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The Bupa Cromwell Hospital magazine for General Practitioners
Issue 05
May - July 2013
In this issue
MMR vaccination
Feeding difficulties in children
What’s new in MRI
Cardiac ablation in AF
GP L I A I SON TE A M
The GP Liaison team provides a bespoke
service for GPs. We can assist you in
any enquiry and help facilitate patient
referrals via our dedicated referral line:
Cromwell Direct - 0800 783 9229.
We understand that our GP colleagues want to keep up-to-date
on new treatments, diagnostics and services. Therefore, we
work closely with the hospital consultants to co-ordinate our
educational programme, which can be found on our website in the
health professionals section and on the back of this magazine. If
you are unable to attend, we can arrange a practice visit talk at a
time convenient for you.
If you have any questions or would like more information about
Bupa Cromwell Hospital, please contact us:
Richard
Longes
Philippa Fieldhouse
Welcome to the fifth issue
of MEDIscene, which takes a
broader look some of the ‘hot
topics’ affecting GPs, and aims
to provide informative clinical
updates from some of our most
respected consultants.
You will read about how to
address feeding difficulties in
young children, the facts about
the controversial MMR vaccine
(particularly relevant after the
recent Measles outbreak in
South Wales), and how to treat
the increasingly common issue
of heart arrhythmia in the older
population.
We also cover kidney
transplantation and take an
in-depth look at the latest
advances in MR scanning; in
particular focused ultrasound,
which has the potential to
drastically reduce treatment
and recovery times for
treatment of everything from
back pain to fibroids and even
neurosurgery.
We hope that you find this issue
enjoyable and informative, and
look forward to seeing you at
one of our symposia or other
educational events soon.
With warm regards,
Philippa Fieldhouse
Director of Clinical Operations
Bupa Cromwell Hospital
Richard Longes
07714 386 680
020 7460 5909
[email protected]
upcoming EDUCATIONAL EVENTS
MORNING SEMINARS - Bupa Cromwell Hospital, 7.30am until 8.30am
Tuesday, 04 JunE Child with developmental delay: when to refer
Dr Skandhini Carthigesan, MRCP MRCS DCH FRCPCH, Consultant Paediatrician
Tuesday, 09 JulY Treatment of Trigeminal neuralgia
Mr Sinan Barazi, FRCS(NeuroSurgery) BSc MB BS, Consultant Neurosurgeon
EVENING SEMINARS - Bupa Cromwell Hospital, 7pm until 9pm
Thursday, 27 JUNE (3 speakers)
Common GI motility disorders presenting in childhood
Dr David Rawat, MB BAO BCh LRCP&SI(Ire) MSc MRCPCH(Ire),
Consultant Paediatric Gastroenterologist
Patient centered outcomes in Crohn’s
Professor Brian Gazzard, MA MD(Camb) FRCP, Consultant Gastroenterologist
Colorectal surgery
Professor Sina Dorudi, BSc MBBS PhD FRCS FRCS(Gen Surg), Consultant
Colorectal Surgeon
Cover Image:
Measles virus. Coloured transmission electron
micrograph (TEM) of measles viruses (morbillivirus
group) budding off the surface of an infected cell
(bottom, pink/yellow). The lipoprotein envelopes
of the viruses (red) surround the nucleocapsid
(blue). The envelopes are acquired from the host
cell’s cytoplasmic membrane as the viruses bud
from the surface. They enclose the nucleocapsid:
a helical structure consisting of a single-stranded
RNA core (genetic material) surrounded by protein.
Magnification: x14,400 at 6x6cm size.
NIBSC / Science Photo Library
MEDIscene - ISSUE 05
The opinions expressed in this magazine are the personal views of the
authors and do not necessarily reflect those of Bupa Cromwell Hospital.
The role of the paediatric
speech and language
therapist in the
management of feeding
difficulties in children
Ms Analou Louw
Ms Analou Louw MSc
Speech and Language Therapist
Feeding difficulties in babies and young children are very common and can be extremely stressful for children
and parents alike. About one in four children admitted to hospital has some type of growth or feeding problem,
which can result from underlying conditions including neurological imairment, gastro-intestinal and muscular
disorders, respiratory illness, prematurity, cancers, congenital heart disease or cleft lip and palate. Without
treatment these highly complex feeding and swallowing problems can result in poor growth and sub-optimal
development.
