Winter 2013 - Sydney Adventist Hospital

Hip Replacement in the
Younger Patient
Dr Hagop Kiyork
Dr HAGOP KIYORK
MBBS(UNSW), FRACS (Orth), FAOA
Dr Kiyork has a particular interest in surgery of the knee and
hip providing joint replacement and arthroscopic surgery.
Dr Kiyork practices at Sydney Adventist Hospital and Hornsby
Public Hospital. P: 9979 1273 E: orthosurgery@bigpond.com
W: www.orthosurgery.com.au
The demand for primary total hip replacement
(THR) has steadily grown with the data from the
Australian Orthopaedic Association National
Joint Replacement Registry (AOANJRR)
confirming this trend. The number of hip
replacements (primary partial, primary total and
revision hip replacement) in 2011 was 39.2%
higher than in 2003. 1
Over the decades, THR has proved in the
majority of instances to be a highly successful
procedure. Many recipients attest to this fact.
With an ageing population, the demand will
only rise.
In the early days of joint replacement surgery,
THR was offered mainly to elderly, so called,
low demand patients. The younger patient with
an arthritic hip, or perhaps osteonecrosis, was
counselled to live with their symptoms until they
were “old enough” or in some cases offered
an arthrodesis, a procedure now seldom seen.
However, there are younger patients, under
60 and some under 55 who have disabling
disease of the hip joint with a desire and realistic
expectations of returning to high functional levels
with a THR.
Many conditions can predispose the patient
to early onset hip disease. These include
developmental dysplasia of the hip (DDH),
a history of Perthe’s disease, trauma and
osteonecrosis. This is in addition to idiopathic
osteoarthritis and rheumatoid disease.
This group’s expectations of life differ from
previous generations, and continuing with an
active lifestyle is very important to many in
this demographic. THR in this age group has
been shown to be a successful procedure with
excellent quality of life outcomes.
The issue of patient age and THR is largely,
but not solely, centred on the potential need
for revision surgery in the ensuing years.
An elderly low demand patient will likely be
served for the rest of their life with a single
primary THR. A young patient however (

SAN DOCTOR WINTER 2013
CANCER GENETICS
Dr HILDA HIGH BSc, MBBS (Hons), MCH, FRACP
Dr Hilda High
Dr High is a registered medical oncologist specialising in cancer genetics. She works at
Sydney Cancer Genetics at the San Clinic having spent two years working in hereditary
cancer services at the Prince of Wales, Westmead and Royal North Shore Hospitals. Dr
High is the recipient of the UNSW Master of Community Health Prize after undertaking her Master in Community Health.
A key member of the Cancer Institute’s eviQ group Dr High has worked with national experts to provide standardised
Australian guidelines for the testing and management of inherited disorders associated with cancer.
P: 9473 8833 W: www.SydneyCancerGenetics.com.au.
Outline
The area of cancer genetics is expanding
rapidly. This article clarifies the difference
between somatic and germline mutations.
It also discusses genetic assessment and
testing, using the Breast and Ovarian
Cancer syndrome (associated with BRCA1
and BRCA2 mutations) as an example.
Cancer and Genetics
All cancer is a genetic disease. It is
caused by mistakes (mutations) in key
genes involved in apoptosis, cell cycle
progression, growth, differentiation and
adhesion. These somatic (acquired)
mutations are usually random. They
occur when a dividing cell makes an error
copying its DNA and they accumulate
over time. Hence most cancer occurs at
an older age (e.g. breast cancer occurs
at an average age of 60) and is why
mammographic screening programs start
at 50.
Knowing what somatic mutations are
present in a particular tumour is important
for Oncologists. It is possible to block the
effect of a mutation that is driving cancer
growth with a targeted therapy. A well
known example is treating a breast cancer
with HER2 over-expression with a HER2
blocking agent such as Herceptin.
