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Hoskin P.J.,Mount Vernon Cancer Center | Kirkwood A.A.,University College London | Popova B.,University College London | Smith P.,University College London | And 9 more authors.
The Lancet Oncology | Year: 2014

Background: Follicular lymphoma has been shown to be highly radiosensitive with responses to doses as low as 4 Gy in two fractions. This trial was designed to explore the dose response for follicular lymphoma comparing 4 Gy in two fractions with 24 Gy in 12 fractions. Methods: FORT is a prospective randomised, unblinded, phase 3 non-inferiority study comparing radiotherapy given as 4 Gy in two fractions with a standard dose of 24 Gy in 12 fractions. Entry criteria included all patients aged over 18 years, having local radiotherapy for radical or palliative local control, with follicular lymphoma or marginal zone lymphoma, who had received no previous treatment for at least 1 month before. The primary outcome was time to local progression analysed on an intention-to-treat basis. Randomisation was centralised through the Cancer Research UK and University College London Cancer Trials Centre. Radiotherapy target sites were randomised (1:1) with minimisation stratified by histology (follicular lymphoma vs marginal zone lymphoma), treatment intent (palliative or curative) and centre. This trial is registered with ClinicalTrials.gov number, NCT00310167. Findings: 299 sites were randomly assigned to 24 Gy and 315 sites to 4 Gy between April 7, 2006, and June 8, 2011, at 43 centres in the UK. After a median follow-up of 26 months (range 0·39-75·4), 91 local progressions had been recorded (21 in the 24 Gy group and 70 in the 4 Gy group). Time to local progression with 4 Gy was not non-inferior to 24 Gy (hazard ratio 3·42, 95% CI 2·09-5·55, p<0·0001). Eight (3%) of 282 patients in the 24 Gy group and four (1%) of 300 in the 4 Gy group had acute grade 3-4 toxic effects. Four (1%) patients in the 24 Gy group and four (1%) patients in the 4 Gy group had late toxic effects. Mucositis was the most common event in the 24 Gy group (two patients with acute mucositis and two with late mucositis; all grade 3) and was not reported in the 4 Gy group. The most common acute effect was pain at the site of irradiation (two patients in the 4 Gy group, one patient in the 24 Gy group; all grade 3), and the most common late effect was fatigue (two patients in the 4 Gy group, one patient in the 24 Gy group; all grade 3). Interpretation: 24 Gy in 12 fractions is the more effective radiation schedule for indolent lymphoma and should be regarded as the standard of care. However, 4 Gy remains a useful alternative for palliative treatment. Funding: Cancer Research UK. © 2014 Elsevier Ltd.


Edey S.,King's College London | Moran N.,Kent and Canterbury Hospital | Moran N.,King's College | Nashef L.,King's College
Epilepsia | Year: 2014

Although data are limited, research in 2004 estimated a 10-fold increase in mortality in pregnancy in the United Kingdom in women with epilepsy (WWE) compared to women without epilepsy. We highlight epilepsy mortality in pregnancy based on the 2011 report of the United Kingdom Confidential Enquiries into Maternal Deaths, relating its findings to previous reports and epilepsy-rates in pregnancy. Among 2,291,493 maternities (2006-2008), we estimated 0.6% or 13,978 were in WWE. Fourteen deaths were epilepsy-related, of which 11 (79%) were sudden and unexpected (SUDEP). Nine occurred during pregnancy and five were postpartum. Nine (64%) were in women taking lamotrigine, seven as monotherapy. We estimated that 1:1,000 women died from epilepsy (mostly SUDEP) during or shortly after pregnancy. Epilepsy-related mortality is a significant risk in pregnancy. Antiepileptic drug-related factors may be relevant. The high proportion of women taking lamotrigine may reflect United Kingdom prescribing practice. Recent observations from the European and International Registry of Antiepileptic Drugs and Pregnancy (EURAP), whereby women on lamotrigine, the levels of which significantly decrease in pregnancy, had more difficulties with epilepsy control, argue against this being the sole explanation. Given the potential risks, every attempt should be made to prevent seizures, particularly convulsive, during pregnancy and postpartum. This, we believe, includes being proactive in maintaining lamotrigine levels during pregnancy. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here. © Wiley Periodicals, Inc. © 2014 International League Against Epilepsy.


