Congi L.,Whittington Hospital |
Roussou E.,King George Hospital
Clinical and Experimental Rheumatology | Year: 2010
Objective: Psoriatic arthritis (PsA) has been defined as a systemic, chronic, inflammatory arthritis, usually seronegative for rheumatoid factor (RF), associated with cutaneous psoriasis. The exact prevalence of PsA is unknown and its estimation has been difficult, partly due to the lack of a widely accepted classification criteria. Agreed and validated criteria will facilitate comparison between centres and different countries in the areas of epidemiology, outcome studies and therapeutic trials. A number of classification criteria have been published by Moll & Wright (M&W), Bennett's, Vasey and Espinoza (V&E), Fournié's, European Spondyloarthropathy Study Group (ESSG), McGonagle, Gladman and most recently, the CASPAR Study Group. In this paper, we present an audit aiming to assess which of these criteria performs better in clinical practice. Methods: Sixty-nine (69) patients with evidence of PsA were seen in the clinic as regular outpatients and were assessed as to whether they fulfil any of the 6 existing criteria for PsA: M&W, Bennett's, V&E, Fournié's, ESSG and CASPAR criteria. All items included in the 6 sets of criteria were recorded for each patient based on interview, clinical examination and scrutiny of clinical medical records. By comparing the criteria between themselves as well as the items used in each one of them we tried to assess which one of the criteria was performing best. Results: A total of 69 patients (M/F=24/45; mean age 46.4 years (±20.3), and delay in diagnosis of 3.4 years (±4.1) was assessed. From those, 9 patients did not fulfil any criteria and excluded from the analysis. From the remaining 60 patients [M/F=21/39; (age 48±15.3)], 21 patients (35%) fulfilled all 6 sets of criteria. The remaining 39 patients (M/F=41/59 %; age 47±14.9) were further analysed with regards to the feature that did not enable concordance. From those 39 patients, Bennett's criteria were positive in only 4139 (10.2%), M&W criteria were positive in 12/39 (30.7%), ESSG criteria in 17/39 (435%), V&E criteria were positive in 18/39 (46.1%), Fournié's criteria were positive in 31139 (79.4%) and CASPAR criteria in 35/39 (89.7%). By including family history of psoriasis in the criteria, 11/39 patients (28.2%), who did not fulfil M& W or V&E due to lack of family history of psoriasis as item, met the CASPAR criteria. In addition, some patients who did not fulfil the M&W criteria, since RF positive (7139; 17.9%), were able to satisfy the CASPAR criteria. Conclusion: Family history of psoriasis is the main advantage of the new CASPAR Criteria over M&W and V&E. In addition, using the CASPAR criteria, it is possible to make a diagnosis of PsA in a patient who develops inflammatory articular disease even if with RF positive and polyarticular symmetrical arthritis. It is also important to have these classification criteria for the development of recommendations for the optimal treatment of patients with PsA. We believe that the CASPAR criteria, which are simple and easy to use, have high potential to be introduced as the universal classification criteria for PsA. However, further study of the validation of these new criteria is required. © Copyright Clinical and Experimental Rheumatology 2010.
Sarker S.K.,Whittington Hospital |
Kumar I.,University College London |
Delaney C.,University Hospitals
World Journal of Surgery | Year: 2010
Background: Competent technical skills performance in complex operations is vital for satisfactory patient outcome. Assessing these skills is therefore of paramount importance. In this study we aim to develop and validate a new tool that can assess both generic and specific technical skills in advanced complex laparoscopic colorectal surgery in the operating room. Methods: Hierarchical task analysis was constructed for generic and specific technical skills on three key advanced laparoscopic colorectal operations (right hemicolectomy, sigmoid colectomy, and anterior resection) after expert discussions. Likert scales were then constructed individually for generic and specific technical skills for each operation using hierarchical task analysis for each operation to identify key elements and steps for each operation. Each operation was assessed independently and blindly by two experienced surgeons. Results: Eighty-four live real operations performed by six consultants and eight trainees were assessed. Interclass correlation coefficient between the two observers was 0.94 (P ≤ 0.05) for generic technical skills and 0.88 (P ≤ 0.05) for the operation-specific technical skills. Construct validity for both generic and specific technical skills for consultants and trainees was significant using ANOVA (P ≤ 0.05). All consultants therefore consistently performed better in both generic and specific technical skills compared to their trainees. Conclusions: This new assessment tool of generic and specific technical skills in advanced laparoscopic colorectal surgery is reliable and has face, content, concurrent, and construct validities. The tool has the possibility of being used as a surgical training and appraisal tool. © 2010 Société Internationale de Chirurgie.