Somatic mutations, while important, are
not heritable. For example, the mutations
that have turned a breast cell into a breast
cancer have occurred in the DNA of the
breast cell only. (See Figure 1). These
mutations are not present in the germ cells
and so cannot be passed on to offspring.
Figure 1.
Inherited Cancer syndromes
Cancer syndromes are caused by inherited
mutations in tumour suppressor genes
(including DNA repair genes such as
BRCA1 and BRCA2) and oncogenes. Most
are autosomal dominant, in that only one
faulty copy is required, either from paternal
germ cells (sperm) or maternal (ovum). (See
Figure 2).
Figure 2.
These inherited mutations are rare. They
are responsible for only 2 to 10% of
all cancer. However, for the individual
carrying the mutation, the risk of certain
cancers can be significantly increased. For
example, while the average lifetime risk
of breast cancer for an Australian woman
is around 10%, for an Australian woman
with a BRCA1 or BRCA2 mutation it is 50
to 60%. For ovarian cancer the risk jumps
from 1% to between 20 and 40%. 1 While
these are significant increases (i.e. the
“penetrance” of these syndrome is high),
not every individual who carries a BRCA1
or BRCA2 mutation will get cancer.
Who to refer to Hereditary Cancer
Services
Genetic Oncologists and Hereditary
Cancer Services provide specialised
medical services to individuals and families
affected by cancer. These services include
risk assessment, genetic counselling and
testing, cancer risk management and
family planning information. But how to
know who to refer
Taking a detailed family history in a busy
GP or specialist practice is not feasible.
However, even brief questioning about the
family history of cancer (remembering to
include the paternal side) can be revealing.
A rule of thumb is to refer if there are 3
blood relatives with cancer, covering
2 generations where ≥1 relative
was diagnosed

Acute Lumbar Disc
Herniation/Sciatica
Dr Randolph J Gray
Dr Randolph J Gray MBBS(Hons), FRACS(Orth), FAorthA
Dr Gray is a fellowship trained Spinal Surgeon. He undertook training in adult and
paediatric spinal surgery in Toronto, Canada. His scope of practice includes paediatric and adult spinal disorders including
surgical management of paediatric scoliosis, adult degenerative and deformity, spinal trauma and tumour surgery. Dr Gray
also has a special interest in minimally invasive spinal surgery (MISS). Dr Gray operates at Sydney Adventist Hospital, Royal
North Shore, Westmead Childrens’ and Westmead Teaching Hospitals. P: 1300 859 500
E: admin@sydneyspinespecialists.com.au W: sydneyspinespecialists.com.au
Is a vegetarian diet adequate
Meeting the Nutrient Reference
Values on a Vegetarian Diet
Carol Zeuschner
CAROL ZEUSCHNER B.Ed(Sc), MAppSc(Clin Chem), PhD(Pharm)
Carol Zeuschner is the Assistant Director of Corporate Services Hotel Services at the San with her role overseeing the
Nutrition & Dietetics, Food Service and Hospitality Departments. Commencing her career at the San as a Clinical Dietitian
and later as Dietetics Manager, Carol has an active interest in enhancing nutritional care in hospitals. Carol has co-authored
a number of review papers on vegetarian nutrition. P: 9487 9570 E: zeuschner@sah.org.au
SAN DOCTOR WINTER 2013
introduction
Lumbar radiculopathy also commonly
known as sciatica is a very distressing
symptom. Although the aetiology changes
with age the presentation can be very
similar. The commonest age of presentation
is 45-64 years. 1 The distribution of the
follows a dermatomal pattern, which if
mapped accurately allows one to make
an very accurate clinical diagnosis of the
compressed and irritated nerve root. (See
figure 1).
Lifetime prevalence of lumbar radiculopathy
is reported to be 5.3% in men and 3.7%
in women. 2,3 Natural history studies have
shown that lumbar radiculopathy due to
acute prolapsed discs resolve spontaneously
in 23-48% of patients. Up to 30% will have
pronounced symptoms after one year, 20%
will be out of work and 5-15% will undergo
surgical intervention. 4-6
Figure 1.