Stevens P.E.,Kent and Canterbury Hospital
Journal of Renal Care | Year: 2012

Anaemia is a common finding in people with diabetes and chronic kidney disease and failure of the kidney to produce erythro-poietin in response to a falling haemoglobin concentration is a key component, correlating with the degree of albuminuria, renal dysfunction and iron deficiency. Anaemia in diabetes is associated with a number of adverse outcomes, including increased risk of all cause and cardiovascular mortality. Whether or not anaemia is a marker or mediator of adverse outcome still remains to be completely resolved. Treatment of anaemia in diabetes has quality of life benefits and reduces transfusion requirements. Correction of anaemia to normal haemoglobin concentrations is associated with significant adverse cardiovascular outcomes and is not recommended, escalating doses of erythropoiesis-stimulating agents should be avoided. The treatment of anaemia in people with diabetes and chronic kidney disease should begin with optimisation of iron stores. An aspirational haemoglobin concentration range of 10-12 g/dl with anaemia management, balances proven benefits of anaemia treatment with potential cardiovascular risk. © 2012 European Dialysis and Transplant Nurses Association/European Renal Care Association.


Green C.H.,Kent and Canterbury Hospital
Journal of Medical Physics | Year: 2012

Nuclear Medicine developed when it was realised that a radioisotopic substitution of Iodine-131 for the stable Iodine-127 would follow the same metabolic pathway in the body enabling the thyroid to be imaged and the thyroid uptake measured. The Iodine could be complexed with pharmaceutical substrates to enable other organs to be imaged, but its use was limited and high gamma energy and beta emission restricted the activity of each radiopharmaceutical used, leading to long acquisition times and degraded images. As a pure gamma emitter of 140 keV and with a 6-h half-life, Technetium-99m is a better radionuclide and images a wider range of bodily organs. However, its short half-life also requires it to be eluted from its mother radionuclide, Mo-99, in a generator, delivered weekly from radiopharmaceutical companies who obtain the Mo-99 in liquid form from high-flux research reactors. All went well till around 2007, when the NRU Reactor in Canada was closed and all other reactors went down for various periods for unrelated problems, leading to widespread Mo-99 shortages. Although the reactors have since recovered, they are 48 to 57 years old, and it seems that few governments have made any future provision such as building replacement reactors.


Stevens P.E.,Kent and Canterbury Hospital | Levin A.,St Pauls Hospital
Annals of Internal Medicine | Year: 2013

Description: The Kidney Disease: Improving Global Outcomes (KDIGO) organization developed clinical practice guidelines in 2012 to provide guidance on the evaluation, management, and treatment of chronic kidney disease (CKD) in adults and children who are not receiving renal replacement therapy. Methods: The KDIGO CKD Guideline Development Work Group defined the scope of the guideline, gathered evidence, determined topics for systematic review, and graded the quality of evidence that had been summarized by an evidence review team. Searches of the English-language literature were conducted through November 2012. Final modification of the guidelines was informed by the KDIGO Board of Directors and a public review process involving registered stakeholders. Recommendations: The full guideline included 110 recommendations. This synopsis focuses on 10 key recommendations pertinent to definition, classification, monitoring, and management of CKD in adults. © 2013 American College of Physicians.


Objectives: The aim of this study was to summarize the available evidence on lumbar facet joint injections and the physiotherapy treatments, land-based lower back mobility exercise, soft tissue massage and lumbar spinal mobilizations for chronic low back pain (CLBP). The plausibility of physiotherapy and lumbar facet joint injections as a combination treatment is discussed. Methods: Using a systematic process, an online electronic search was performed using key words utilizing all available databases and hand searching reference lists. Using a critical appraisal tool from the Critical Appraisal Skills Programme (CASP), the literature was screened to include primary research. The main aspects of the research were summarized. Results: The evidence for lumbar facet joint injections suggests an overall short-term positive effect on CLBP. Land-based lower back mobility exercise and soft tissue massage appear to have a positive effect on CLBP in the short term and possibly in the longer term. There is insufficient evidence to draw conclusions for lumbar spinal mobilizations. Conclusion: The review indicates that lumbar facet joint injections create a short period when pain is reduced. Physiotherapy treatments including land-based lower back mobility exercise and soft tissue massage may be of benefit during this time to improve the longer-term outcomes of patients with CLBP. It is not possible to make generalizations or firm conclusions. The current review highlights the need for further research. A randomized controlled trial is recommended to assess the impact of physiotherapy in combination with lumbar facet joint injections on CLBP. © 2013 John Wiley & Sons, Ltd.


