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Schreiber B.E.,Royal Free Hampstead NHS Trust | Agrup C.,University College London | Haskard D.O.,Imperial College London | Luxon L.M.,The National Hospital for Neurology and Neurosurgery
The Lancet | Year: 2010

Sudden sensorineural hearing loss is usually unilateral and can be associated with tinnitus and vertigo. In most cases the cause is not identified, although various infective, vascular, and immune causes have been proposed. A careful examination is needed to exclude life threatening or treatable causes such as vascular events and malignant diseases, and patients should be referred urgently for further assessment. About half of patients completely recover, usually in about 2 weeks. Many treatments are used, including corticosteroids, antiviral drugs, and vasoactive and oxygen-based treatments. Although no treatment is proven, we recommend a short course of oral high-dose corticosteroids. There is much to learn about pathogenesis of sudden sensorineural hearing loss, and more clinical trials are needed to establish evidence-based management. © 2010 Elsevier Ltd. All rights reserved.


Vanderpump M.P.J.,Royal Free Hampstead NHS Trust | Lazarus J.H.,University of Cardiff | Smyth P.P.,University College Dublin | Smyth P.P.,National University of Ireland | And 4 more authors.
The Lancet | Year: 2011

Background: Iodine deficiency is the most common cause of preventable mental impairment worldwide. It is defined by WHO as mild if the population median urinary iodine excretion is 50-99 μg/L, moderate if 20-49 μg/L, and severe if less than 20 μg/L. No contemporary data are available for the UK, which has no programme of food or salt iodination. We aimed to assess the current iodine status of the UK population. Methods: In this cross-sectional survey, we systematically assessed iodine status in schoolgirls aged 14-15 years attending secondary school in nine UK centres. Urinary iodine concentrations and tap water iodine concentrations were measured in June-July, 2009, and November-December, 2009. Ethnic origin, postcode, and a validated diet questionnaire assessing sources of iodine were recorded. Findings: 810 participants provided 737 urine samples. Data for dietary habits and iodine status were available for 664 participants. Median urinary iodine excretion was 80·1 μg/L (IQR 56·9-109·0). Urinary iodine measurements indicative of mild iodine deficiency were present in 51% (n=379) of participants, moderate deficiency in 16% (n=120), and severe deficiency in 1% (n=8). Prevalence of iodine deficiency was highest in Belfast (85%, n=135). Tap water iodine concentrations were low or undetectable and were not positively associated with urinary iodine concentrations. Multivariable general linear model analysis confirmed independent associations between low urinary iodine excretion and sampling in summer (p<0·0001), UK geographical location (p<0·0001), low intake of milk (p=0·03), and high intake of eggs (p=0·02). Interpretation: Our findings suggest that the UK is iodine deficient. Since developing fetuses are the most susceptible to adverse effects of iodine deficiency and even mild perturbations of maternal and fetal thyroid function have an effect on neurodevelopment, these findings are of potential major public health importance. This study has drawn attention to an urgent need for a comprehensive investigation of UK iodine status and implementation of evidence-based recommendations for iodine supplementation. Funding: Clinical Endocrinology Trust. © 2011 Elsevier Ltd.


Pabari A.,Royal Free Hampstead NHS Trust | Lloyd-Hughes H.,Royal Free Hampstead NHS Trust | Seifalian A.M.,Royal Free Hampstead NHS Trust | Mosahebi A.,Royal Free Hampstead NHS Trust
Plastic and Reconstructive Surgery | Year: 2014

Autologous nerve grafts are the current criterion standard for repair of peripheral nerve injuries when the transected nerve ends are not amenable to primary end-to-end tensionless neurorrhaphy. However, donor-site morbidities such as neuroma formation and permanent loss of function have led to tremendous interest in developing an alternative to this technique. Artificial nerve conduits have therefore emerged as an alternative to autologous nerve grafting for the repair of short peripheral nerve defects of less than 30 mm; however, they do not yet surpass autologous nerve grafts clinically. A thorough understanding of the complex biological reactions that take place during peripheral nerve regeneration will allow researchers to develop a nerve conduit with physical and biological properties similar to those of an autologous nerve graft that supports regeneration over long nerve gaps and in large-diameter nerves. In this article, the authors assess the currently available nerve conduits, summarize research in the field of developing these conduits, and establish areas within this field in which further research would prove most beneficial. Copyright © 2014 by the American Society of Plastic Surgeons.