Assessment
It is important to accurately map the
distribution of the pain. Using this
diagrammatic representation of the pain it is
often possible to make a accurate diagnosis
of the level of pathology.
Segmental Innervation of Lower
Limb Muscles
L3± Knee extensors (quadriceps)
L4± Ankle dorsi exors (tibialis anterior)
L5±Long toe extensors (extensor hallucis
longus)
Observed Power
Total paralysis 0
Palpable or visible contraction 1
Active movement, full range of motion (ROM), with gravity eliminated 2
Active movement, full ROM against gravity 3
Active movement, full ROM against moderate resistance 4
(Normal) active movement, full ROM against full resistance 5
Not testable
Table 1. MRC Grading and Myotomal Innervation
S1± Ankle plantar exors
(gastrocnemius, soleus)
A detail history of bladder and bowel habits
is very important as it could be the only sign
of cauda equina syndrome.
A comprehensive neurological assessment is
imperative. This should include a assessment
myotomal power based on MRC grading
(Table 1), sensation, reflexes and long tract
signs. Specific tests for nerve root irritation
(ie tension signs) such as a straight leg
raise (SLR) and a cross leg SLR is useful in
assessing the degree of nerve root irritation.
Patients presenting with sciatica associated
with an acute neurological deficit or
bladder and bowel disturbance (ie sphincter
dysfunction) are best referred to and treated
in the setting of an emergency department
of a hospital providing an acute spinal
service. 8
Investigation
The investigation of choice for a patient
presenting with a acute neurological
symptom would be an MRI scan. A erect
spinal radiograph is an useful adjunct to
exclude spinal instability/deformity and for
assessments of the alignment of the lumbar
spine. Some of. These subtle changes may
be masked on the non weight bearing
supine MRI scan of the lumbar spine.
Management
In the absence of a neurological deficit or
evidence of a cauda equina syndrome the
management of lumbar ridiculous thy is
essentially patient driven. The known natural
history of lumbar radiculopathy would
MRC
Grading
NT
tell us that in most patients the symptoms
would resolve in time. 6 Symptomatic
management in the initial stage is achieved
by rest, NSAID’s medication, flexion based
core exercises if symptoms allow. If these
measures do not relieve the pain satisfactorily
then a CT guided peri neural injection
of corticosteroids can be considered9.
However he efficacy of this has been
questioned by some researches especially
corticosteroids delivered to the epidural
space. 10 My anecdotal experience echoes
most of the studies that are supportive of
CT guided trans foraminal injections as an
excellent intervention for acute sciatica. 11-14
Surgical intervention is reserved for those
whose pain does not improve satisfactorily
in a reasonable time frame. As to how long
a reasonable time frame is very variable.
It depends on the response to conservative
measures, severity of the residual symptoms,
patients need to get back to normalcy, his or
her tolerance to pain, and the aetiology of
the radiculopathy. It is always important to
counsel the patients that in a far majority of
patients acute onset radiculopathy symptoms
would settle with symptomatic treatment.
Studies have shown that in the short term
early surgery provides faster recovery
and likely to be cost effective compared
to prolonged conservative care. 15,16 Long
term follow up studies have failed to show
a clinical difference at 1 and 2 years in
the early surgery vs prolonged conservative
care groups. 5,16
Cauda Equina Syndrome (CES)may present
in varying combinations of lower extremity
weakness, sensory loss in the lower
extremities and/or saddle area, pain in the
Continues on next page colour panel
A vegetarian population in the US have
been identified as one of the Blue Zone 1
communities known for their unique health
advantages, particularly longevity, and is
also well known for the Adventist Health
Studies (AHS) 2 on vegetarian diets. Yet
scepticism remains about the nutritional
adequacy of vegetarian diets for all age
groups.
