annual Meeting Laboratory Hematology 15 - 19 July 2007 MARCH 2007 8 - 11 August 2007 San Diego, USA Miami, USA http://www.aacc.org/AACC/events/ann_meet/annua 2 l2007/ http://www.islh.org/2007/ Pathology Update 2007 2 - 4 March 2007 27 22 Sydney, Australia 9th Indo-Pacific Congress on Legal [email protected] 5th Asia Pacific International Academy of Pathology Congress and Chapter of Medicine and Forensic Sciences Pathologists Annual Scientific Meeting 22 - 27 July 2007 APRIL 2007 27 - 31 May 2007 Colombo, Sri Lanka [email protected] 23 Singapore [email protected] Focus 2007 AUGUST 2007 23 - 26 April 2007 JUNE 2007 Manchester, UK 16 [email protected] 3 First World Congress on Pathology 11th Greek Australian International Informatics (WCPI) 27 Legal & Medical Conference 16 - 17 August 2007 CIDM Public Health Symposium 3 - 9 June 2007 Brisbane, Australia Series 2007 Crete, Greece www.pathologyinformatics.org/ 27 April 2007 [email protected] Sydney, Australia 20 [email protected] 3 24th World Congress of Pathology and 17th IFCC – FESCC European Laboratory Medicine MAY 2007 Congress of Clinical Chemistry and 20 - 24 August 2007 Laboratory Medicine Kuala Lumpur, Malaysia 2 3 - 7 June 2007 [email protected] ICPMR Immunology Course The Netherlands 2 - 4 May 2007 Sydney, Australia [email protected]
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postscript
hard act to follow
HE WAS BOLD AND EVEN BRILLIANT, BUT COLOURFUL MEDICAL PIONEER JAMES EDWARD NEILD HAD HIS FAIR SHARE OF PUBLIC HUMILIATIONS, WRITES WENDY LEWIS.
is Sherlock Holmesian reputation as a He also had a penchant for the bizarre Hforensic pathologist ensured James – like the sorry saga of the young bride
Edward Neild was never far from the E from Tasmania who sadly died on her N R
public eye. U wedding night from ‘sexual excitement’. O B L This founding figure of the AMA was E M
The mid to late 1800s were formative F O unperturbed by the publicity that dogged Y times for medicine. A new kind of T I
him in his regular attempts to solve S R
E practitioner – the ‘specialist’ – was V I
controversial murders. N U
emerging and Australian doctors were a , M
Probably his most famous case was U
E world away from cutting-edge discoveries. S that of Frederick Deeming, whose trial U M
Y Naive diagnoses were not uncommon electrified Melbourne society in a way not R O T
S and this was apparent in Neild’s work as a I
seen since Ned Kelly. H
L
A forensic pathologist. C Deeming, who went under several I D E
M He was appointed a foundation
aliases, was a bigamous cad who : T I D
E clinical lecturer in forensic medicine at the
murdered his wife and four children, R C
O University of Melbourne in 1865, a post he
buried them under a hearth in Lancashire, T O H
and then jaunted off to Australia. Once P held for nearly 40 years. Although not here, he did exactly the same thing to his Forensic pathologist James Neild revelled in especially qualified to even assume the new wife. the ‘theatre’ of medicine. position, Neild became much in demand He was considered second to Jack as a medical witness and post-mortem the Ripper in notoriety and as a result, the expert. He presided over a number of case came to prominence in newspapers One such victim was the unfortunate triumphant discoveries as well as some all over the world. American actor McKean Buchanan. grossly embarrassing misdiagnoses. Neild was acting coroner at the 1892 “Let me tell you, Mr B,” Neild wrote in In one post-mortem, where a woman’s inquest into Deeming’s last victim and the 1856, “that a good deal of your Richard throat had been slit, he found a sliver of courtroom was an entertaining mix of the Third was violent, boisterous and crockery under her skin and pronounced theatrics and forensics, with both unnatural, and a good deal more of it silly that her death was the result of a freak protagonists not accustomed to sharing and puerile; that you maltreated accident with a broken plate and not centre stage. In the end, justice was served. Shakspeare [sic] with a relentless cruelty murder, as had been assumed. Deeming was committed to stand trial and enough to make his dust rise in a Another, where his interests in theatre was found guilty as a matter of course. whirlwind and choke you…” and forensic medicine collided, proved to Neild was equally at home alienating The unfortunate actress playing be Neild’s biggest faux pas. He was actors with his caustic critiques. His Adalgisa in Bellini’s opera Norma also summoned to the hotel room of a dying passion for the theatre saw him emerge came in for a beating. Nield declared her theatrical agent and found the man as Australia’s leading theatre critic during fulsome bosom inappropriate for a virgin stretched out in bed, neck and mouth the second half of the nineteenth century. of the temple, a view not necessarily covered in blood. Neild diagnosed a burst Arriving in Australia in 1853, he had shared by the theatre management: when blood vessel. Moments after he had gone, studied surgery at London’s University he next took his usual seat, he was it was discovered that the poor man had College but never completed the degree. politely asked to leave. shot himself twice in the chest. After starting a general practice, he Neild’s way with words made him a discovered he could get free passage to worthy editor of the Australian Medical Ah, but the most gifted among us are Australia as a ship’s doctor so, being 29 Journal in 1862, a role he performed but mere mortals. years old and single, off he went. admirably – and with a great deal of James Edward Neild made his fair editorial freedom – for 16 years. He began his journalistic assault share of mistakes and raised many writing theatrical reviews under the name He was ahead of his time in publishing hackles, but he will be fondly remembered of Christopher Sly, the tinker from The local cases, rather than simply reprints of for his literary accomplishments, his sharp Taming of the Shrew. He was not averse to overseas material, and covered studies on wit and the contributions he made to the offending fellow journalists and certainly a range of topics including hydatids, the field of medicine in that brave new world didn’t mind sticking the knife into actors. medical uses of ozone, and septicaemia. of nineteenth-century Melbourne.
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