Feeding difficulties are best addressed from a multidisciplinary framework. The Speech and Language
Therapist (SALT) specialised in paediatric dysphagia provides an assessment which looks at safe maximisation
of the child’s eating and drinking potential, using appropriate strategies that promote safe and adequate
nutritional intake. They support the child and carer in choosing between a number of feeding options and
strategies where oral feeding is not be possible, help make meal times more pleasurable, and manage risks to
the child as a result of dysphagia.
Children with feeding and swallowing problems have a wide variety of symptoms. In very young children
these might include irritability and arching the body during feeding, difficulty breastfeeding, refusing food or
liquid, failure to accept different food textures, long feeding times (more than 30 minutes) difficulty chewing
or gagging during meals. Children may also have difficulty coordinating breathing with eating and drinking,
regularly spit food back up, suffer from regular respiratory infections, or have slow weight gain or growth.
As a result, children may be at risk from dehydration or poor nutrition, aspiration or penetration (food or liquid
entering the airway), pneumonia, repeated upper respiratory infections or chronic wheeze that can lead to
chronic lung disease, and embarrassment or isolation in social situations
involving eating.
The primary role of the SALT is to determine whether the child has a
swallow disorder. Swallowing disorders, also called dysphagia, can occur
at different stages in the swallowing process. These are the oral phase
(sucking, chewing, moving food or liquid into the oro-pharynx where
the swallow is triggered), the pharyngeal phase (starting the swallow,
propelling food down the pharynx, closing off the airway), and the
oesophageal phase (relaxing and tightening the openings at the top and
bottom of the oesophagus and propelling food into the stomach).
The SALT will do a case history; keeping a food diary, taking body
measurements and recording symptoms. Feeding observation enables
assessment of the child’s oral structures, oral sensory-motor skills,
eating and drinking skills, swallowing and feeding efficiency, and general
behaviour before, during and after the meal.
An assessment of the child’s social interaction and communication skills is
also carried out.
Feeding develops as the child matures, in line with the rest of their
development, and therefore needs to be viewed from a developmental
framework - atypical or delayed global development will also affect
Ian Hooton / Science Photo Library
WELCOME
cromwell direct 0800 783 9229
feeding development. If required an objective assessment of the child’s swallow function with
videofluoroscopy swallow study (VFSS) can be carried out. This is the gold standard for the
objective evaluation of swallow function.
Following the assessment of the safety of the child’s swallow and oral feeding
efficiency, further assessment by a paediatrician might be required to exclude any underlying
organic reason for the child’s feeding difficulties. A comprehensive nutritional assessment by an
experienced paediatric dietician completes the multidisciplinary assessment.
Children with a history of feeding difficulties with an underlying organic cause
frequently present with challenging behaviour at meal times, and a
range of behaviours are reported by parents: Not showing clear signs of hunger. Children with
gastroesophageal reflux disease often ‘graze feed’ or fill
up on milk or juice due to their difficulty in eating solid
foods, and tend to take a long time to feed. This means
that the gaps between meals are too short to create
hunger.
Gagging or spitting of textured, chewable foods. Some
children struggle to progress from liquids to solids, and
can be intolerant of mixed textures and chewable solids as
these make them gag or vomit. Learning to bite and chew
efficiently is influenced by the sensory properties of the food
and its placement in the mouth. Difficulty tolerating textures
often results from food making the child feel unwell or the texture
being too advanced for them. They subsequently try to avoid new
tastes and textures.
Refusal to eat or drink, tantrums during meals. Children with
longstanding feeding difficulties due to an underlyling organic
cause often associate eating or drinking with pain or discomfort.
Anticipation of meal times can cause real distress by both the
parent and child, and the inability to feed their child properly can
have a real impact on parents who can feel like ‘failures’ as a result.
Following the outcome of the feeding assessment the SALT will
liaise with the child’s GP or paediatrician regarding referral to
other specialists for further investigation or management. These can
include gastroenterologists, allergists, neurologists and developmental
paediatricians. From an oral feeding point of view that SALT can adapt
feeding regimes to allow for more time between feeds, adapt feeding utensils and textures,
which will be tolerated by the child, and liaise with a specialist dietician regarding supplementation of the
child’s diet whilst addressing the behavioural difficulties during meal times. Finally the SALT supports the
parent by setting realistic and achievable goals to reach the child’s full oral feeding potential.