Kelsey M.,Whittington Hospital
Journal of Antimicrobial Chemotherapy | Year: 2013
The problem of Pseudomonas as a nosocomial pathogen is not new, withsome authors dating its onset to the start of the antimicrobial era, although other factors, such as the growth of intensive or augmented care, have a part to play. This paperoutlines the historicalandenvironmental issues thatmaybe associatedwitha potential increase in the incidence of this difficult-to-treat pathogen. © Crown copyright 2013.
Horst C.,Whittington Hospital |
Kapur N.,Whittington Hospital
Clinical and Experimental Dermatology | Year: 2014
Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon, idiopathic disease that manifests as dermal or subcutaneous red or brown papules or nodules, most commonly on the head and neck. Histologically, ALHE is characterized by vascular proliferation with epithelioid endothelial cells with surrounding lymphocytic and eosinophilic infiltrate. There may be an accompanying serum eosinophilia and local lymphadenopathy. We report a case of a 32-year-old woman who presented with multiple erythematous nodules in the periauricular area and the vertex of her scalp. The nodules had been present for several months. Surgical removal of one of the lesions confirmed the histological diagnosis of ALHE. The patient was started on oral propranolol (40 mg once daily) in an effort to reduce the vascular component of the lesions. Within 6 weeks, the patient noted that several of the lesions had decreased in size, and all were less erythematous. Propranolol was subsequently stopped within a few months of initiating treatment. One lesion recurred over a year later, and propranolol was then restarted. No new lesions occurred after 2 years of follow-up. © 2014 British Association of Dermatologists.
Tan S.S.Y.,University of Glasgow |
Sarker S.K.,Whittington Hospital
Scottish Medical Journal | Year: 2011
The ability to acquire surgical skills requires consistent practice, and evidence suggests that many of these technical skills can be learnt away from the operating theatre. The aim of this review article is to discuss the importance of surgical simulation today and its various types, exploring the effectiveness of simulation in the clinical setting and its challenges for the future. Surgical simulation offers the opportunity for trainees to practise their surgical skills prior to entering the operating theatre, allowing detailed feedback and objective assessment of their performance. This enables better patient safety and standards of care. Surgical simulators can be divided into organic or inorganic simulators. Organic simulators, consisting of live animal and fresh human cadaver models, are considered to be of high-fidelity. Inorganic simulators comprise virtual reality simulators and synthetic bench models. Current evidence suggests that skills acquired through training with simulators, positively transfers to the clinical setting and improves operative outcome. The major challenge for the future revolves around understanding the value of this new technology and developing an educational curriculum that can incorporate surgical simulators.
Ahmad O.F.,Whittington Hospital |
Akbar A.,St Marks Hospital
British Medical Bulletin | Year: 2015
Introduction Food is a recognized trigger for most patients with irritable bowel syndrome (IBS). In recent years, an emerging evidence base has identified dietary manipulation as an important therapeutic approach in IBS. Sources of data Original and review articles were identified through selective searches performed on PubMed and Google Scholar. Areas of agreement Randomized controlled trials have supported the use of a diet that restricts a group of short-chain carbohydrates known collectively as fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs). There is evidence that specific probiotics may improve symptoms in IBS. Areas of controversy The role of a high-fibre diet remains subject to ongoing debate with a lack of high-quality evidence. The long-term durability and safety of a low FODMAP diet are unclear. Growing points A paradigm shift has led to a focus on the relationship between diet and pathophysiological mechanisms in IBS such as effects on intestinal microbiota, inflammation, motility, permeability and visceral hypersensitivity. Areas timely for developing research Future large, randomized controlled trials with rigorous end points are required. In addition, predictors of response need to be identified to offer personalized therapy. © 2014 The Author.
Freeman-Wang T.,Whittington Hospital |
Walker P.,Royal Free Hospital
Best Practice and Research: Clinical Obstetrics and Gynaecology | Year: 2011
The true value of colposcopy in pregnancy is under debate; the examination may be more difficult depending on the gestation at which a woman presents. Cervical intraepithelial neoplasia does not have an accelerated progression during pregnancy, and treatment is usually deferred until postpartum. The prevalence of cervical intraepithelial neoplasia is greater in women with immune compromise. Those with human immunodeficiency have a higher prevalence, more persistence and less regression of human papillomavirus-related infections. Cervical cancer remains an AIDS-defining illness. Women who have had renal transplants also have a higher risk of developing cervical intraepithelial neoplasia. By contrast, other chronic illnesses that require immunosuppressant therapy do not seem to show this added risk. In young women, human papillomavirus infection is common and cervical intraepithelial neoplasia is also evident, but regression of these lesions is frequent and so conservative review may be appropriate. At the menopause, colposcopy is often unsatisfactory. The use of human papillomavirus testing for triage of low-grade cytological abnormalities may benefit this age group. © 2011 Elsevier Ltd. All rights reserved.