Vanderpump M.P.J.,Royal Free Hampstead NHS Trust
British Medical Bulletin | Year: 2011

Introduction: Thyroid disorders are prevalent and their manifestations are determined by the dietary iodine availability. Sources of data: Data from screening large population samples from USA and Europe. Areas of agreement: The most common cause of thyroid disorders worldwide is iodine deficiency, leading to goitre formation and hypothyroidism. In iodine-replete areas, most persons with thyroid disorders have autoimmune disease. Areas of controversy: Definition of thyroid disorders, selection criteria used, influence of age and sex, environmental factors and the different techniques used for assessment of thyroid function. Growing points: Increasing incidence of well-differentiated thyroid cancer. Environmental iodine influences the epidemiology of non-malignant thyroid disease. Areas timely for developing research: Iodine supplementation of populations with mild-to-moderate iodine deficiency. An evidence-based strategy for the risk stratification, treatment and follow-up of benign nodular thyroid disease. Is there any benefit in screening adults for thyroid dysfunction? © The Author 2010. Published by Oxford University Press. All rights reserved.


Vanderpump M.P.J.,Royal Free Hampstead NHS Trust
Clinical Endocrinology | Year: 2010

A mildly increased serum thyrotrophin (TSH) is usually because of mild thyroid failure, and the most common aetiology in iodine-replete communities is chronic autoimmune thyroiditis. It is more common in women, and the prevalence increases with age in both men and women and is associated with the presence of antithyroid antibodies. The majority will have serum TSH levels between 5-10 mIU/l, normal free thyroxine (T4) levels and relatively few symptoms. In 2004, US evidence-based consensus guidelines concluded that there were no adverse outcomes of a mildly increased serum TSH other than a risk of progression to overt hypothyroidism and few data to justify levothyroxine therapy. There is still debate as to what constitutes an increased serum TSH, particularly in older subjects. Although some subjects will progress to overt hypothyroidism, recent data suggest a significant proportion revert to a serum TSH within the reference range without treatment. Two recent meta-analyses have suggested that the possible cardiovascular risks may be more significant in younger adults. Other data suggest that mild thyroid failure may be the only reversible cause of left ventricular diastolic dysfunction. No appropriately powered prospective, randomized, controlled, double-blinded interventional trial of levothyroxine therapy for a mildly increased serum TSH exists. However, treatment in subjects who are symptomatic, pregnant or preconception, aged less than 65 years and older subjects with evidence of heart failure appear justified. © 2010 Blackwell Publishing Ltd.


Vanderpump M.P.J.,Royal Free Hampstead NHS Trust
European Journal of Internal Medicine | Year: 2011

The management of a patient with subclinical hyperthyroidism or mild thyroid over-activity is controversial. Subclinical hyperthyroidism is defined as a serum thyrotrophin (TSH) below the reference range but a normal thyroxine (T 4) and triiodothyronine (T 3) level in a patient who is either asymptomatic or has only non-specific symptoms. Epidemiological studies report an overall prevalence of approximately 3%, with men and women over 65 years and those in iodine deficient regions having the highest prevalence. Approximately 50% of subjects are taking levothyroxine. The aetiology for those with endogenous subclinical hyperthyroidism is Graves' disease, toxic nodular goitre or rarely a solitary toxic adenoma or thyroiditis. Non-thyroidal illness is an important cause of false positive low serum TSH test results. Subjects with low but detectable serum TSH values (0.1-0.4 mU/L) usually recover spontaneously when re-tested. It has been estimated that in those with an undetectable serum TSH (< 0.1 mU/L) conversion to overt hyperthyroidism occurs at a rate up to 5% per year. Advocates of intervening for subclinical hyperthyroidism argue that early treatment might reduce mortality, prevent the later development of atrial fibrillation, osteoporotic fractures, and overt hyperthyroidism but data supporting improvement in outcomes are sparse. No appropriately powered prospective, randomised, controlled, double-blinded trial of intervention for subclinical hyperthyroidism exists. For the vast majority of patients adopting a "wait and see" policy rather than intervention may avoid unnecessary treatment or the potential for harm. Any potential benefits of therapy in subclinical hyperthyroidism must be weighed against the significant morbidity associated with the treatment of hyperthyroidism. © 2011 European Federation of Internal Medicine.