An Australian first scientific literature review
of vegetarian diets was recently conducted
by a group of accredited practising dietitians,
clinicians and academics with expertise in
plant-based nutrition. Three staff from the
Sydney Adventist Hospital were involved
in the development of the series which was
published in June 2012 as a supplement
to the Medical Journal of Australia. It
addressed key nutrients of interest including
protein, iron, zinc, omega-3 and vitamin
B12 in vegetarian diets. The supplement
presents a balanced view of common myths,
questions and misconceptions surrounding
the adequacy of plant-based eating patterns.
It also included a research paper referencing
practical meal plans on how vegetarian diets
meet the Nutrient Reference Values. 3
Australia’s National Health and Medical
Research Council (NHMRC) and the New
Zealand Ministry of Health set the Nutrient
Reference Values (NRV) as recommended
target levels for all nutrients, in the form
of Recommended Dietary Intake (RDI) or
Adequate Intakes (AIs). Since the release
in 2006 there has been some concern
expressed about the ability to meet these
recommendations. Compared with the 1991
RDIs, the 2006 NRVs recommend a small
increase in iron for men, women and pregnant
women and an increase in zinc for men.
For vegetarians, the further recommended
increases in iron requirement (80% higher
than current RDIs for non-vegetarians) and
zinc requirement (50% higher than current
RDIs for non-vegetarians) present additional
challenges. The higher iron requirement
is based on the assumption that only 10%
of iron is absorbed from a vegetarian diet,
compared with 18% from a mixed diet that
includes meat. The higher zinc requirement is
based on the fact that vegetarian diets have
a higher phytate content in conjunction with
evidence that the phytate-to-zinc ratio can
affect zinc absorption.
Sample single-day lacto-ovo vegetarian
meal plans were developed to meet the
NRVs including increased requirements
for iron and zinc at 180% RDI and 150%
RDI respectively for vegetarians across all
age and gender groups. This clinical focus
project shows that well planned vegetarian
diets can meet almost all nutritional needs of
children and adults of all ages.
The meal plans met key requirements with
respect to energy; protein; carbohydrate; total
fat; saturated, poly- and monounsaturated
fats; α linolenic acid; fibre; iron; zinc;
calcium; folate; and vitamins A, C, E and
B12.
Vitamin D and long-chain n-3 polyunsaturated
fatty acids (PUFAs) were below requirements,
however these same nutrients are also a
concern for non-vegetarians who have limited
sun exposure and consume minimal amounts
of oily fish. Small amounts of short chain n-3
PUFAs (found in chia seeds, flaxseeds and
walnuts) were included in the meal plans
and provided significant amounts of ALA.
ALA is endogenously converted to long-chain
omega-3 fatty acids, but conversion depends
on age, sex and dietary composition.
The meal plans used minimal amounts of
omega-6 fatty acids (oils and margarines) to
optimise conversion.
The sample meal plan for pregnant women
provided 36.6mg of dietary iron, but fell short
of the 48.6mg NRV for iron in pregnancy for
vegetarians. The iron requirements set by the
NHMRC for pregnant vegetarians exceeds
the safe upper limit and did not account for
the body’s adaptive absorptive mechanism
or dietary enhancers of iron absorption
such as vitamin C. It is common practice
for pregnant women (irrespective of their
dietary preferences) to take iron supplements
during pregnancy or have their iron levels
monitored.
More Australians are now consuming
regular plant-based meals in the belief that
eating less meat and more plant foods
improves overall health. Requirements for
most key nutrients can be met across the life
cycle by well planned plant-based lacto-ovo
vegetarian diets. Furthermore, nutrient-dense
vegetarian diets are more likely to provide
additional health benefits, particularly with
respect to prevention and treatment of many
chronic diseases.
For a more in depth discussion of the results
and full references, please refer to the full
paper at the MJA OPEN website. These meal
plans are available to use as tools in clinical
practice.