Screening Questions for Primary Care Physicians
There are four key questions that GPs can ask parents when an infant or young child presents at the surgery
with concerns related to feeding. The answers help determine if a comprehensive clinical feeding and
swallowing assessment is needed, even though the answers do not necessarily define the problem:
1.How long do mealtimes typically take? If more than about 30 minutes on any regular basis, there is a
problem. Prolonged feeding times are red flags pointing to the need for further investigation.
2.Are meal times stressful? Regardless of descriptions of factors that underly the stress, further investigation is
needed. It is very common for parents to state that they “just dread mealtimes.”
3.Does the child show any signs of respiratory stress? These may include rapid breathing, gurgly voice quality,
nasal congestion that increases as the meal progresses, and panting by an infant with nipple feeding. Recent
upper respiratory illness may be a sign of aspiration with oral feeds, although there may be other causes.
4.Has the child not gained weight in the past two to three months? Steady appropriate weight gain is
particularly important in the first two years of life for brain development as well as overall growth. A lack of
weight gain in a young child is like a weight loss in an older child or adult.
MEDIscene - ISSUE 05
WHAT’S NEW IN MRI
Professor
Wladysaw
Gedroyc
Prof. Wladysaw Gedroyc MB BS MRCP FRCR
Consultant Radiologist
Magnetic Resonance (MR) guided focused ultrasound is an exciting new non-invasive treatment
that is likely to replace surgery and radiotherapy in a variety of clinical situations, allowing
patients to be treated with no in-hospital stay.
Focused ultrasound uses very high power ultrasound (up to 10,000 times the power of conventional
diagnostic ultrasound), focused on a very small point deep in the body. At this point tissue molecules
are rapidly vibrated, leading to quick temperature rises for one second which causes local mitochondrial
protein precipitation and coagulative cellular death. The tissues in front of and behind the focal spot are
only heated a very small amount so are unharmed. Only the focused ultrasound beam extends through the
skin and no direct intervention is required to achieve tissue ablation using this technique.
The temperature produced in the tissues is monitored using MR temperature sensitive sequences. MR can
be made extremely sensitive to temperature
and can provide a thermal map of the
treated area so that feedback and
adjustment of the whole process can be
carried out in near real-time. This allows
for maximum tissue ablation effects with
minimal side-effects.
What this process provides is a noninvasive method of destroying selected
areas of tissue deep within the body.
The desired ablation can be performed
in a very controllable manner using MR
imaging, and can be altered to suit the
patient requirements and the individual
tissue variability that is encountered. It is
personalised medicine at a very high level.
Applications
Fibroid focused ultrasound
Approximately 10,000 fibroid focused ultrasound cases are carried out worldwide, and it is the largest
application of this technology. Although other forms of treatment are available for fibroids these are
mostly more invasive, requiring inpatient stays and often surgery. Up to $4 billion is spent each year on
the treatment of fibroid related conditions in the USA, so although a common, benign disease, the health
economic aspects are immense.
The patient lies face-down in the scanner, with the abdomen opposed to a water bath in which the MR
compatible focused ultrasound source is place. This allows sonication directly into the fibroid by the
anterior abdominal wall, producing areas of tissue destruction when the temperature is raised to over 55°C
for one second.
Sonication is carried out on a spot by spot basis, slowly covering the whole targeted area. Each sonication
is monitored by MR thermal maps before, during and immediately after the application of ultrasound power,
providing a detailed image of the lesion that allows the operator to understand what needs to be done in
the next sonication. This is personalised medicine at its highest level.
Procedures take around three hours but are entirely outpatient based, with the patient usually able to
return to work the next day. Approximately 40% of patients with fibroids are suitable for MR guided
focused ultrasound, but this depends on ethnic mix; we know for example that black women tend to have
many more fibroids of a much greater size, and the larger the fibroid the more difficult it is to treat it with
focused ultrasound.