Ameen M.,Royal Free Hampstead NHS Trust
Current HIV Research | Year: 2010

Skin and mucosal diseases can be the first manifestation of asymptomatic HIV infection, may indicate advancing immunodeficiency, or may represent systemic opportunistic infections or neoplasms. Mucocutaneous diseases are highly prevalent in the HIV-infected population and multiple pathologies are common particularly with advanced immunosuppression. The dominant HIV-associated skin diseases are infectious and inflammatory and they can cause significant morbidity. Although skin cancers are less common their prognosis is often worse. Clinical presentations are often atypical and may vary depending on the level of immunosuppression. Managing skin disease in the context of advanced immunosuppression is challenging and they often respond poorly to conventional therapies. This improves with the commencement of antiretrovirals (ARVs) and immune restoration. Despite the significant decline in HIV-related skin diseases with ARVs, the drugs themselves have brought with them a range of other skin-associated problems: adverse effects, an increased risk of drug reactions, and immune reconstitution-associated skin diseases. Therefore, the burden of skin disease remains high even in the era ARVs and the aim of this review is to equip physicians managing HIV-infected patients with knowledge of the spectrum of skin disorders associated with HIV-related immunosuppression. © 2010 Bentham Science Publishers Ltd.


Schreiber B.E.,Royal Free Hampstead NHS Trust | Noor N.,Bedford Hospital NHS Trust | Juli C.F.,Imperial College London | Haskard D.O.,Imperial College London
Seminars in Arthritis and Rheumatism | Year: 2011

Introduction: We describe the successful treatment of pulmonary arterial aneurysms in Behçet's syndrome using a tumor necrosis factor (TNF) inhibitor. Methods: A case is reported of Behçet's syndrome complicated by pulmonary arterial aneurysms that responded to anti-TNF therapy. This is accompanied by a literature review of previously published cases. We searched the English language medical literature using the PubMed and Medline search terms: "Behçet's," "Pulmonary aneurysms," and "infliximab," "etanercept," or "adalimumab.". Results: A 43-year-old man with a 6-month history of oral and genital ulcers, weight loss, and fatigue developed arterial aneurysms in the common carotid and common iliac arteries and thromboses in a femoral vein and pulmonary arteries. Treatment with high-dose oral corticosteroids and pulsed intravenous cyclophosphamide was initiated but while on treatment he developed pulmonary arterial aneurysms with hemoptysis. His treatment was changed to intravenous infliximab with methotrexate to which he showed a good response with marked clinical improvement, reduction in his inflammatory markers, and regression of the pulmonary arterial aneurysms. The review of the literature identified 3 reported cases of treatment of pulmonary arterial aneurysms in Behçet's syndrome with anti-TNF therapy, with good outcomes in each case. Conclusions: Pulmonary artery aneurysms are important complications of Behçet's syndrome. Anti-TNF inhibitors should be considered in patients who do not respond to treatment with corticosteroids and cyclophosphamide. © 2011 Elsevier Inc.


Vanderpump M.,Royal Free Hampstead NHS Trust
Nature Reviews Endocrinology | Year: 2011

Up to one-third of patients treated with levothyroxine for primary hypothyroidism have biochemical evidence of inadequate thyroid hormone replacement. Could treatment effects of levothyoxine be optimized by bedtime administration on an empty stomach? A new study reveals the answer and also sheds light on other possible benefits of this alternative timing. © 2011 Macmillan Publishers Limited. All rights reserved.


Mallucci P.,The London Clinic | Branford O.A.,Royal Free Hampstead NHS Trust
Journal of Plastic, Reconstructive and Aesthetic Surgery | Year: 2012

Background: This article identifies the key parameters that define the aesthetic ideal of the breast. Whilst much has previously been written on the aesthetic characteristics of the breast, thus far objective indices of beauty have not been identified. Methods: In this observational study the breasts of 100 consecutive women in three quarter profile pose, having been chosen as topless models for the attractiveness of their breasts by editors of mass print media, were analysed to identify specific proportions common to all of them. Analysis of a series of less attractive breasts was subsequently carried out looking at divergence from the 'norms' identified in the first part of the study. Results: We have identified 4 key features consistently found in all the models in the consecutive series: the proportion of the upper to the lower pole is a 45:55 ratio, the angulation of the nipple is upwards at a mean angle of 20° from the nipple meridian, the upper pole slope is linear or slightly concave, and the lower pole is convex. Conclusions: Deviation from this pattern yields a less attractive breast - the greater the deviation, the less attractive the breast. The importance of this template lies in its use as a guide for the design of aesthetic breast surgery as well as objective analysis of both good and bad results. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

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