Percie Du Sert N.,National Center for the Replacement |
Rice A.S.C.,Imperial College London |
Rice A.S.C.,Chelsea and Westminster Hospital NHS Foundation Trust
British Journal of Pharmacology | Year: 2014
Neuropathic pain remains an area of considerable unmet clinical need. Research based on preclinical animal models has failed to deliver truly novel treatment options, questioning the predictive value of these models. This review addresses the shortcomings of rodent in vivo models commonly used in the field and highlights approaches which could increase their predictivity, including more clinically relevant assays, outcome measures and animal characteristics. The methodological quality of animal studies also needs to be improved. Low internal validity and incomplete reporting lead to a waste of valuable research resources and animal lives, and ultimately prevent an objective assessment of the true predictivity of in vivo models. © 2014 The British Pharmacological Society.
Gedela K.,Chelsea and Westminster Hospital NHS Foundation Trust |
Vibhuti M.,Allington Clinic |
Pozniak A.,Chelsea and Westminster Hospital NHS Foundation Trust |
Ward B.,Chelsea and Westminster Hospital NHS Foundation Trust |
Boffito M.,Chelsea and Westminster Hospital NHS Foundation Trust
HIV Medicine | Year: 2014
This review looks at the evidence for potential and theoretical risks of combining antiretroviral treatment with drugs prescribed for cardiovascular disease and diabetes. These conditions are common in the HIV-infected population as a result of ageing and the increased risk associated with both HIV infection and antiretroviral intake. © 2013 British HIV Association.
Raffi F.,University of Nantes |
Pozniak A.L.,Chelsea and Westminster Hospital NHS Foundation Trust |
Wainberg M.A.,McGill University
Journal of Antimicrobial Chemotherapy | Year: 2014
Efavirenz has been recommended as a preferred third agent together with two nucleos(t)ides for first-line combination antiretroviral therapy (ART) for >15 years. The availability of efavirenz in a fixed-dose combination makes it very attractive. However, because of (i) adverse events associated with efavirenz, (ii) a poorer overall efficacy of efavirenz compared with newer antiretrovirals, (iii) the ranking of efavirenz as FDA Pregnancy Category D and (iv) the relatively high prevalence of transmitted drug-resistance mutations, there is a need to reconsider the role of efavirenz in first-line ART. We review the available evidence that challenges efavirenz's current position in first-line HIV treatment guidelines. Apart from its animal teratogenic potential, and moderate neuropsychiatric adverse events associated with its use, efavirenz has recently been associated with an increased risk of suicidality when compared with other antiretroviral drugs. Most importantly, efavirenz has demonstrated overall inferior efficacy to various comparator drugs, which include rilpivirine, raltegravir and dolutegravir, in antiretroviral-naive patients. Furthermore, epidemiological data indicate that the prevalence of non-nucleoside reverse transcriptase inhibitor resistance has reached 5%-8% in various parts of the world, and minority transmitted non-nucleoside reverse transcriptase inhibitor resistance-associated mutations can have a negative impact on the outcome of first-line efavirenz-based ART. Based on considerations of efficacy, toxicity and resistance, it is time to reconsider the routine use of efavirenz in ART. This, of course, presupposes that other antiretrovirals will be available in place of efavirenz, and may not be applicable in certain developing country settings where this is not the case. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.
Maughan E.F.,St Georges NHS Healthcare Trust |
Lewis J.S.,St Georges NHS Healthcare Trust |
Lewis J.S.,St George's, University of London |
Lewis J.S.,Chelsea and Westminster Hospital NHS Foundation Trust
European Spine Journal | Year: 2010
The purpose of this prospective, single site cohort quasi-experimental study was to determine the responsiveness of the numerical rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), Oswestry disability index (ODI), pain self-efficacy questionnaire (PSEQ) and the patient-specific functional scale (PSFS) in order to determine which would best measure clinically meaningful change in a chronic low back pain (LBP) population. Several patient-based outcome instruments are currently used to measure treatment effect in the chronic LBP population. However, there is a lack of consensus on what constitutes a "successful" outcome, how an important improvement/deterioration has been defined and which outcome measure(s) best captures the effectiveness of therapeutic interventions for the chronic LBP population. Sixty-three consecutive patients with chronic LBP referred to a back exercise and education class participated in this study; 48 of the 63 patients had complete data. Five questionnaires were administered initially and after the 5-week back class intervention. Also at 5 weeks, patients completed a global impression of change as a reflection of meaningful change in patient status. Score changes in the five different questionnaires were subjected to both distribution- and anchor-based methods: standard error of measurement (SEM) and receiver operating characteristic (ROC) curves to define clinical improvement. From these methods, the minimal clinically important difference (MCID) defined as the smallest difference that patients and clinicians perceive to be worthwhile is presented for each instrument. Based on the SEM, a point score change of 2.4 in the NRS, 5 in the RMDQ, 17 in the ODI, 11 on the PSEQ, and 1.4 on the PSFS corresponded to the MCID. Based on ROC curve analysis, a point score change of 4 points for both the NRS and RMDQ, 8 points for the ODI, 9 points for the PSEQ and 2 points for the PSFS corresponded to the MCID. The ROC analysis demonstrated that both the PSEQ and PSFS are responsive to clinically important change over time. The NRS was found to be least responsive. The exact value of the MCID is not a fixed value and is dependent on the assessment method used to calculate the score change. Based on ROC curve analysis the PSFS and PSEQ were more responsive than the other scales in measuring change in patients with chronic LBP following participation in a back class programme. However, due to the small sample size, the lack of observed worsening of symptoms over time, the single centre and intervention studied these results which need to be interpreted with caution. © 2010 Springer-Verlag.
