Medical Care |

Medical Care




New techniques and one stop service ofered by
leading specialists in purpose built facility

How parents can help by taking recordings
of their youngsters

How best to identify early pulmonary
hypertension in patients with scleroderma

Surgical trends and emerging
biological therapies

Diagnosing Breast Cancer
through the ‘Triple Test'

GPi Dear all,
Welcome to the Summer 2014
edition of GPi magazine
2014 has been so far extremely promising for the Hospital, with January
recording our second highest number of patients in nearly a decade. This

BREAST CANCER FACTS builds on the success we enjoyed in the last half of 2013, which is helping
us to fund a number of exciting projects across the organisation, including
the refurbishment of our 1.5T MRI scanner and the current expansion of our

REVOLUTIONARY TEChNIQUES Physiotherapy and Cardiology Units.
AT LONDON SPINE UNIT We have also just increased staing for our urgent care centre, Casualty
First, yet again as patient numbers continue to grow. In fact, Casualty

PALLIATIVE CARE hELP First had its busiest month ever in April as patients enjoyed its ability to
treat all minor illnesses and accidents on a walk in basis with virtually no
waiting. Please note its Consultants, who are all experienced A&E Doctors,
are always available to assist you. Patients enjoy swift referral within the

Hospital on both an inpatient and outpatient basis.
Thanks to all of you who attended our Hot Topics Symposium in March;
details of the rest of our education programme for 2014 are on page 22.

ChILDhOOD OBESITY: NATURE OR NURTURE Each referral to us helps fund our onsite St John's Hospice, which cares for
over 2,000 terminally ill patients and their families every year for free.

As ever, our Palliative Medicine Consultants as well as the Hospice's
DIAGNOSING AND TREATING community teams are available to support you with your patients, please
see pages 8 and 9.
Thank you once again for your ongoing support of the Hospital as it's very
CONSTIPATION IN PREGNANCY LIKELY CAUSES OF A ChRONIC COUGh 24hr GP Hotline. ThYROID EYE DISEASE For urgent referrals and admissions, call

Casualty First has its own dedicated reception
26,500 patients have now been treated since our 2011 opening Dr André van Nierop with two members of his team
Casualty First has become London's leading private walk-in, self-pay urgent care centre since opening in Sept 2011. A recent patient survey found that 99% of patients rated their experience as good or excellent. Continual expansion of Casualty First has been necessary due to ever increasing demand and the need to keep waiting times to a minimum. This has included the addition of a third consulting room, re-designed reception area and the recruitment of more full-time staff. Casualty First is able to treat minor injuries and illnesses on a walk in basis, with most patient problems being remedied at their initial consultation.
Nearly one in five patients have been instantly referred on to one of the 600 specialist Consultants who work at the Hospital of St John & St Elizabeth. Most commonly this is for specialist orthopaedic referral, scarless wound closure and paediatric allergy.
Our doctors are also available to you if you need advice on one of your patients. Simply call Casualty First on the number below.
l Sports injuriesl Fractures, soft tissue injuries, sprains and strains l Cuts and grazesl Ear, nose and throat conditionsl Gynaecological conditions l respiratory and chest complaintsl Stomach, bowel and bladder problemsl Eye conditionsl Ear consultation and ear syringingl l Flu vaccinesl Travel vaccinations and advice. Plus many other medical issues on a walk-in basis. or telephone 020 7432 8300
Worldwide, more than a million women are diagnosed with breast Professor Mo Keshtgar
cancer every year PhD, frCsI, frCs (gen)
Professor of Cancer surgery
& Consultant oncoplastic surgeon
Lead Clinician, the Breast Unit
hospital of st John and st elizabeth
Breast cancer is by far the
most common cancer in
women. It accounts for 31%
of all cancers in females in
the UK (life time risk of 1 in 8
There have been signiicant
advances in breast cancer
diagnosis and treatment.
Surgical management of
breast cancer has become
less radical over the years
without compromising the
local control or long-term
There has been a signiicant
reduction in breast cancer
mortality in the recent
years, which is due to early
diagnosis and advances in
multimodality treatment.
This is a two part article, the
irst part briely discusses
the presenting symptoms
and diagnosis of breast
cancer and the subsequent
article is planned to focus on
the treatment.