References available on request.
ACUTE LUMBER DISC HERNIATION/SCIATICA (Continued from page 4)
low back and/or lower extremities, and visceral impairment of bladder, rectal, and/or
sexual function. Patients suspected with this form of presentation should be referred to
emergency department for further management. 8
Surgical options
Acute lumbar disc herniation (ALDHA)
Far majority of patients in the age group of 45-64 present with this pain secondary to
ALDH. The offending fragments can either be contained or sequestered. Once conservative
measures have been exhausted a microdiscectomy is a reasonable option that would
relieve most of the residual pain. 16,17 This can be performed in a minimally invasive fashion
using paramedian tubular retractors or in the convention open technique through the
midline. Whilst there may be some sort term benefits form the MIS technique for treatment
of postero lateral LDH no long term benefits have Been demonstrated compared to the open
technique. 18,19 A detail discussion of the pro and cons of each approach is beyond the
scope of this article.
References available upon request
4 5
SAN DOCTOR WINTER 2013

SAN DOCTOR WINTER 2013
DIAGNOSIS AND MANAGE-
MENT OF SUBMANDIBULAR
GLAND CALCULI
Dr James Younessi
Dr James Younessi BSc(Path) BDSc MDSc(OMFS) FDSRCS(Eng) FFDRCS(Ire)
Oral Maxillofacial surgeon Dr James Younessi has a special interest in implant surgery, facial trauma management, wisdom
teeth surgery, and management of benign salivary gland pathology. He operates from the Sydney Adventist Hospital and his
practice is at Hornsby. Apart from his surgical craft he has a keen interest in literature and is a published author of 4 books.
P: 9987 2666 E: hornsbyomfs@live.com.au W: www.dryounessi.com.au
In Australia, malignant diseases of the
oro-facial region are typically managed by
ENT/Head and Neck surgeons.
Accordingly, in this article only benign
pathology of the salivary glands are
considered, as appropriate to the practice
of oral and maxillo-facial surgery.
The salivary glands exist in two forms:
• Large well encapsulated, but not
necessarily well defined aggregates of
cells and stroma that share a common,
histologically distinct and well defined
duct, viz – parotid and submandibular
glands.
• “Free” un-encapsulated aggregates of
salivary glands known as minor salivary
glands.
This article covers the diagnosis and
management of submandibular gland
salivary calculi – but does not imply other
salivary gland calculi are less important
although parotid calculi are indeed less
frequent.
Salivary stones cause ductal obstruction,
salivary stasis and therefore infection. Why
they occur in the first place remains unclear,
but almost certainly regular dehydration
plays a part. There is, as with calculi
elsewhere in the body, particular cohorts of
patients who are “stone formers”. Patients
with multiple calcifications should be
investigated for a metabolic cause. There
is a statistically significant association with
hypertension and diabetes mellitus.
For the benefit of my patients, I have found
it easier to compare the principles of
sialolithosis in roughly the same form as an
oyster developing a pearl. That is, a foreign
body, perhaps a food particle or pumice
from tooth paste has been lodged in the
salivary duct and the attempt at “warding
off” this insult leads to sialolithosis.
There is an interesting report of a fish bone
as causative of a salivary stone. 1
The potential explanation for a
preponderance of submandibular
Papillary
stone (50%)
Mouth floor stone
Sublingual stone
Extradochal
stone (ulcerated
throught wall)
Figure 1. Site and approximate incidence of salivary calculi
sialadenitis over the parotid or minor
glands may be the more mucous nature
of the saliva. Increased viscidity may
mean more likelihood for stone formation.
Another explanation may be the rather
sharp angle the duct takes as it ascends
from the gland in the neck proper to enter
the mouth. Routine dehydration could lead
to ready stagnation.
In the above context, any person with
xerostomia such as the elderly (gland
involution), Sjogrën’s syndrome sufferers,
diabetes mellitus, or athletes who
insufficiently rehydrate themselves between
bouts of sporting exertion are all at risk.