Very effective relief of symptoms can be achieved if over 60% of targeted fibroids are destroyed, with a low
cromwell direct 0800 783 9229
Prostate MR guided focused ultrasound
Complete new endorectal prostate systems are
now available. These procedures will involve hemiquadrant ablations of prostatic cancer using MR
guidance with focused ultrasound applied via
the endorectal route. A new transducer has been
developed which can be placed in the rectum
surrounded by a balloon full of circulating cold
water to maintain the temperature of the rectal
mucosa. Areas of destruction can be easily
produced and these can be monitored as to their
precise site and the temperature produced by MR.
The main complication of all prostatic surgical
and ablation procedures has been damage to the
neurovascular bundle, leading to incontinence
and impotence. Because the MR approach can
directly visualise the exact site of temperature
deposition and its extent, this should minimise
these devastating complications for patients. Early
studies are underway and to date ablations have
been carried out with only very minor convocations
and no incidence of significant neural damage.
Painful bone metastases
Studies are at an early stage but suggest that
effective, long-lasting (three to six months)
palliation of painful bone metastasis is easily
achievable with focused ultrasound. This
procedure can relieve pain by destroying the
neural structures in the periosteum overlying
the lesion. It will also cause pain relief in patients
who have secondaries that are non-responsive to
radiotherapy. 80% of patients showed significant
improvement in pain from bone secondaries with
this approach. Currently the underlying tumour in
the bone is not necessarily treated by this process
but it is utilised purely as a palliative procedure.
Chronic low back pain: Facet focused
ultrasound
A pilot study looking at safety and early efficacy
of focused ultrasound for the treatment of facet
joint related back pain was recently completed.
Radiofrequency ablation is a common approved
therapy for the treatment of pure facet joint origin
back pain, applied using a percutaneous needle
placed under conventional screening techniques.
This aims to destroy the neural structures running
over the facet joints at the posterior aspect of the
spinal canal, which are believed to be responsible
for pain in patients with have this type of chronic
back pain.
This type of thermal therapy can alternatively
be delivered completely noninvasively using
MR guided focused ultrasound, delivered to the
posterior aspect of the facet joints without using
any form of needles through the skin. A pilot study
MEDIscene - ISSUE 05
of 19 patients showed extremely promising results
in terms of symptomatic response, and an excellent
safety profile with no complications to date. If
this can be proved to be a successful and durable
treatment then the potential is enormous.
Liver focused ultrasound
Small-scale pilot studies in this area have
been underway for five years using MR guided
focused ultrasound. The difficulty is that it is very
problematic to get focused ultrasound effectively
across the ribs into the moving liver. Ribs absorb
much of the focused ultrasound beam and destroy
it so that a coherent beam cannot be delivered to
a focal spot in the liver. Respiratory motion can be
overcome by utilising general anaesthesia with a
ventilator that is linked to the focused ultrasound
machine. However using this technique sonication
can only be carried out when the diaphragmatic
excursions return to exactly the same point each
time so that control of the 3-D space is achieved.
Patients that have been treated so far have been
restricted to the few who have lesions that are not
covered by ribs (i.e. in the centre of the left lobe),
and results suggest that focused ultrasound can
effectively destroy areas that can be accessed
with very low complications and good results.
Study groups are actively collaborating with
manufacturers to try and improve the technology
and I anticipate that a successful liver transducer
system will be developed in the next two years.
The potential of patients with liver tumours being
treated in a completely non-invasive manner as
an outpatient is extremely exciting. Percutaneous
ablation techniques have already shown the
benefits of using locoregional therapy with heat in
this field, and eliminating all interventional aspects
of this type of approach would allow this process
to be carried out easily, quickly and repeatedly for
many patients.
Drug activation
Low Power heat can be delivered to discrete
areas of the body in a very controlled manner
using MR guided focused ultrasound. Such sub
necrotic heating within tissues can be used to
activate drugs held in an otherwise inert carrier
which is heat sensitive. This type of approach
may be important in overcoming the very narrow
therapeutic window that many drugs have
between efficacy and toxicity. Chemotherapy is
an easily recognised example of this problem.
Extensive work is evolving to develop new drug
combinations so that chemotherapeutic agents
can be given in an inert format and only activated
at the required site by focused ultrasound. This
would mean the agents could be made to have
only a local effect at the site of heating, drastically
lessening potentially serious side-effects.
Work is underway to develop new compounds of
inert Liposomal carriers which are heat sensitive
to MR contrast agents, so they can be visualised
whilst containing active chemotherapeutic
payloads. Other non-liposomal combinations are
also in development. It is likely that this type of
new drug could be combined with other types
of focused ultrasound, for example in the liver,
to improve the area of tissue destruction that is
achieved when treating tumours. This approach
could also be applied to other drugs with narrow
therapeutic windows.