Khoyratty S.,Whittington Hospital
Journal of perioperative practice | Year: 2010
OBJECTIVE: Study preoperative fasting times of adult elective surgical patients. METHODS: Fasting times for food and clear fluids, and the information used by patients to decide when to start fasting were studied. RESULTS: Among 200 patients, median fasting times were 2-4 times the guideline recommendations. Most patients used hospital written instructions but many started fasting substantially earlier than the instructions stipulated. DISCUSSION: Improved communication with patients could improve fasting times.
Thorat M.A.,Queen Mary, University of London |
Thorat M.A.,Whittington Hospital |
Cuzick J.,Queen Mary, University of London
European Journal of Epidemiology | Year: 2015
A careful assessment of benefits and harms is required to assess suitability of aspirin as a prophylactic public health measure. However, comprehensive population-level data on harms are lacking. We collected and synthesized age and sex-specific data on harms relevant to aspirin use in average-risk individuals aged 50 years or older. We conducted systematic literature searches to identify baseline rates of gastrointestinal (GI) bleeding, peptic ulcer, major extra-cranial bleeding, and case-fatality rates due to GI bleeding or peptic ulcer in general population. The magnitude of aspirin-associated increase, the prevalence and attributable risk of Helicobacter pylori infection on these events in aspirin users was also assessed. Baseline rates of major extracranial bleeding events and GI complications increase with age; an almost threefold to fourfold increase is observed from age 50–54 to 70–74 years. Low or standard-dose aspirin use increases GI bleeding events by 60 % leading to an annual excess of 0.45 and 0.79 GI bleeding events per 1,000 women and men aged 50–54 years respectively. 5–10 % of major GI complications are fatal; a clear age dependence—higher fatality in older individuals, is seen. Eradication of H. pylori infection before aspirin use could reduce the incidence of upper GI complications by 25–30 %. GI complications are increased by about 60 % due to aspirin use but are fatal only in a very small proportion of individuals younger than 70 years of age. Major bleeding events that are comparable in severity to cancer or CVD, are infrequent. Screening and eradication of H. pylori infection could substantially lower aspirin-related GI harms. © 2014, Springer Science+Business Media Dordrecht.
Pasterski V.,University of Cambridge |
Prentice P.,Whittington Hospital |
Hughes I.A.,University of Cambridge
Archives of Disease in Childhood | Year: 2010
Objective: To assess clinical management of disorders of sex development (DSD) subsequent to recommendations issued in the 2006 Consensus Statement. Design: Online questionnaire and audit of DSD literature. Setting: Invitation to complete a 28-item online questionnaire and a 12-item follow-up questionnaire, both assessing current clinic statistics and clinical management of DSD. Participants: Paediatric endocrinologists from 60 medical centres representing 23 European countries. Main outcome measures: Clinic activity, multidisciplinary team composition, provision of psychological support services, incidence of feminising clitoroplasty and use of diagnostic algorithms and newly proposed nomenclature. Analyses: Data are reported in terms of percentages with respect to implementation of recommendations outlined in the Consensus Statement. χ2 was used to analyse changes in nomenclature reported in the literature. Results: 60 centres reported on management of an average of 97.3 (range 8-374) patients per year, totalling approximately 6000. The mean number of new referrals in the previous year was 23.27 (range 8-100). 57% of centres regularly included the services of recommended paediatric subspecialists: paediatric endocrinologist, paediatric surgeon/urologist, plastic surgeon, paediatric psychiatrist/psychologist, gynaecologist, clinical geneticist, histopathologist and neonatologist; 35% reported providing these and additional services of endocrine and surgical nurses, a social worker and a medical ethicist. Additionally, 95% of centres reported offering primary psychological support services (either child psychiatrist or psychologist). 65% of centres reported using a diagnostic algorithm, and 83.3% supported the development of a standardised algorithm. 52% and 44.8% of centres reported having performed fewer or similar numbers, respectively, of clitoroplasties than in previous years and only 3.4% reported an increase. Finally, 100% of respondents reported using the newly proposed terminology. Likewise, an audit of the literature reflected a recent reduction in usage of the non-preferred historical terminology. Conclusions: There is evidence that the majority of European DSD centres have implemented policies and procedures in accordance with the recommendations issued by the 2006 Consensus Group. These findings represent a change in practice with the collaborative goal of improved patient care.