Mann J.,Kent and Canterbury Hospital | McFadden J.P.,St Thomas Hospital | White J.M.L.,St Thomas Hospital | White I.R.,St Thomas Hospital | Banerjee P.,St Thomas Hospital
Contact Dermatitis | Year: 2014

Background Negative patch test results with fragrance allergy markers in the European baseline series do not always predict a negative reaction to individual fragrance substances. Objectives To determine the frequencies of positive test reactions to the 26 fragrance substances for which labelling is mandatory in the EU, and how effectively reactions to fragrance markers in the baseline series predict positive reactions to the fragrance substances that are labelled. Methods The records of 1951 eczema patients, routinely tested with the labelled fragrance substances and with an extended European baseline series in 2011 and 2012, were retrospectively reviewed. Results Two hundred and eighty-one (14.4%) (71.2% females) reacted to one or more allergens from the labelled-fragrance substance series and/or a fragrance marker from the European baseline series. The allergens that were positive with the greatest frequencies were cinnamyl alcohol (48; 2.46%), Evernia furfuracea (44; 2.26%), and isoeugenol (40; 2.05%). Of the 203 patients who reacted to any of the 26 fragrances in the labelled-fragrance substance series, only 117 (57.6%) also reacted to a fragrance marker in the baseline series. One hundred and seven (52.7%) reacted to either fragrance mix I or fragrance mix II, 28 (13.8%) reacted to Myroxylon pereirae, and 13 (6.4%) reacted to hydroxyisohexyl 3-cyclohexene carboxaldehyde. Conclusions These findings confirm that the standard fragrance markers fail to identify patients with contact allergies to the 26 fragrances. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.


Azizi T.,Kent and Canterbury Hospital
Journal of perioperative practice | Year: 2013

This article discusses issues surrounding online social networking, and the implications of the use of these sites by healthcare professionals. The article provides guidance to healthcare professionals, as the increased use of sites like Facebook and Twitter have the potential to bring risks to healthcare. Use of these websites can be a very grey area, and boundaries need to be clearly set to ensure protection of service users and healthcare staff alike.


Hadjiphilippou S.,Kent and Canterbury Hospital | Odogwu S.-E.,Kent and Canterbury Hospital | Dand P.,University of Kent
BMJ Supportive and Palliative Care | Year: 2014

Objective Dyspnoea is a distressing and common symptom in palliative care. There is evidence that opioids can improve the experience of dyspnoea. Limited data suggest that doctors' attitudes may be a barrier to prescribing opioids for the relief of refractory dyspnoea. This study explored UK hospital doctors' experience of, and attitudes towards, prescribing opioids for refractory dyspnoea in advanced disease. Methods Anonymous semistructured questionnaires were distributed by convenience sampling. Data were collated and descriptive analysis performed. Doctors of all grades attending routine educational events within the medical directorate of a UK district general hospital were included in this study. Results Sixty-five questionnaires were analysed. Most doctors (61/64) reported a willingness to prescribe opioids for refractory dyspnoea, although the majority felt less confident than when prescribing opioids for pain. Three-quarters of doctors (49/65) had initiated, or under supervision, prescribed opioids for refractory dyspnoea. This was most often for a patient in the last hours/days of life (44/49), followed by patients with cancer (34/49), heart failure (26/49) and chronic obstructive pulmonary disease (COPD) (21/49). Confidence in prescribing was highest in relation to the dying and lowest in COPD. A significant proportion (40/64) of respondents expressed concerns when prescribing. Conclusions This group of doctors was aware of the use of opioids for refractory dyspnoea and reported a willingness to prescribe opioids for this symptom. However, confidence varied considerably depending on clinical context. Fears about side effects were prevalent and should be addressed. Doctors would benefit from clearer guidance on prescribing regimes, specifically in circumstances other than the dying patient.


Hay R.J.,International Foundation of Dermatology | Fuller L.C.,Kent and Canterbury Hospital
International Journal of Dermatology | Year: 2011

The assessment of health needs is a key step in determining the nature and level of health service provision required in any global region. In dermatology, information on needs has provided information on the scale and impact of skin conditions in poor rural and urban populations. In such areas, additional problems in providing adequate services are access to trained health care professionals and cost to families and individuals, set against the background of a village-mixed economy. A further problem is health literacy, which may limit the use of services. However, some of the most comprehensive surveys of the prevalence of skin disease have been carried out in resource-poor countries, and attempts have been made to assess these along with their impact on individual disability. These studies and their outcomes are described in this article. © 2011 The International Society of Dermatology.

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