Comparison of cancer incidence and mortality in solid tumors in Europe
Breast cancer is diagnosed by the ‘triple test' or ‘triple assessment', which includes clinical assessment by a breast specialist, imaging (mammography, ultrasound scan etc) and tissue diagnosis (core needle biopsy or cytology etc). All palpable breast lumps and asymmetrical nodularities must be referred for specialist evaluation and ofered triple assessment.
Mammography can accurately We have state of the art diagnostic facilities at the Hospital of St John
diagnose over 95% of cases and St Elizabeth including digital mammography and 3T MRI scan.
when there is a palpable lump in We run triple assessment Breast Clinics on a daily basis.
the breast. With modern digital mammography machines, the acquisition is faster with higher resolution images and lower radiation dose to patients.
Ultrasound scanning (ultrasonography) is a safe and common procedure. Ultrasonography is extremely accurate in distinguishing between solid lumps and cystic lumps. It is particularly helpful in patients with lumpy and dense breast tissue. The majority of needle biopsies are performed under ultrasound guidance. Other imaging modalities such Presenting symptoms and signs in Breast Cancer
as magnetic resonance imaging (MrI) and nuclear medicine scans can be used in speciic circumstances. MrI Scans are useful BREAST CANCER PRESENTATION in evaluation of dense breast and also used as a screening tool in patients who fall in the high risk Breast cancer can present in the following ways:
category for family history of breast l Lump: Most patients with breast cancer irst see their doctor because of the
cancer in the young age group.
discovery of a lump. This is usually painless and hard, and may be irregular in shape.
All lesions that have a l Changes in breast shape and size: Breast cancer can cause dimples to form in the
indeterminate cytology (C3,C4) skin of the breast, the nipple to draw in, or the breast to change in size.
or inadequate cells (C1) need l Bloody nipple discharge: This is rarely due to breast cancer. If there is a lump as
to undergo core biopsy. Lesions well, it is more likely to be cancer.
that are reported to be equivocal l Lump in the axilla: Sometimes it is not possible to identify the primary tumour
on core biopsy need to be within the breast, and the only symptom may be a lump in the armpit as a result of
further assessed by additional enlargement of lymph nodes.
interventional procedure including l Skin involvement: In more advanced cases of breast cancer, the skin starts to
mammotome or excisional biopsy. ulcerate (develop open wounds). Sometimes the skin looks like orange peel; this is
Patients with family history of known as peaud'orange.
Breast Cancer must be assessed l Pain: Breast cancer is rarely painful unless it has locally advanced.
and their risks stratiied based on l Asymptomatic: In some patients who are totally asymptomatic, breast cancer is
published guidelines (*refer to diagnosed through screening mammography, whilst the cancer is not palpable.
NICE guidelines for Family History of Breast Cancer). All patients who Breast Unit Tel: 020 7266 4272
fall in the high-risk category must have risk assessment and genetic counselling.
REVOLUTIONARY NEW TECHNIQUES AT NEW PURPOSE-BUIlT LONDON One of the world's most advanced spine units is giving patients at the Hospital of St John and St Elizabeth, an unrivalled pathway to recovery One of the country's leading spinal surgeons is giving patients at the newly built Spine Unit at the Hospital of St John and St Elizabeth, an unrivalled (Hons) FRCS (Orth) pathway to recovery.
The new dedicated facility on Mr Akmal is
the 3rd Floor of the main hospital the Chief of
provides consultant led detailed Orthopaedic
assessment and treatment plans Surgery at
within 24 hours ensuring patients Imperial
can move rapidly towards returning to active lives. The unit, lead by Healthcare
acclaimed orthopaedic surgeon Mo Akmal, can now ofer a Concentrated clinical expertise, from London's busiest trauma unit, from a team Trust and
comprehensive range of treatments packed with world-leading consultants, is available to treat anything from minor niggles to complex conditions and injuries.
practices at
from basic pain management St. Mary's
to advanced surgeries for acute specialist nurses, an osteopath and some back pain and couldn't work Hospital,
physiotherapists, pain specialist and and wasn't sleeping well. I put of "We understand that back pain spinal fellows who work in harmony. doing anything for too long but when Privately,
and problems are very worrying and They are powered by a suite of I had the MRI scan it showed a facet he runs the
that patients want a rapid diagnosis technology including the 3-Tesla joint problem and had a quick day to take away the uncertainty," says MrI scanner, one of only a handful in surgery procedure and now my back Spine Unit
Mr Akmal. "We can provide a fast operation in the UK.
is better than ever." diagnosis - up to 90% within 24 "The main message is that we The Spine Unit's approach is to hours - because we have experienced can help whatever the problem," employ its expertise to locate what is staf and the best diagnostic adds Mr Akmal. "There is a lot of fear known as the ‘pain generator' of any equipment on site. and misunderstanding about spinal back problems so that any therapy "Often we can administer the treatments and many people assume attacks the root of the problem rather treatment within the same week and there is little that can be done or that than acting as temporary relief to this makes the unit so attractive to they will have to go through very symptoms. "Often it is about simple patients who need rapid pain relief." communication and understanding Mr Akmal, former Chief of "But they don't have to grin and what the pain indicates. The answer Orthopaedic and Spinal Surgery at bear it. We have a way of picking out can be anything from exercise and Imperial College Healthcare NHS Trust the diferent pathological problems joining our Pilates classes to targeted and practices at St. Mary's Hospital, and targeting treatment accurately. injections or keyhole surgery. "Back Paddington, devised a master plan A lot of patients endure lengthy and pain can be a corrosive inluence on to blend knowledge from medical inappropriate physio regimes along suferers and their families but the disciplines and the latest technology with taking anti-inlammatory drugs good news is we can help and help with a patient-focused ethos to create when really they probably only need a unique and premium service.
a day procedure to get rid of the pain "One of the biggest changes 6 The unit has eminent staf and get back to normal, if not better. over the last ten years has been including a neurosurgeon, "I can vouch for this because I had endoscopic spinal surgery which TECHNIQUES FOR BACK PAIN LONDON SPINE UNIT allows us to operate through a "We have people in acute pain pain-relieving medicines." keyhole opening where once it and not able to walk more than 20 would have been surgery leaving a yards and their problems are often "Using this simple, quick procedure means that patients no longer four inch scar," says Mr Akmal. " I can put down to age but this is now a 15 sufer acute back pain, they make now take a disc from the spine using minute local anaesthetic procedure fewer trips to their GP and older just a nick in the skin and a camera that can dramatically change their patients regain their independence. to guide me. It is now a 40-minute lives because they are pain free and The results are amazing and can give procedure with no damage to the can regain mobility." pain relief almost immediately." Most muscles or surrounding tissues with Mr Akmal, who is also one of patients we have seen require only the patient up and walking about on the irst in the UK to ofer patients 1 follow up after the procedure and a procedure known as Balloon have often returned to their normal "Patients are completely surprised Kyphoplasty seven years ago. The activities in a matter of days.
by the recovery time as they expect balloon surgery is a simple minimally- to be in a hospital bed for a fortnight. invasive procedure which ofers Yet, in most cases, they can be back at quick pain relief and better quality of Mr Akmal, front-line trauma spinal surgeon at St. Mary's work within two weeks.
life. The procedure, which does not Major Trauma centre has "This is very important for people require an overnight stay in hospital, dealt with an increasing number of who are in pain and not able to work. involves surgeons inserting a small patients who survive severe accidents They say it destroys their lives and the orthopaedic balloon into the cracked and go on to recovering to enjoy a impact of back pain is psychological vertebrae (bones in the spine). near full life.
as well as physical." The balloons are slowly inlated "We had a gardener who fell from a The new range of minimally and illed with cement to push the building and suffered a nasty spinal invasive techniques and more collapsed vertebrae back in place. injury," he says. "He came back to see us detailed knowledge of spinal Once the vertebrae are in the correct a few months later totally amazed that structures using high resolution position, the balloons are delated he wasn't in a wheelchair and that he imaging allows the unit to provide and removed with a tiny syringe. The was actually back at work. He couldn't a fast remedy for one of the most procedure, which takes about 20 common back conditions when minutes and can be performed under "We have had people in bad car and bones in the spine compress and sedation, is recommended by NICE as bike accidents yet they can be helped pinch the nerve channels that run a treatment for these types of spinal and get back to work. It is all the around the back of the spine, causing techniques that we develop to treat debilitating pain. The condition is Mr Mo Akmal said: "Treating these serious cases that gives us the known as spinal stenosis and afects these fractures with BKP is a cost experience and knowledge to deal with mainly elderly patients.
efective and relatively safe surgical the entire range of back problems. It is Around a decade ago, the solution procedure to treat lingering chronic amazing what can be done now. The would be lengthy and intensive pain and it could potentially save spinal unit is looking to develop a spinal surgery with consultants stripping lives. These fractures, which mainly injuries rehabilitation service at the muscle and delicately shaving away afect the elderly, are very common, Hospital which will fill a vital need for bone to free the nerve channels. extremely debilitating and can lead patients who require expert care.
Today's technique involves keyhole to other health problems such as "There is so much misunderstanding surgery to place an interspinous chest infections, sleeping problems and mystery about back pain and spacer – a wedge of special plastic and further fractures. The only other spinal trauma but we now have or metal – that lifts the bone and options to the surgery are bed rest, the knowledge, the experience, the releases the nerves.
back bracing, physiotherapy and dedicated team and the equipment to treat anything. Patients are always Tel: 0844 589 2020
amazed at how well they feel and how quickly they recover and wonder why they didn't seek treatment earlier.
Left: Our nurses are dedicated to help patients. Middle: Dr Samantha Jayasekera (left). Right: Dr Chris Farnham, Hospice Director and some of his t
PALLIATIVE CARE ADVICE St John's hospice, the only Referral to the Hospice is by General Practitioners, M
independent hospice in Central London, is part of the charitable hospital of St John YoUr QUestIons ansWereD
and St Elizabeth. The hospice aims to provide the best quality care to seriously How does a patient get referred to the Hospice?
ill people ensuring that they and A GP, District Nurse or hospital Doctor can refer to the their families have the support they hospice. Once the referral has been received the patient will be assessed either at home, in the hospice or in hospital by Over 2000 patients and their one of our specialist nurses or doctors. families are looked after by the hospice each year. All the services we ofer are absolutely free of Call us for advice
Are there charges at St
or referrals on our
John's Hospice?
The staf at the hospice are dedicated GP hotline
No. All of the services are specialists in caring for the physical, Our Consultants and provided free to patients emotional, social and spiritual Nurses are always here and their families. It costs concerns of the patient, and their to ofer advice and help over £5 million a year family and friends. Volunteers also with your patients - to run the services with work alongside the professional allowing you to access funding coming from the staf to enhance many aspects of the Inpatient Unit as well hospital of St John and St as our Community Teams Elizabeth, the NhS, and and hospice@home the generosity of the local 020 7806 4040
Michelle's story of the kindness
shown to her father