Ravindra P.,University of Derby |
Fitzgerald J.E.F.,Chelsea and Westminster Hospital NHS Foundation Trust
World Journal of Surgery | Year: 2011
Background: Positive encounters with surgeons have previously been shown to influence perceptions of surgical careers. Despite this, negative perceptions persist. We investigated whether identifying role models in surgery influences career choice and defined the ideal qualities of a surgical role model as perceived by newly qualified doctors. Methods: A 36-item questionnaire was distributed to newly qualified graduates from a large UK medical school. Results were analysed using GraphPad Prism 5.00. Results: Questionnaires were returned by 208 of 320 graduates (65%). Median age was 24 years (range = 23-51); 63% female, 37% male; 71% standard undergraduate course, 28% graduate-entry course. Overall, 131 respondents (63%) felt they were able to identify a surgical role model; there were no statistically significant differences between gender or course type. There was a significant difference between identification of a surgical role model and interest in pursuing surgical careers (P = 0.0006), with 41% of those who identified a role model interested compared with 17% of those who did not. Overall, 564 key qualities for a surgical role model were suggested by respondents. These were grouped by theme, with common attributes including good teacher, enthusiastic, and approachable. Conclusions: Junior doctors were twice as likely to express interest in pursuing a surgical career if they identified a positive surgical role model. Changes in medical school demographics are occurring, with increasing proportions of female and graduate-entry doctors. These groups are less likely to choose a surgical career, so promoting interest in surgery will become increasingly important to maintain high-quality applicants. Defining and promoting perceptions of surgical role models to the wider surgical community may be one way of addressing this. © 2011 Société Internationale de Chirurgie.
Mancini A.,Chelsea and Westminster Hospital NHS Foundation Trust |
Kelly P.,University College London |
Bluebond-Langner M.,University College London
Seminars in Fetal and Neonatal Medicine | Year: 2013
Neonatal palliative care is an emerging specialty, developing in the context of the significant prevalence of life-limiting and life-threatening conditions amongst the population treated and cared for by neonatologists and neonatal nurses. In this paper we explore the need and provision for training among practitioners in neonatal palliative care to date. We describe several different educational and training programme models with attention to structure, content and impact on participants' knowledge, capacity, competency and confidence in delivering palliative care services suggesting what is needed to ensure the highest standards of care for newborns and babies with life-limiting illness and life-threatening conditions. © 2012 Elsevier Ltd.
Johnston M.J.,Imperial College London |
King D.,Imperial College London |
Arora S.,Imperial College London |
Behar N.,Chelsea and Westminster Hospital NHS Foundation Trust |
And 3 more authors.
American Journal of Surgery | Year: 2015
Background Outdated communication technologies in healthcare can place patient safety at risk. This study aimed to evaluate implementation of the WhatsApp messaging service within emergency surgical teams.Methods A prospective mixed-methods study was conducted in a London hospital. All emergency surgery team members (n = 40) used WhatsApp for communication for 19 weeks. The initiator and receiver of communication were compared for response times and communication types. Safety events were reported using direct quotations.Results More than 1,100 hours of communication pertaining to 636 patients were recorded, generating 1,495 communication events. The attending initiated the most instruction-giving communication, whereas interns asked the most clinical questions (P <.001). The resident was the speediest responder to communication compared to the intern and attending (P <.001). The participants felt that WhatsApp helped flatten the hierarchy within the team.Conclusions WhatsApp represents a safe, efficient communication technology. This study lays the foundations for quality improvement innovations delivered over smartphones. © 2015 Elsevier Inc. All rights reserved.