Brain
Surprisingly, focused ultrasound can be made
to penetrate the skull in a controlled manner.
This application has generated a huge amount
of interest, driven by the possibility of carrying
out functional neurosurgery in a completely noninvasive manner - a specialised brain transducer in
the shape of a helmet can deposit sonications at
discrete sites deep within the brain. Studies have
generally focused on functional neurosurgery
and the potential to replace conventional
operative interventions (such as deep
brain stimulation electrodes) with a noninvasive procedure carried out under local
anaesthesia.
energy is applied, and no invasion whatsoever.
This allows for greater accuracy and safety in the
delivery of the therapy, and has the potential to
convert what are currently quite large invasive
surgical or similar procedures into closed, noninvasive outpatient therapies.
The potential economic benefit of this change
would be considerable (despite the initial capital
outlay for the focused ultrasound machinery),
and focused ultrasound will enter into many areas
of practice in the next decade as the desire grows
for less invasive and more costeffective therapies.
MRI scan of normal brain - Mehau Kulyk /
Science Photo Library
requirement for further fibroid related therapies.
The results are slightly better than comparable
therapies such as uterine artery embolisation and
myomectomy.
In these studies discrete deep brain nuclei
have been targeted to alleviate specific
symptoms. The two areas investigated
thus far are thalamic ablations for pain
syndromes and discrete basal ganglia
ablations for the treatment of essential
tremor. Early results seem very promising,
particularly in the essential tremor group.
The treatment can be carried out as an
outpatient procedure.
Associated work is also underway
using focused ultrasound to open
the blood brain barrier in discrete
areas of the brain, to allow the
administration of drugs or other
substances which can pass
into that specific area of the
brain (where previously they
could not enter the brain at
all). These techniques allow
the blood brain barrier to close
spontaneously within 36 hours, and
are carried out in such a way that the
temperature rise does not produce
tissue necrosis at the site of sonication.
Summary
These are just some of the applications
that are currently being explored in the
field of focused ultrasound. Others are
evolving and being investigated by many
groups around the world. The basic premise
is that this type of approach allows one to
deliver destructive energy deep in body
tissues in a controlled manner, with careful
monitoring of what is done as the thermal
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Catheter Ablation of Atrial Fibrillation
Dr Matthew Wright CCT Cardiology MRCP MB BS PhD
Consultant Cardiologist
Atrial Fibrillation (AF) is the most common form of sustained heart arrhythmia, with an estimated 1.7% of
the general population in the UK affected. The prevalence increases with age, meaning that 6.5% of people
will have AF at the age of 65, and 12% by the age of 80.
Atrial Fibrillation is responsible for a quarter of all strokes, and managing the condition is complex. It
requires risk analysis taking into account the appropriate use of anticoagulation, management of associated
medical conditions such as hypertension and diabetes, and control of the patient’s symptoms.
The natural progression of AF is one of patients presenting with paroxysmal AF (self terminating, with
episodes lasting less than a week), to one of persistent AF, with electrical or pharmacological cardioversion
needed to return to sinus rhythm, and episodes lasting longer than a week. The rate of progression from
paroxysmal AF to persistent AF varies, but up to 30% of patients are in persistent AF within 5 years. All
treatments aimed at maintaining sinus rhythm have been demonstrated to be more effective when patients
are in paroxysmal AF rather than in persistent AF, so early recognition and definitive treatment is essential.
The latest European Society of Cardiology guidelines for the management of AF (published in 2012)
advocate the use of the CHADSVASC scoring system to properly classify patients, from low risk of stroke not requiring anticoagulation, to those who require formal anticoagulation (Figure 1). Aspirin has no role in
the management of AF, having been demonstrated to have similar bleeding complications to Warfarin but
without significantly lowering the risk of stroke.
Although Warfarin, and the novel oral anticoagulants such as Dabigatran, Rivoroxaban and Apixaban do
increase the risk of a major bleed, the HASBLED score is used to properly risk assess patients at high risk of
bleeding. The vast majority of patients with AF should be on oral anticoagulation.