My name is Michelle. My sister, Nikki and I, lost our Dad, Rod, to cancer in May 2010. his cancer was originally diagnosed as terminal but he bravely fought it for nearly two years before he died. he lived in the North East of England but when things started to Michelle with father, Rod deteriorate Nikki and I brought him down
to London to be with us. Following lots of conversations with the GP we were relieved when a bed was found for him at St John's. We could not have dared wish for any- thing so amazing! Dad said he thought it was like a hotel and he felt immediately safe and calm in the hospice environment. The level of care and expertise of the staf or and some of his team with an appreciative patient
Michelle and Nikki
in the hospice, from the volunteers to the medical teams, was second to none. ADVICE FOR GPs We were even able to bring our two dogs and dad's two cats into the hospice to see him as all the animals spent time to-gether with him when he was ill at home in the North East. he was always asking about the dogs and cats so we took them , Medical Consultants and District or Specialist nurses
to visit him to put his mind at rest. It was these personal touches that made all the diference. Words cannot Over 2,000 patients and their families express how grateful we are.
Since then we have maintained strong are looked after by the Hospice links with the hospice and try to help each year free of charge wherever we can. They have also contin-ued to support and comfort us. I was able to give back to St John's in 2013 when the company I work for, Marks Is St Johns only for
Are all of the services
and Spencer's, was searching for a new people with cancer?
provided at the
Charity Partner. I nominated St John's and No. St John's looks Hospice in St John's
to my absolute joy – they were picked! after patients with any My colleagues in the inance team terminal illness. St John's No. There are 19 beds in are now fundraising to support St John's hospice is pioneering in the Inpatient Unit and up throughout 2014. We held a ‘pub quiz' in developing an inclusive to 20 people per day in November and raised enough money to approach to looking the Clinical Day Unit. The purchase hundreds of pairs of new night- after people living with team also support people wear for all the patients. We also now have hIV/AIDS, and now a in the community through a beautiful leaf on the Giving Tree. One of wide range of illnesses the Community Team and my colleagues ran the London Marathon including: dementia, hospice@home service. for the hospice in April and we are looking heart disease, respiratory The Lymphoedema Service forward to hosting another fundraising disease, renal failure and sees people in clinics at event in the summer. long term neurological the hospice and in their This is all because of my Dad, if he could diseases, as well as cancer. see what he has created, he wouldn't believe it! study is a large international (18 Dr JG Coghlan MD FRCP Consultant Cardiologist
against the gold standard diagnostic
tool (right heart catheterization),
has for the irst time produced a
The Cardiac Unit of the
Hospital of St John and St
Elizabeth played a pivotal role
in supporting high quality

