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PubMed | St Marys Hospital, Guys & St Thomas Hospitals NHS Foundation Trust, University of Sussex and King's College
Type: Journal Article | Journal: Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology | Year: 2016

The concept of a general practitioner with special interest (GPwSI) was first proposed in the 2000 National Health Service Plan, as a way of providing specialized treatment closer to the patients home and reducing hospital waiting times. Given the patchy and inadequate provision of paediatric allergy services in the UK, the introduction of GPwSIs might reduce pressure on existing specialist services.A total of 100 consecutive referrals to a specialist paediatric allergy clinic were reviewed to assess what proportion could be managed by a GPwSI allergy service with a predefined range of facilities and expertise (accurate diagnosis and management of allergy; skin prick testing; provision of allergen avoidance advice; ability to assess suitability for desensitization). Each referral was reviewed independently by three allergy specialists. Cases were initially judged on the referral letter and then, to determine whether appropriate triage decisions could be made prospectively, cases were re-assessed with information summarized in the clinic letter. The proportion of referrals suitable for a GPwSI was calculated and their characteristics identified.At least 42% and up to 75% were suitable for management by a GPwSI in allergy based on unanimous and majority agreement, respectively. The appropriateness of 79% referrals could be identified based on the information in the referral letter. A total of 19% referrals were unsuitable for a GPwSI service because of complex or multisystem disease, need for specialist knowledge or facilities or patients young age.At least two-fifths of paediatric allergy referrals to our hospital-based service could be dealt with in a GPwSI clinic, thereby diversifying the patient pathway, allowing specialist services to focus on complex cases and reducing waiting times for appointments.


PubMed | Amgen, Hospital Clinic Of Barcelona, Adelphi Values, Guys & St Thomas Hospitals NHS Foundation Trust and 2 more.
Type: | Journal: European journal of cancer (Oxford, England : 1990) | Year: 2016

With the recent emergence of immunotherapies and novel targeted treatments for advanced and metastatic melanoma such as selective B-Raf inhibitors and checkpoint inhibitors, the treatment landscape in Europe has changed considerably. The aim of this review was to provide an overview of current treatment pathways in Europe for the treatment of advanced melanoma, unresectable stage III-IV.A literature search of four databases was conducted to identify publications reporting on the treatment patterns of advanced and metastatic melanoma (stage III-IV) in European populations.Seven full-text publications and two conference abstracts reported on observational studies of melanoma treatment practices in France, Italy and the United Kingdom. Treatment patterns were identified for two time periods: 2005-2009 and 2011-2012. Common treatments reported for both periods included chemotherapy with dacarbazine, fotemustine or temozolomide. The main differences between the two periods were the introduction and prescription of immunotherapy ipilimumab and targeted therapy vemurafenib between 2011 and 2012. Across the three countries studied, the types of treatments prescribed between 2005 and 2009 were relatively similar, however, with noticeable differences in the frequency and priority of administration.Treatment practices for advanced melanoma vary markedly across different European countries and continue to evolve with the introduction of new therapies. The results of this review highlight a considerable evidence gap with regards to recent treatment patterns for advanced melanoma in Europe, especially post-2011 after the introduction of novel therapeutic agents, and more recently with the introduction of programmed cell death 1 inhibitors.


PubMed | New Hill, University of Zürich, Cedars Sinai Medical Center, University of Washington and 18 more.
Type: Journal Article | Journal: European heart journal | Year: 2015

Transcatheter mitral interventions has been developed to address an unmet clinical need and may be an alternative therapeutic option to surgery with the intent to provide symptomatic and prognostic benefit. Beyond MitraClip therapy, alternative repair technologies are being developed to expand the transcatheter intervention armamentarium. Recently, the feasibility of transcatheter mitral valve implantation in native non-calcified valves has been reported in very high-risk patients. Acknowledging the lack of scientific evidence to date, it is difficult to predict what the ultimate future role of transcatheter mitral valve interventions will be. The purpose of the present report is to review the current state-of-the-art of mitral valve intervention, and to identify the potential future scenarios, which might benefit most from the transcatheter repair and replacement devices under development.