Intraglandular stone
ANATOMICAL SITES OF SUBMANDIBULAR CALCULI.
The seminal paper by Rose describes
the anatomical sites of submandibular
calculi and as this is immediately relevant
to management, Table 1 2 sets out these
findings:
As is clear from the table, stones of the
ostium and the intra-orally accessible
aspect of the duct account together for
57% of the stones.
No data exists for extra-ductal stones which
are presumably eroded out of the duct. The
author has seen this on only one occasion
but it may have been more in keeping
with earlier efforts by other colleagues at
Duct opening 50% Intra-glandular 16%
Mid third of duct 7% Hilar aspect 27%
Table 1.
Hilar stone
(27%) 7cm
posterior to the
mandibular
incisors in adults
calculus removal. The local anatomy may
well have been therefore perverted.
Hilar and intra-glandular calculi are not
accessible intra-orally and together account
for 43% of the sialolithosis affecting the
submandibular gland.
Diagnosis is generally made clinically with
pain and swelling prompting presentation.
Erythema of ductal opening is not
invariable. Swelling of the salivary glands
and perhaps, particularly with glands
being repeatedly infected, fibrosis is
not uncommon. Accordingly, bi-digital
examination could variably yield a swollen
and painful gland in the neck (sialstasis/
sialadenitis) or a small atrophic gland
(fibrosis). A healthy normal submandibular
gland is about the size of a walnut.
Perhaps the most revealing symptom is
pain and swelling on consumption of food
stuffs, particularly tart foods.
Clinical suspicions are generally easily
confirmed when the calculus is digitally
palpable and in rarer cases visually
obvious. This is most commonly possible
with extravasated (partial) calculi or those
at the very opening of the gland duct.
Clinical findings are appropriately
confirmed by imaging.
Asymptomatic stones have been
incidentally found on otherwise routine
imaging but for the purposes of this article
we are concerned with confirmatory
evidence of clinically suspected stones.
As such a three dimensional localisation
would have to be the most appropriate
modality. Not only will it allow anatomical
localisation and in turn assist in treatment
planning but also should help exclude
concurrent and perhaps more sinister
pathology.
Conventional sialography is probably
outmoded. Cannulation of the duct in
inexpert hands was not only painful
but could also lead to false passages,
infection/sepsis or proximal spread of
the infection. Perhaps the most unpleasant
consequence however was the inadvertent
proximal herniation of a calculus. This
would make an otherwise accessible
calculus difficult to access.
A CT sialogram performed expertly has
perhaps only marginal benefit over a
routine CT scan. Sialectasis, multiple
stones, or additional pathology such as
Sjögren’s syndrome is perhaps better
illustrated. An MRI scan is valuable when
additional pathology such as a tumour is
suspected. Ultrasound is useful in depicting
the gland in the neck but is of lesser value
in 3D identification of the pathology and
intra-oral examination of the duct is not
practical.
MANAGEMENT OF SALIVARY STONES.
Duct:
Gland/Hilum:
Table 2.
Management is dependant upon the
anatomical location of the stone and the
operator’s preference and expertise.
Immediate management centres on
rehydration of the patient, steroids,
analgesia and antibiotics.
Perversely, a tart diet or sucking on a lemon
wedge as has been advocated by some
authorities is inappropriate in the acutely
inflamed and painful gland. Sialogogues,
aperitifs or tart foods would encourage
gland activity and the secretion beyond
the obstructed duct can cause pain.
It is preferable to consume a bland diet
until the gland is less inflamed and/
or the obstruction addressed. Of course
thereafter sialogogues are appropriate
to encourage residual gland activity and
mechanical flushing.
Appropriate antibiotics are those with
cover for oral flora and a combination
of Amoxicillin and Metronidazole is
often quite appropriate. Up to 8mg of
Dexamethasone or equivalent given as a
once only dose is also appropriate.