validated simple algorithm that
timely investigations for the largest
can identify almost all patients with
enrolling centre – the Royal Free
scleroderma associated pulmonary
Hospital. The principle investigators
arterial hypertension even while
were Dr JG Coghlan (Royal Free
Hospital) & Prof J Seibold (University
Our understanding of early
in patients with of Michigan) and the study was fully
pulmonary hypertension and
funded by Actelion Ltd.
the strengths and limitations of
Pulmonary arterial hypertension
available screening tools has been
(high blood pressure conined to the
greatly enhanced by this study.
pulmonary circulation without lung
Among the pivotal indings are
or heart disease) is a progressive
that echocardiography while
disorder that, untreated, leads
the best available tool, cannot
to right heart failure and death
ever be a stand-alone screening
within a few years. It is however
tool. Of the 28 echocardiographic
a rare condition (approx. 50 per
parameters evaluated only three
million), associated with non-
were independently associated
speciic symptoms (breathlessness,
with early pulmonary hypertension
ankle swelling) and easily missed
(triscuspid velocity, right atrial
on routine examination and
area & right ventricular area), and
even the best of these (triscuspid
Over the past 18 years multiple
velocity) will miss nearly 40% of
therapies have been developed, that
patients with pulmonary arterial
have been shown to improve quality
hypertension if set to the most
of life, efort tolerance and reduce
sensitive usable threshold, while
morbidity and mortality. Use of these
incorrectly suggesting the presence
treatments has been associated
of pulmonary hypertension in 1 in
with a substantial improvement in
every 2 patients screened. Setting
survival in patients diagnosed with
the triscuspid velocity threshold
pulmonary arterial hypertension.
to the level recommended in the
However, most patients are
European Society of Cardiology
diagnosed late and despite therapy,
guidelines fails to identify 78% of
quality of life remains very impaired.
patients with pulmonary arterial
In some groups, most notably
scleroderma the incidence
In order to complete this study,
of pulmonary hypertension
patients had to undergo multiple
is much higher than in the
investigations (echocardiography,
general population, allowing
lung function testing and cardiac
the development of screening
catheterization) on the same day.
programs and early therapy. Most
The organizational eiciency of the
screening programs have relied on
Hospital of St John & St Elizabeth
echocardiography as the primary
and the ability to deliver consistency
tool for identifying patients that
(all studies were performed by
might have pulmonary hypertension.
the same personnel) ensured that
The DETECT study by evaluating all
patients had minimal inconvenience
currently proposed screening tools
and the study proceeded smoothly.
Austria (2 / 16)
Germany (10 / 118)
Netherland (1 / 15)
Romania (1 / 5)
Slovakia (1 / 0)
Turkey (3 / 5)
Bosnia (1 / 0)
China (1 / 11)
Czech Republic (1 / 5)
Hungary (2 / 7)
Poland (1 / 6)
Russia (1 / 3)
Switzerland (2 / 14)
Norway (2 / 13)
UK (1 / 57)
Spain (1 / 2)

Canada (10 / 41)
USA (21 / 170)

Contact details: The Cardiac Unit 020 7806 4080
, is the interaction between the environmen
NATURE OR s, simticene
"What came first - the chicken or the egg?" was the question that my patient aged 6 always greeted me with, and my inevitable response was "I don't know!" It has made me wonder however, in the last 5 years or so, with increased knowledge of epigenetics, whether its genes as being overweight by the or jeans (size), or indeed both, WHO whilst obesity starts from that are responsible for a large the 95th centile or 30kg/m2 in number of disorders seen by clinicians in the present day.
Less appreciated is the fact Epigenetics, simplified, that in some ethnic subgroups is the interaction between such as the S Asians, the risk of the environment and genes, co-morbidities begins with a leading to modification in the expression of the latter. The The incidence of co-morbities, clinical implications of this can particularly Type II diabetes might explain this, with obesity be appreciated when several and the metabolic syndrome, in adults, especially women, conditions are considered. The is increasing in children. This is altering gene expression in focus of this article will children. This would be however be on obesity.
mediated by alteration of Obesity has received inutero factors e.g. insulin.
much publicity in the last It is well known that decade and most clinicians breast fed babies tend can recite verbatim the to be smaller than those risks of co-morbidities fed formula. This has such as diabetes and life- always been attributed to the ability of the former Obesity in children is being able to restrict widely assessed using their intake according to centile charts produced from linked also to obesity in one or their needs. More recently a link anthropometric data obtained both parents. Of significance between protein intake in feeds from Caucasian children in the however, is that in some cases and size (growth rate) has been 1990s (1990 Growth reference obese children may develop demonstrated. Formula feeds data). The 85th centile is impaired glucose tolerance have a higher protein content equivalent to 25kg/m2 in adults, before their parents, with a BMI (2.1g/100ml) than breast milk. 12 the body mass index (BMI) at that is lower. It is reasonable The protein content, and type, which individuals are defined to speculate that epigenetics of breast milk varies throughout ment and genes, leading to modifica
the course of lactation, being highest at the beginning (-1.4g/100mls) and drops by 6 months to about half of this. rapid growth contributes to cardiovascular and hypertensive disorders in later life.
Significant links between asthma, particularly non- atopic, higher total IgE levels and obesity have been demonstrated. The age of la onset of puberty has shown a
tt downward trend with a clear
e link to bigger size. If these
r phenomena influence gene
expression then irrespective of "obesity", their incidence will continue rising. Epigenetics is extremely new at present and more is being understood about this with time. However, it highlights the need for consideration of the impact of environmental influences on not only the current population but the future as well.
0207 7078 3831
DIAGNOSING AND TrEATING ASTHM Parents can help with diagnosis by recording the sounds of their child's wheezing
Consultant in Paediatric Respiratory Medicine
Royal Brompton Hospital and Chelsea & Westminster Hospital

the ProBLeM
Many infants have recurrent
episodes of cough and wheeze
with colds and are completely
well in between episodes. They
are usually diagnosed as having
episodic viral wheezing. A small
proportion will have genuine
infantile asthma which is difficult
but not impossible to diagnose
in children under 2 years. Despite
what many parents are told,
there is certainly no rule that says
asthma can not be diagnosed until
the child is older.
MaKIng the