Johnston M.,Center for Patient Safety |
Arora S.,Center for Patient Safety |
Anderson O.,Center for Patient Safety |
King D.,Center for Patient Safety |
And 4 more authors.
Annals of Surgery | Year: 2015
Objective: To systematically risk assess and analyze the escalation of care process in surgery so as to identify problems and provide recommendations for intervention. Background: The ability to escalate care appropriately when managing deteriorating patients is a hallmark of surgical competence and safe postoperative care. Healthcare-Failure-Mode-Effects-Analysis (HFMEA) is a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended. Methods: Forty-two hours of ethnographic observations on surgical wards in 3 London hospitals (phase 1) formed the basis of an escalation process diagram. A risk-assessment survey identified failures associated with process steps and attributed hazard scores (phase 2). Patient safety and clinical risk experts validated hazard scores through a group consensus meeting (phase 3). Hazardous failures were taken forward to multidisciplinary HFMEA where cause analysis was applied and interventions were recommended (phase 4). Results: Observations identified 33 steps in the escalation process. The risk-assessment survey (30 surgical staff members, 100% response) and expert consensus group identified 18 hazardous failures associated with these steps. The HFMEA team identified 3 adequately controlled failures; therefore, 15 were subjected to cause analysis. Outdated communication technology, understaffing, and hierarchical barriers were identified as root causes of failure. Participants recommended interventions based on these findings including defined escalation protocols, human factors education, enhanced communication technology, and improved clinical supervision. Conclusions: Failures in the escalation process amenable to intervention were systematically identified. This mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety. © 2014 Wolters Kluwer Health, Inc. All rights reserved.
Falconer J.,Chelsea and Westminster Hospital NHS Foundation Trust
The journal of family health care | Year: 2010
Gastro-oesophageal reflux (GOR) is a norma physiological process occurring daily in healthy infants with similar frequency in both breast- and bottle-fed infants. It is generally considered uncomplicated and self-limiting, resolving spontaneously by 12-14 months of age. In contrast, gastro-oesophageal reflux disease (GORD) is associated with more severe symptoms and, on occasions, oesophagitis. In the small percentage of cases that do not respond to simple feeding measures, a trial for 2-4 weeks using an extensively hydrolysed formula may be considered. Thickeners and antiregurgitation feeds may help with the frequency of overt regurgitation. Feeding difficulties can be a problem in infants with reflux, with some suffering extreme aversion to texture. In the small percentage of infants who experience faltering growth, high-calorie formulae can be used. In those with severe feeding difficulties or severe faltering growth, tube feeding may be required. Infants should ideally be managed within a multidisciplinary team including a speech and language therapist, psychologist, dietitian and paediatrician.
Roche A.J.,Chelsea and Westminster Hospital NHS Foundation Trust |
Calder J.D.F.,Chelsea and Westminster Hospital NHS Foundation Trust |
Calder J.D.F.,The London Clinic
Knee Surgery, Sports Traumatology, Arthroscopy | Year: 2013
Purpose: The aim of this study is to better inform the sports surgeon of current evidence for the treatment of Jones fractures of the base of the 5th metatarsal. The study aimed to establish what the outcomes were for different treatments modalities. By doing this, the clinician will be better prepared to institute a logical, evidence-based approach to the treatment of their patients with this injury. Methods: A thorough literature search was performed from 1980 to present day. Studies were included based on set criteria and analysed for their validity, and their results were scrutinised. Jones fractures were segregated into acute fractures, delayed unions and non-unions. Results: Twenty-six studies were included, of which 22 were level 4 evidence, with only 1 randomised controlled trial. Functional outcome data were limited to return to sports in most studies with few studies using established scoring systems. Return to sports following intra-medullary screw fixation for acute fractures ranged from 4 to 18 weeks. Acute fractures treated non-operatively had a union rate of 76 % (pooled), whereas in fractures treated with a screw it was 96 % (pooled). Delayed unions treated non-operatively had a union rate of 44 and 97 % treated operatively. Non-unions treated with screw fixation healed in 97 % of cases. Conclusions: Although supported by mostly level 4 evidence, intra-medullary screw fixation is more likely to lead to successful union of all types of Jones fractures compared to non-operative treatments. Early return to play in athletes prior to full radiological union is not advised in case of re-fracture. Level of evidence: IV. © 2012 Springer-Verlag.