Definitive management often warrants
surgical intervention and is tabulated in
Table 2 for quick reference.
Please recall that not all ductal obstructions
are calcified and thus they may not be
subject to imaging. Thickened saliva can
often occlude a duct, particularly one with
a smaller lumen, and manifest identically.
Provided the stone is accessible, suction
extraction may be possible. A small ductal
incision may be needed.
More often, though, formal dissection
of the duct and gentle exploration under
good lighting with meticulous haemostasis
is needed. The best recommendation to
assist here is the use of a “stay suture”
proximal to the ductal occlusion, lest the
stone be displaced further away from
the sublingual (accessible) aspect of the
floor of the mouth. Recall ductal dilatation
and salivary pooling would make such a
prospect otherwise perfectly plausible.
The major impediment for ductal calculus
extraction is the rich nearby vasculature
and the lingual nerve as it “double
crosses” the submandibular gland duct
more proximally. Lingual altered sensation
and partial loss of taste (chorda tympani)
is possible. Here, as always informed
consent is essential.
Removal of stone/Meatotomy/Duchoplasty/Lithotripsy
Sialoadenectomy with a cervical approach.
Hilar or intra-glandular stones mandate
a submandibular sialoadenectomy. An
incision is made in the neck proper
some 4cm below the lower border of the
mandible. Keeping the dissection beneath
the platysma muscle gives the operator
the greatest chance of preserving the
marginal mandibular branch of the VII
cranial nerve. The fascia propria of the
submandibular gland is utilised, and care
taken to avoid nicking it. In this way, a
neat bloodless field assists the procedure.
The lingual nerve needs to be identified
and preserved whilst the oral aspect of the
duct tied as far anteriorly as practical. The
clue is often the submandibular ganglion.
Some authorities have suggested oral
cannulation of the duct pre-operatively to
assist intra-operative identification and
in turn preservation of the lingual nerve
which would appear very similar.
A suction drain is usually used for a day or
two, once the wound is repaired.
Shockwave lithotripsy has not seen wide
application in salivary calculi management
and certainly in the early genesis of this
treatment modality, shattering of nearby
teeth was reported.
Sialolithosis is common and the majority
occur in the submandibular system. A
sizeable stone or ductal irritation and
fibrosis from a smaller calculus could
cause complete obstruction and sepsis.
Anteriorly placed ductal stones may be
subject to removal intra-orally but hillar or
intra-glandular stones generally warrant
sialoadenectomy. Perhaps there may
be a role for fibroptically assisted stone
extraction for gland preservation in the
future.
References:
1. Abe K, Higuchi T, Kubo S and Oka M (1990)
Submandibular sialadenitis due to a foreign
body.
British Journal of Oral Maxillofacial Surgery 28:
50-52
2. Rose SS (1954)
A clinical and radiological survey of 192 cases
of recurrent swellings of the salivary glands.
Annals of the Royal College of Surgeons,
England 15: 374-401
SAN DOCTOR WINTER 2013
6 7

NEWLY ACCREDITED
SPECIALISTS
Dr Garrick Don
B.Med.Sci.(Hons I), MBBS (Hons), FRACP
Respiratory & Sleep Medicine,
Bronchoscopy/EBUS
Dr Garrick Don is a Respiratory & Sleep Physician,
who has an interest in servicing the Hills, North
Shore and Central Coast, with practices at Sydney
Adventist Hospital, Hornsby and Gosford Hospitals. His current
clinical practice covers a wide range of disorders including Airway
Disease (COPD, emphysema, asthma & bronchiectasis), Interstitial
Lung Diseases, Lung Cancer, Tuberculosis and Sleep Medicine with
an additional special interest in bronchoscopy and further advanced
endoscopic sampling techniques, such as EBUS. P: 9477 7867
F: 9477 1278 E: drgarrickdon@gmail.com
Dr Richard L Haddad
B.Med.(Newc) M.S.(Syd)(Urol) FRACS(Urol)
Urological Surgeon, Robotic Uro-Oncology
Dr Richard Haddad has completed dual Fellowships.