History – is it actually wheeze?
Many parents report that their child
wheezes, when what they are really describing are the harsh sounds of l Family history of atopy - asthma, hay fever or eczema in
upper airway secretions in the back a parent or sibling
of the throat. Some will be confusing wheeze with stridor. Asking the l Personal history of atopy - genuine atopic eczema
parents to record the sounds on rather than the occasional patch of dry skin, or a proven
mobile phones is helpful.
food allergy
Examination is usually normal and unhelpful. rarely the presence l Pattern of wheeze - background daily or nighttime
of Harrison sulci indicates chronic symptoms, or exercise / excitement induced symptoms,
respiratory diiculties and is rather than the more common pattern of symptoms
signiicant. Low height and weight only when the child has a viral cold
may indicate a more signiicant underlying condition.
Investigations are usually and wheeze that has not responded unhelpful. Children under 6 years to standard therapy.
of age are unable to perform lung function testing and skin prick Salbutamol works in infants, it
testing under 2 is rarely helpful.
is not true that only ipratropium If symptoms are marked or of genUIne
bromide works in this age group. atypical, referral to a paediatrician InfantILe
Bronchodilators should only be is warranted, particularly one with used on an ‘as required' basis a respiratory interest. In some rather than automatically taken cases, further investigations may be The best thing most parents could
3-4 times a day. The syrup form performed to exclude less common do is to stop smoking, however this is far less effective and not worth diagnoses. Gastro-oesophageal rarely happens; it is still our duty to using, as the oral dose required to 14 relux must always be borne in mind, inform the parents of the harm they have an impact inevitably leads as it may manifest as recurrent cough are doing to their children. to side effects. They should be TING ASTHMA IN UNDEr 2s be warned that a small proportion of children get bad dreams and disturbed sleep, in which case it should be stopped. InhaLeD

A small minority of pre-school
children will require regular
prophylaxis. Inhaled steroids are
not too effective for children with
simple viral wheezing but are
more likely to work in those with
genuine infantile asthma. In those
with background troublesome
symptoms who are using a
bronchodilator several times
a week, or who are frequently
in A&E, or requiring hospital
admissions, a trial of inhaled
steroids is warranted. It takes
4-6 weeks to take full effect, so
they can not be used just during
colds. There is also little point in
increasing the dose when the
child is acutely unwell. Side effects
Infants tend to tolerate
administered through a spacer are rarely seen at standard low small volume spacers
device with a facemask. By about better, for example an
3 years of age, most children can AeroChamber® (orange
use the spacer with a mouthpiece. for <3 months, yellow for
Importantly lung deposition is drastically reduced if the child screams or struggles with the The prognosis is
spacer; parents are often told generally very good.
incorrectly that it is a good time However although
to give the drug when a child most wheezy infants
is crying! There is no advantage do not turn out to have
to using a nebuliser at home, persistent childhood
compared to a spacer device.
asthma, most asthmatics
do start wheezing when

young. There is nothing
to predict with certainty

Montelukast 4 mg granules can
what will happen to any
be very useful in reducing viral airway inflammation. rather than using them every day, since they work within 4 hours they can be started at the beginning of a cold or chest symptoms and continued until the child is better. They must be mixed in cold food e.g. yoghurt, fruit puree, and not hot food nor liquids. Parents should London Paediatric Unit 020 7078 3831