Doumou G.,King's College London | Siddique M.,King's College London | Tsoumpas C.,King's College London | Tsoumpas C.,University of Leeds | And 5 more authors.
European Radiology | Year: 2015

Objectives: Measuring tumour heterogeneity by textural analysis in 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) provides predictive and prognostic information but technical aspects of image processing can influence parameter measurements. We therefore tested effects of image smoothing, segmentation and quantisation on the precision of heterogeneity measurements. Methods: Sixty-four 18F-FDG PET/CT images of oesophageal cancer were processed using different Gaussian smoothing levels (2.0, 2.5, 3.0, 3.5, 4.0 mm), maximum standardised uptake value (SUVmax) segmentation thresholds (45 %, 50 %, 55 %, 60 %) and quantisation (8, 16, 32, 64, 128 bin widths). Heterogeneity parameters included grey-level co-occurrence matrix (GLCM), grey-level run length matrix (GLRL), neighbourhood grey-tone difference matrix (NGTDM), grey-level size zone matrix (GLSZM) and fractal analysis methods. The concordance correlation coefficient (CCC) for the three processing variables was calculated for each heterogeneity parameter. Results: Most parameters showed poor agreement between different bin widths (CCC median 0.08, range 0.004–0.99). Segmentation and smoothing showed smaller effects on precision (segmentation: CCC median 0.82, range 0.33–0.97; smoothing: CCC median 0.99, range 0.58–0.99). Conclusions: Smoothing and segmentation have only a small effect on the precision of heterogeneity measurements in 18F-FDG PET data. However, quantisation often has larger effects, highlighting a need for further evaluation and standardisation of parameters for multicentre studies. Key points: • Heterogeneity measurement precision in18F-FDG PET is influenced by image processing methods. • Quantisation shows large effects on precision of heterogeneity parameters in18F-FDG PET/CT. • Smoothing and segmentation show comparatively smaller effects on precision of heterogeneity parameters. © 2015, European Society of Radiology.


PubMed | Guys & St Thomas Hospitals NHS Foundation Trust and University of Leeds
Type: Evaluation Studies | Journal: Journal of medical microbiology | Year: 2014

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) provides rapid, accurate and cost-effective identification of a range of bacteria and is rapidly changing the face of routine diagnostic microbiology. However, certain groups of bacteria, for example streptococci (in particular viridans or non-haemolytic streptococci), are less reliably identified by this method. We studied the performance of MALDI-TOF MS for identification of the Streptococcus anginosus group (SAG) to species level. In total, 116 stored bacteraemia isolates identified by conventional methods as belonging to the SAG were analysed by MALDI-TOF MS. Partial 16S rRNA gene sequencing, supplemented with sialidase activity testing, was performed on all isolates to provide gold standard identification against which to compare MALDI-TOF MS performance. Overall, 100% of isolates were correctly identified to the genus level and 93.1% to the species level by MALDI-TOF MS. However, only 77.6% were correctly identified to the genus level and 59.5% to the species level by a MALDI-TOF MS direct transfer method alone. Use of a rapid in situ extraction method significantly improved identification rates when compared with the direct transfer method (P<0.001). We recommend routine use of this method to reduce the number of time-consuming full extractions required for identification of this group of bacteria by MALDI-TOF MS in the routine diagnostic laboratory. Only 22% (1/9) of Streptococcus intermedius isolates were reliably identified by MALDI-TOF MS to the species level, even after full extraction. MALDI-TOF MS reliably identifies S. anginosus and Streptococcus constellatus to the species level but does not reliably identify S. intermedius.


PubMed | Guys & St Thomas Hospitals NHS Foundation Trust and King's College
Type: Journal Article | Journal: Heart (British Cardiac Society) | Year: 2014

To identify the effects of preprocedural significant mitral regurgitation (MR) and change in MR severity upon mortality after transcatheter aortic valve implantation (TAVI) using the Edwards SAPIEN system.A retrospective analysis of 316 consecutive patients undergoing TAVI for aortic stenosis at a single centre in the UK between March 2008 and January 2013. Patients were stratified into two groups according to severity of MR: grade 3 were classed as significant and grade 2 were non-significant. Change in MR severity was assessed by comparison of baseline and 30-day echocardiograms.60 patients had significant MR prior to TAVI (19.0%). These patients were of higher perioperative risk (logistic EuroScore 28.716.6% vs 20.310.7%, p=0.004) and were more dyspnoeic (New York Heart Association class IV 20.0% vs 7.4%, p=0.014). Patients with significant preprocedural MR displayed greater 12-month and cumulative mortality (28.3% vs 20.2%, log-rank p=0.024). Significant MR was independently associated with mortality (HR 4.94 (95% CI 2.07 to 11.8), p<0.001). Of the 60 patients with significant MR only 47.1% had grade 3-4 MR at 30days (p<0.001). Patients in whom MR improved had lower mortality than those in whom it deteriorated (log-rank p=0.05).Significant MR is frequently seen in patients undergoing TAVI and is independently associated with increased all-cause mortality. Yet almost half also exhibit significant improvements in MR severity. Those who improve have better outcomes, and future work could focus upon identifying factors independently associated with such an improvement.