He was awarded a grant to complete a Robotic
Uro-Oncology Fellowship at the prestigious McGill
University Health Centre, Montreal Canada. As a result, he intends
to use the robotic platform for major urological surgery. He is an
extensively trained open and laparoscopic urological surgeon. He
has published and holds a Master of Surgery (Urology) from Sydney
University, in prostate cancer. P: 1300 964 463 E: drrhurol@gmail.com
W: roboticurologysydney.com.au
NEWS FROM
THE SAN
• The Sydney Adventist Hospital Education Centre will open
in September this year. Providing education and simulated
learning facilities for interprofessional multidisciplinary
clinical training of medical, nursing and allied health
professionals, the $17 million purpose-built Centre of
Excellence will be home to the Sydney Adventist Hospital
Clinical School of The University of Sydney (SAHCS) and
Avondale College Faculty of Nursing and Health. By
2016, the Education Centre will deliver 37,208 training
days for healthcare students and professionals.
• Developing such landmark education project like
the Education Centre requires vision, leadership and
collaboration. Dedications of an auditorium seat or
learning space in someone’s honour are welcomed
and can be discussed with Assistant Director of
Medical Services Catherine Murphy on 9487 9400.
See www.sah.org.au for more details.
• The San’s New Multi-deck car park,
which is now open, offers 896 new
places. The total car spots on site will be close to 1900
by the end of the Redevelopment.
• The $181 million Redevelopment is on target to complete
by mid - 2014 and will include an extra 200 beds, a new
Maternity and Women’s Health Unit, up to 12 operating
theatres, an Integrated Cancer Centre and new arrivals
and entrance areas. See www.sah.org.au.
SAH GRAND ROUNDS (ALL GP’S INVITED)
Dr Callum Gilchrist
BMedSc(Hons) MBBS FANZCA
Anaesthetist
Dr Callum Gilchrist’s sub-specialty areas of interest
are anaesthesia for ENT, dental-maxillofacial,
endocrine, and general surgery, in addition to
anaesthesia for interventional neuroradiology.
He practices at Sydney Adventist Hospital and is the Specialised
Study Unit Supervisor for head and neck, ENT, dental
surgery and ECT anaesthesia at Royal North Shore Hospital
within the ANZCA training program. P: 02 8078 4281
E: drcallumrgilchrist@gadr.com.au W: www.gadr.com.au
July 24
A/Prof Henry Woo Urology
August 19 Dr Auriel Jameson General Medicine
October 15 A/Prof Henry Woo Urology
19 August Professor Sharon Kilbreath Breast cancer and
exercise, lymphoedema management and
prevention of shoulder impairments post
mastectomy.
15 October Professor Sharon Kilbreath
Breast cancer and exercise, lymphoedema
management and prevention of shoulder
impairments post mastectomy.
11 November Professor John Watson Neurology
Grand Rounds are held in the Level 2 Conference Room from
12.30 – 13.30pm. (Light refreshments available from 12.00pm.
Please register on arrival).
SAN DOCTOR WINTER 2013
8
The San’s Hospital in the Home (HITH) accepts direct
GP referrals for suitable patients. Ring HITH Director
Dr Suhan Baskar to discuss details of clinical eligibility
and referral pathways.
P: 9487 9111 E: Suhan.baskar@sah.org.au
DIARY DATES
GP CONFERENCES (CPD points available with proof
of attendance)
July 24
August 21
October 17
men’s Health
Emergency Medicine
Oncology
FREE PUBLIC FORUM (everyone welcome)
September 10
Men’s Health
Dates and topics are subject to change. Contact 9487 9871
to register or visit www.sah.org.au for further details.