Vaginal prolapse describes the protrusion of the Consultant Obstetrician and

pelvic organs towards or through the vagina. Sub-specialist in
Approximately 50% of parous women will have some degree of prolapse and only 10–20% of sYMPtoMs anD sIgns
these will seek medical help [1]. The lifetime risk of Prolapse may be asymptomatic undergoing an operation for prolapse is 11% and and the severity of symptoms may not always relate to the degree 30% will undergo re-operation for recurrence of the of prolapse. Common symptoms problem [2]. The aetiology is not fully understood include a dragging sensation or bulge in the vagina, diiculty but is strongly linked with ageing, vaginal delivery, urinating or emptying bowels, urinary and collagen weakness [1, 3].
incontinence and frequency, and sexual diiculties. Prolapse can occur in the anterior, middle, or posterior compartments of the vagina. Anterior compartment defects result in prolapse into the vagina of the urethra (urethrocele), bladder (cystocele), or both (cystourethrocele). Middle compartment defects result in uterine or vaginal vault descent or an enterocoele (herniation of the Pouch of Douglas). Posterior compartment OF vAGINAL
defects result in prolapse of the rectum into the vagina (rectocele).
(Figure 1.).
There are several grading symptoms for prolapse of which the most validated method is the pelvic organ prolapse quantiication system. This grades the prolapse according to descent of the anterior, posterior and apical segments of the vaginal wall relative to the hymen.
can be avoided. (ii) Pessaries - These can be used in patients unit for or A cystocele can be repaired using an refusing surgery, in those awaiting anterior colporrhaphy which plicates Women with urinary symptoms surgery, and in women who have the layers of the vaginal muscularis should have a midstream urine not completed their family. There and adventitia overlying the bladder. sample sent for culture and are a variety of pessaries available in The recurrence rate of prolapse after sensitivity. A post void residual urine a number of shapes and sizes that anterior colporrhaphy is 0–20%. scan and urolowmetry should be allow tailoring of the pessary to a Alternatively a paravaginal repair can performed if there is any voiding speciic site defect and individual be done which aims to reattach the diiculty or recurrent urinary tract anatomy. Generally pessaries are detached lateral vagina to the level infections. Urodynamic studies can changed every 6 months to decrease of the arcus tendineus fasciae pelvis. be performed prior to surgery if the risk of erosion and infection. The failure rate for this procedure is there is associated incontinence or (Figure 2)[1, 6].
reported as between 3% and 14%.
to reveal incontinence masked by Factors that elevate intra-abdominal the prolapse. Stress incontinence pressure, such as heavy lifting, chronic occurs in 36–80% of women with cough and constipation, and obesity A vaginal hysterectomy is the advanced prolapse [1, 5, and 6] are associated with utero-vaginal preferred option for uterine and if conirmed on urodynamics a prolapse and these conditions should prolapse. Simultaneous suspension simultaneous continence procedure be treated at the same time.
of the vaginal vault at the time of can be performed at the time of the hysterectomy either by sacrospinous prolapse repair. ixation or a McCall culdoplasty There are numerous surgical reduces the risk of future vault techniques used to correct prolapse prolapse [6].
This should be considered prior to using abdominal or vaginal performing surgery.
approaches. The aims of surgery are For those women who wish to retain (i) Pelvic loor exercises - These are restoration of normal anatomy, relief their uterus or have not completed usually of beneit only in those with of vaginal prolapse symptoms, and childbearing, options include a 16 mild degrees of prolapse and may improvement in urinary, bowel, and Manchester procedure (shortening alleviate symptoms so that surgery sexual function [1, 6, 7].
the uterosacral and cardinal ligaments regional analgesia, so reducing morbidity further. As obliterative procedures preclude further assessment of the cervix and uterus, a vaginal hysterectomy should be performed prior to this.
Mesh for prolapse repair
Prolapse and continence surgery has
been revolutionised over the past
decade by the advent of synthetic
and biological graft materials and
mesh kits that have been marketed to
improve outcomes. There is very little
data available to support the use of
mesh kits for primary prolapse surgery
unless the surgeon has reason to
suspect that the patient is at high risk
for recurrence. Potential complications
Figure 1. Uterovaginal prolapse
include mesh erosion, dyspareunia and visceral injury. The data supporting the biological grafts is also weak although they are associated with fewer complications [8].
Figure 2 Fof pessaries for
treatment of vaginal prolapse

Pelvic organ prolapse is a common
health problem, and though severe
morbidity is rare, it can have marked
efects on quality of life. All women
should be ofered conservative
treatment irst and if this fails surgery
ofered. Choice of surgery should
be tailored to the individual woman
and address any associated bowel,
bladder and sexual dysfunction.
Multidisciplinary care amongst
with amputation of the cervix), increase in dyspareunia, secondary to gynaecologists, urologists and transvaginal sacrospinous ixation, atrophy and scarring of muscle ibres. colorectal surgeons has now been and a sacrohysteropexy – anchoring Alternatively a transanal repair can be advocated to address complex pelvic the cervix/uterus to the sacral performed as favoured by colorectal loor problems and to streamline promontory with mesh.
management appropriately. repair of isolated defects in the fascia have been reported to cure This can be repaired using by a rectocoeles in 82% of cases, as well vaginal sacrospinous ixation or as resulting in an improvement in abdominal open or laparoscopic constipation, tenesmus, and splinting 1.Thakar R, Stanton S. Management of genital prolapse. BMJ 2002;324:1258-62.
sacrocolpopexy. The latter procedure of the vagina and perineum during 2. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark is associated with a lower recurrence AL.Epidemiology of surgically managed pelvic organ rate and less dyspareunia but is not prolapsed and urinary incontinence.
Obstet Gynecol 1997; 89; 501-506.
without complications, including obliterative procedures
3. Maclennan AH, Taylor AW, Wilson D.The prevalence major intra-operative bleeding and a – colpectomy and
of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. 3.3% incidence of mesh erosion. BJOG 2000; 107: 1460-1470. Most procedures to correct prolapse 4. 12 Bump RC, Mattiason A, Bo K et al.The operations to repair
standardization of terminology of female pelvic organ aim to restore normal anatomy. prolapse and pelvic floor dysfunction. posterior compartment
In the frail, elderly and those not Am J Obstet Gynecol 1996; 175: 10-17. wishing to retain sexual function, 5. Rosenzweig BA, Pushkin S, Blumenfield D, Bhatia NN.
Prevalence of abnormal urodynamic test results in
A rectocele can be repaired by either obliterative procedures can be continence women with severe genitourinary prolapse. levator plication or fascial repair. considered. The primary advantage Obstet Gynecol 1992; 79; 539-542.
6. Doshani et al. Uterine prolapse. BMJ 2007;335:819-23.
Levator plication is associated with an of these procedures is that they 7. Baessler et al. Surgical management of pelvic organ are relatively quick to perform, and prolapse. Cochrane Database Syst Rev. 2013 Apr 30;4:CD004014. can be performed under local or Weber AM, Walters MD.Anterior vaginal prolapse: review of anatomy and techniques of surgical repair.Obstet Gynecol 1997; 89: 311-318. 020 7806 4098
8. The surgical repair of vaginal wall prolapse using mesh. NICE IPG 267, 2008. What exaCtLY are
Hemorrhoids are vascular
structures in the anal canal.
They act as a cushion composed
of arterio-venous channels and
connective tissue. Hemorrhoid
cushions are important for

They can get swollen or
inlamed and are called piles.
They can be internal or external

CONSTIPATION depends on where they
present. It can cause painless
rectal bleeding or pain when