PubMed | Guys & St Thomas Hospitals NHS Foundation Trust
Type: Editorial | Journal: Expert review of hematology | Year: 2015

Myelofibrosis is a heterogeneous disorder, which, although sometimes asymptomatic in the early stages, is frequently associated with debilitating constitutional symptoms, poor quality of life and high degree of morbidity as the disease progresses. Ruxolitinib, a JAK1/2-inhibitor, has transformed the management of many patients by reducing disease-related symptoms and splenomegaly in intermediate-2 and high-risk patients. As demonstrated by the COMFORT studies, unprecedented clinical benefit can be gained by some patients on ruxolitinib; however, this is not without potential adverse effects, notably cytopenias, weight-gain and an increased risk of opportunistic infections. No other JAK inhibitors are currently approved for myelofibrosis. Moreover, long-term effects of JAK-inhibitor agents, such as ruxolitinib, remain unknown. Consequently, the use of ruxolitinib in the low-risk patient, in the absence of high symptom burden remains controversial and requires further randomized clinical trials. In such patients, an individualized approach should be adopted, balancing likely clinical benefit with the potential side-effect profile.


PubMed | Guys & St Thomas Hospitals NHS Foundation Trust
Type: Journal Article | Journal: British journal of haematology | Year: 2015

The approach to the diagnosis and management of essential thrombocythaemia (ET) is steadily changing, influenced by advances in molecular biology, data from clinical trials and retrospective analyses of patient cohorts. In the past decade options for clinical management largely remain unchanged, but who we treat, and with what target in mind, is evolving. A further area of change is recognition of symptoms that may be associated with ET, as well as other myeloproliferative neoplasms, and that potential options for their management are becoming available. Judicious and careful diagnosis is increasingly a fundamental key to successful management followed by cytoreductive therapy in a subset of patients. In this review we demonstrate our management strategies for ET using a case-based format.


PubMed | Guys & St Thomas Hospitals Nhs Foundation Trust
Type: | Journal: BMC medical education | Year: 2013

Most assessments of the quality of postgraduate training are based on anonymised questionnaires of trainees. We report a comprehensive assessment of the quality of training at a large postgraduate psychiatry training institute using non-anonymised face-to-face interviews with trainees and their trainers.Two consultant psychiatrists interviewed 99 trainees and 109 trainers. Scoring of interview responses was determined by using a pre-defined criteria. Additional comments were recorded as free text. Interviews covered 13 domains, including: Clinical, teaching, research and management opportunities, clinical environment, clinical supervision, adequacy of job description, absence of bullying and job satisfaction. Multiple interview domain scores were combined, generating a Combined score for each post.The interview response rate was 97% for trainers 88% for trainees. There was a significant correlation between trainee and trainer scores for the same interview domains (Pearsons r = 0.968, p< 0.001). Overall scores were significantly higher for specialist psychiatry posts as compared to general adult psychiatry posts (Two tailed t-test, p < 0.001, 95% CI: -0.398 to -0.132), and significantly higher for liaison psychiatry as compared to other specialist psychiatry posts (t-test: p = 0.038, 95% CI: -0.3901, -0.0118). Job satisfaction scores of year 1 to year 3 core trainees showed a significant increase with increasing seniority (Linear regression coefficient = 0.273, 95% CI: 0.033 to 0.513, ANOVA p= 0.026).This in-depth examination of the quality of training on a large psychiatry training programme successfully elicited strengths and weakness of our programme. Such an interview scheme could be easily implemented in smaller schemes and may well provide important information to allow for targeted improvement of training. Additionally, trends in quality of training and job satisfaction amongst various psychiatric specialities were identified; specifically speciality posts and liaison posts in psychiatry were revealed to be the most popular with trainees.

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