THE QUARTERLY MAGAZINE FROM THE HOSPITAL OF ST JOHN & ST ELIZABETH
New techniques and one stop service ofered by
leading specialists in purpose built facility
ASTHMA IN UNDER 2s
How parents can help by taking recordings
of their youngsters
THE DETECT STUDY
How best to identify early pulmonary
hypertension in patients with scleroderma
THYROID EYE DISEASE
Surgical trends and emerging
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
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.
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
DAVID MARSHALL CHIEF EXECUTIVE
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.
[email protected] 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
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
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.
(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 www.thebreastunit.org.uk
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
assessment and treatment plans
within 24 hours ensuring patients
can move rapidly towards returning
to active lives. The unit, lead by
acclaimed orthopaedic surgeon
Mo Akmal, can now ofer a
Concentrated clinical expertise, from London's busiest trauma unit, from a team
comprehensive range of treatments
packed with world-leading consultants, is available to treat anything from minor niggles to complex conditions and injuries.
from basic pain management
to advanced surgeries for acute
specialist nurses, an osteopath and
some back pain and couldn't work
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
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
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
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 [email protected]
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
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 [email protected]
the generosity of the local
020 7806 4040 [email protected] www.stjohnshospice.org.uk
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
[email protected] 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
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
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 www.thecardiacunit.org.uk [email protected]
, is the interaction between the environmen
NATURE OR s, simticene
BY DR PIYUSHA KAPILA MB ChB MD FRCPH
"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
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 www.londonpaediatricunit.co.uk [email protected]
DIAGNOSING AND TrEATING ASTHM
Parents can help with diagnosis by recording
the sounds of their child's wheezing
BY IAN BALFOUR-LYNN
BSc MD MBBS FRCP FRCPCH FRCS (Ed) DHMSA
Consultant in Paediatric Respiratory Medicine
Royal Brompton Hospital and Chelsea & Westminster Hospital
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.
POINTERS TO INFANTILE ASTHMA RATHER
History – is it actually wheeze?
Many parents report that their child
THAN SIMPLE EPISODIC vIRAL WHEEzING
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.
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
bromide works in this age group.
atypical, referral to a paediatrician
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
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.
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
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
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,
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 www.londonpaediatricunit.co.uk
BY CHARLOTTE CHALIHA
MB BCHIR, MA, MD, MRCOG
Vaginal prolapse describes the protrusion of the
Consultant Obstetrician and
pelvic organs towards or through the vagina.
Approximately 50% of parous women will have
some degree of prolapse and only 10–20% of
sYMPtoMs anD sIgns
these will seek medical help . 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 . 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
defects result in prolapse of the rectum into the vagina (rectocele).
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
ixation or a McCall culdoplasty
There are numerous surgical
reduces the risk of future vault
techniques used to correct prolapse
This should be considered prior to
using abdominal or vaginal
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 .
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.
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
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.
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.
www.londonwellwomanclinic.co.uk 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?
BY MR OlIpARAMBIl ASHOkkUMAR MD FRCOG
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.
www.londonwellwomanclinic.co.uk 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
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
production), fevers, smoking
sinusitis and post nasal dripping may
targeted treatment can then be
history and medications. Initial
have an upper airway cause. Often
www.therespiratoryunit.org.uk 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
BY COSTAS PAPAGEORGIOU MD Oculofacial Plastic Surgeon
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
post-operative double vision as the
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
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
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
l free of Charge!
Open to all practising GPs in London
this programme is ideal for GPs
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
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more Gp's are turning to
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Lectures are 1 hour long and we will
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Consultants are also
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as arranged by our Gp
We have had excellent
liaison Team. learn about
feedback from our
Wed 11th June Evening
the latest developments
Sat 14th June Seminar
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Tue 17th June Evening
leading Consultants in their
and it continues to
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Wed 25th June Evening
grow in popularity.
have a wealth of knowledge
Please contact us with
Wed 2nd July Evening
and experience, the vast
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majority of whom hold
topic in mind and we
senior positions in NHS
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To register for more information for all
medical professionals please contact: Email: [email protected]
We have confirmed the
agenda for our short lecture
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2014. To attend any of our
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us : [email protected].
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.
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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.