IN PREGNANCY they are thrombosed.
hoW Long Before
theY CLear UP?
Usually they clear up soon after
Consultant Obstetrician & Gynaecologist
the delivery as long as there is no
WhY DUrIng PregnanCY Do WoMen
sUffer froM ConstIPatIon?
During pregnancy, pressure from the fetus on the abdomen and
hoW Can sUfferers
hormonal changes cause the hemorrhoidal vessels to enlarge.
reLIeVe the PaIn?
Gravid uterus puts pressure on the pelvic and abdominal veins.
This can slow the return of blood from the lower half of the body,

l Apply an ice pack wrapped in a
which increases the pressure on the veins and causes them to become
towel to the afected area several
more dilated or swollen.
times a day. Direct contact with
Constipation, which is a common problem during pregnancy, can also
ice should be avoided.
cause or aggravate hemorrhoids.
l Soak the bottom in warm
water in a tub for 10 to 15

What tIPs are there for
minutes three to four times each
CLearIng UP ConstIPatIon?
l Try alternating cold and warm
l Eat a high-ibre diet - plenty of whole grains, beans, fruits, and
l Clean the afected area after
l Drink plenty of water (eight to ten glasses a day)
each bowel movement using soft,
l Regular exercise
unscented, white toilet tissue,
l Treat constipation by a iber supplement or stool softener
which causes less irritation than
colored, scented varieties.

What enCoUrages haeMorrhoIDs?
l Moistening the tissue.
l Topical creams can be bought
The exact cause of symptomatic hemorrhoids is unknown. A number
over the counter, make sure that
of factors are believed to play a role including: irregular bowel habits,
medicines in the cream are safe
a lack of exercise, low-ibre diets, increased intra-abdominal pressure
to use in pregnancy.
genetic factors like an absence of valves within the hemorrhoidal
l Simple analegesics like
veins, and aging. Tel: 020 7806 4098
A chronic cough is one that lasts for eight weeks or moreand here we pinpoint the likely causes BY AMIT pATEl MBBS MRCp AHEA
Consultant Respiratory physician

All year round waiting rooms are illed with patients complaining of a cough. Nearly a quarter of people will see a doctor about a respiratory illness every year with many presenting with a cough. Most often the cough is in the setting of a viral infection and abates within a few weeks. A chronic cough is one that lasts for more than 8 weeks. Asthma, gastroesophageal relux disease (GORD), COPD, upper airway syndrome and smoking are common causes of chronic cough. Other causes include bronchiectasis which is associated with increased sputum production and repeat infective episodes. Infective causes such as tuberculosis have also been on the rise in London. Patients may have a history of night sweats, weight loss, sputum production and previous contact with TB but this is often culture of sputum not the case. Conditions such as sarcoidosis and pulmonary ibrosis are under recognised. Patients In the absence of may present with a dry cough and infective symptoms, breathlessness and ine crackles there is no evidence to may be audible on auscultation suggest antibiotics should of the chest. Lung cancer can also be used to help chronic present with a chronic cough. Recent cough. It is reasonably common national campaigns have highlighted for patients to sufer from a the importance of considering a post-viral cough which is usually chest x-ray in those patients with secondary to a combination of the cause can be diicult to get to a cough that persists for longer inlammation, increased sensitivity the bottom of. In "cough variant" than 3 weeks. If these conditions of cough receptors and epithelial asthma for example, cough can be are suspected, patients should be damage. Mucus production can the only symptom. Diagnosis will referred for a specialist respiratory also then contribute to symptoms. often require specialist pulmonary Symptoms do usually settle within 8 function testing and review. It is important when trying to weeks. Treatment is directed at the When a patient is referred to elucidate the cause of a cough to most likely underlying cause. If for a specialist clinic, the history is exclude serious underlying causes example a patient has a history of reviewed once again. Further testing requiring urgent investigation and wheeze with a cough that is worse is arranged where appropriate management. Questions focus on at night, perhaps with a trigger such including CT scan of the chest, duration, associated features (for as dust or exercise, this may point lung function testing and rarely example haemoptysis and sputum to asthma. Patients with a history of bronchoscopy. Appropriate production), fevers, smoking sinusitis and post nasal dripping may targeted treatment can then be history and medications. Initial have an upper airway cause. Often Tel: 020 7078 3819
Emerging biological therapies and minimally invasive surgical techniques improve the quality of life by reversing facial disfigurement and reducing the likelihood of sight-threatening complications.
Surgical trends and emerging
biological therapies
BY COSTAS PAPAGEORGIOU MD Oculofacial Plastic Surgeon
Reined surgical
Minimally invasive orbital
The commencement of surgical For moderate to severe disease with rehabilitation is a major step in the more prominent proptosis, patients life of a patient with Graves disease may need bony decompression in and should be approached in a addition of fat removal. Deep lateral conservative and studied fashion.
wall decompression is the preferred Technical advancements in orbital approach which involves sculpting decompression relate to the new areas of bone from the deep lateral areas of bone removal, removal of wall of the orbit. The advantage of orbital fat and the use of hidden this minimally invasive approach is that it doesn't violate the relationship of the orbit with the adjacent sinus spaces and is less likely to induce Micro-liposuction of
post-operative double vision as the the orbit
eye muscle compartments are not For less severe cases where 2-3 shifted during surgery.
mm of proptosis is reduction is needed, Mr Papageorgiou Sculpting the eyelid and
may use a technique that only removes soft tissue or ibroblast-fat Even after multi-staged corrective through a hidden incision from the surgeries, some patients ind that eyelid and eyebrow soft issues. inner surface of the lower eyelid the disease has left its mark. Loss These changes can be addressed (transconjuctival approach). Fat of elasticity and puiness of the with sculpting surgery such as decompressions have the advantage eyelid and eyebrow proile can aesthetic blepharoplasty or eyebrow of being performed under sedation be permanent features as the recontouring via micro-liposuction. anesthesia with no skin incisions, proliferative adipogenenic and The goal of these procedures is to allowing surgical time and shortened inlammatory phase of the disease reine the proportions and symmetry 20 recovery period.
has afected the volume of the of the periorbital tissues.
The recent success of immune therapies for allied autoimmune diseases has spurred use of these for patients with TED. As our knowledge of the immune pathogenesis of the disease grows, paralleling our experience with targeted immunotherapies, there will likely be a future paradigm shift in the DISEASE management of patients
Following a three-year presence
in the USA in two renowned
academic institutions Mr
papageorgiou brings his expertise
B Cell regulation
in select patients with moderate to and latest techniques and
B Cells play a critical role in the severe active disease who may be innovations from the Unviersity
initiation of the autoimmune intolerant or poorly responsive to of California los Angeles (UClA)
processes related to TED. to the Hospital of St John & St
Rituximab (RTX) is a genetically engineered humanized antibody, Mr papageorgiou trained in two
which depletes circulating mature Speciic anticytokine therapies, B cells, and can help control including TNF-a targeting leading academic centres in the
the inlammatory cascades by agents, have been evaluated USA which pioneered minimally
afecting antigen presentation and in TED patients. While these invasive orbital decompression
cytokine production mediated reports show some potential surgery and adopted the latest
by B cells. Most importantly beneit anticytokine therapy, no trends in immunomodulation
RTX does not induce signiicant randomized controlled trials have immunosuppression, as it does been performed.
He has extensive clinical and
not target the bone marrow stem cells and circulating plasma cells.
translational research experience
One recent prospective study The results of a recently published in the molecular pathogenisis
from UCLA reported reduction trial to determine the efects of of TED and has studied
in the disease activity in patients selenium and pentoxifylline in histopathologic and anatomic
with moderate-to-severe patients with mild TED revealed changes afecting the orbit using
symtoms. RTX dosages used signiicant improvement in the sophisticated 3D software and
were the same as for treatment of selenium-treated group in terms of rheumatoid arthritis (2 doses of quality of life, reduced progression 500mg, spaced 2 weeks apart).
of eye disease, and improvement Mr Papageorgiou specialises
Adverse efects, though in clinical activity scores. Selenium in a select number of surgical
not common according to (100 micrograms twice daily) procedures and aesthetic
published literatrue, have been can be a valuable adjunctive in rejuvenating treatments involving
demonstrated, highlighting the early stages of disease for certain the face. With a robust clincical
need for judicious use of the drug and surgical experience informing
his work, he is well established as
a highly skilled surgeon bringing credibility and trust to a sensitive
and often emotive area of medical
GP Lectures & Seminars Calendar May 2014 - July 2014 24 hr Gp Hotline: For urgent referrals and admissions call 07736 22 33 44
We provide Outreach Lectures
regular Gp
lectures &

l free of Charge!
Open to all practising GPs in London this programme is ideal for GPs covering all
with a busy schedule. We will arrange Certiicate of CPD provided current topics from our
the lectures around your availability at a l Comfort of your own practice time that is convenient to you morning, Every year more and
l Date arranged by you afternoon or evening.
more Gp's are turning to
l Can be a topic of your choice Lectures are 1 hour long and we will our lecture and seminar
l Interactive lectures provide catering and a post lecture programmes, keeping up
l Reputation of providing high certiicate of attendance to count to date with the latest
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development. Topics can be arranged by you so you can get Consultants are also
a tailor made lecture available to make personal
completely FREE OF Special topics of interest: visits to your local practices
as arranged by our Gp
We have had excellent liaison Team. learn about
feedback from our paediatrics
Wed 11th June Evening
the latest developments
outreach lecture Cardiology
Sat 14th June Seminar
in secondary care from
programme to date Shoulders
Tue 17th June Evening
leading Consultants in their
and it continues to respective fields who all
Gpi Evening
Wed 25th June Evening
grow in popularity. have a wealth of knowledge
Please contact us with Wed 2nd July Evening
and experience, the vast
the date, time and majority of whom hold
topic in mind and we senior positions in NHS
will do the rest.
To register for more information for all
medical professionals please contact: Email:
We have confirmed the
agenda for our short lecture
and seminar series in
2014. To attend any of our
programmes please email

us :
uk. One of our dedicated

Holly Miles and Karl Brown have liaison Team will be happy
recently joined the GP Liaison to arrange this for you.
team at the Hospital. They are both We strive to bring you the
dedicated to bridging the gap highest quality education.
between GPs and the Hospital, and therefore value your
providing educational lectures and events for GPs in the Central and Holly: 020 7432 8325
feedback and suggestions
North West London areas.
so if you have any comments
To book an outreach lecture please karl: 020 7432 8326
please let us know.
l Your local casualty for all
minor injuries
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from the age of one
l All minor accidents and
injuries treated
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Common military list of the european union

22.3.2012 Official (Notices) NOTICES FROM EUROPEAN UNION INSTITUTIONS, BODIES, OFFICES AND COMMON MILITARY LIST OF THE EUROPEAN UNION (adopted by the Council on 27 February 2012) (equipment covered by Council Common Position 2008/944/CFSP defining common rules governing the control of exports of military technology and equipment)

Il segreto del ginkgo

IL SEGRETO DEL GINKGO E UNA POESIA DI GOETHE La cultura apre alla conoscenza, la conoscenza alla comprensione, la comprensione al rispetto ed all'amore. Testo di una conferenza tenuta dalla Storica dell´arte Martina Brunner-Bulst il giorno sabato 12 maggio 2007 presso il teatro Giotto di Vicchio di Mugello. La conferenza è stata accompagnata da un balletto con la coreografia di Lisa Salmoria. È un'antica usanza che l'ospite, anche se straniero, abbia con sé un dono da offrire a chi lo accoglie e lo ospita. Questo pensiero è stato il motivo che ha ispirato l'idea e mi ha dato l'entusiasmo necessario per dedicarmi in questa ricerca, che ho poi presentato nel maggio 2007 al Teatro Giotto nel programma culturale "Affinità elettive" del Comune di Vicchio di Mugello.