Figure 1
Risk factor Score
Score
Congestive heart failure/LV dysfunction
1
Hypertension
1
Age _> 75
2
Diabetes mellitus
1
Stroke/TIA/thrombo-embolism
2
Vascular
diseasea
1
Age 65-74
1
Sex category (i.e. female sex)
1
Maximum score
9
Despite management of a patients’ symptoms with beta-blockers, German registry data demonstrates that
almost half of patients with ‘stable’, treated AF are admitted to hospital once a year due to uncontrolled
symptoms, and a fifth are admitted more frequently. Patients with AF suffer both physically and socially.
Quality of life studies suggest that patients with AF have a worse morbidity rate than patients who have
suffered a heart attack.
MEDIscene - ISSUE 05
Figure 2
Relevant structural heart disease
No or minimal structural heart disease
Paroxysmal
Yes
Patient Choice
AF
No
Due to AF
No
a
Catheter
ablation
Yes
Persistent
dronedarone,
flecainide,
propafenone,
sotalol
b
amiodarone
dronedaronec
/sotalold
Patient Choice
Patient Choice
amiodarone
Catheter ablationb
AF = artrial fibrillation; HF = heart failure. a Usaully pulmonary vein isolation is appropraite. b More extensive left atrial ablation may be needed.
c Caution with coronary heart disease. d Not recommended with left ventricular hypertrophy. Heart failure due to AF = tachycardiomyopathy
For patients with persistent AF, long term success is related to its duration (patients with AF duration
of less than two years do better), the left atrial diameter (the smaller the better), and the degree of
organisation as measured by the coarseness of AF on a standard ECG (the ‘coarser’ the better). Studies
have also shown that for patients with both atrial flutter and AF, those undergoing an AF ablation as
opposed to just ablation of typical atrial flutter do much better. It is therefore important for patients with
atrial flutter to be assessed for AF with Holter monitoring, as these conditions co-exist in 30% of cases.
However, despite the strong evidence for the effectiveness of catheter ablation for patients with AF, the
success rates are still not as good as those for other supraventricular tachycardias, such as AVNRT, and
Wolff Parkinson White syndrome, where long-term cure rates are over 95%. Patients often require multiple
procedures to have a long term freedom from AF.
Background image - Electrocardiogram - Steve Allen / Science Photo Library
Dr Matthew
Wright
Catheter ablation of AF has progressed dramatically over the last 15 years. The team led by Professor
Haissaguerre in Bordeaux, where I trained and with whom I continue to collaborate, has demonstrated
that ectopic beats from the pulmonary veins are responsible for triggering AF in over 97% of cases. Since
that seminal study, ablation techniques have improved, as has the safety of catheter ablation. There is
now a large body of evidence that catheter ablation is a very effective treatment for patients with both
paroxysmal and persistent AF. Numerous studies have demonstrated that catheter ablation is more effective
at maintaining sinus rhythm, more effective at improving patients’ symptoms, and is cost effective when
compared to standard medical therapy.
These data have led to the strong recommendation in the latest ESC guidelines for the use of catheter
ablation as first line therapy in appropriately selected and counselled patients with paroxysmal AF, and in
patients who have failed one anti-arrhythmic medication with persistent AF (Figure 2).
A key point is that catheter ablation is indicated for symptomatic benefit. Symptoms can be difficult to
assess in patients with AF as they are often multifactorial. A large French primary practice registry showed
that patients’ perception of symptoms changes in relation to age. Younger patients tend to complain of
palpitations, those in middle age complain more of breathlessness, and the elderly of general fatigue. Often
the easiest way to assess whether a patient can benefit from an AF ablation is to perform a cardioversion. If
the patient returns to sinus rhythm and has symptomatic relief then catheter ablation should be discussed.
cromwell direct 0800 783 9229
The major reason for recurrence of AF in patients with paroxysmal AF who have undergone a catheter
ablation is due to the pulmonary veins electrically reconnecting across previously ablated tissue. Over the
last four years there has been considerable research into improving the ablation procedure using a number
of technologies. Catheter contact is critical to forming stable lesions, yet until recently there was no way
that the operator could objectively assess what contact force was being applied.
The latest catheter technology incorporates force sensing technology so that the operator can judge
the contact at each individual lesion. Studies have already demonstrated that there is a wide variation in
operators with respect to force applied during ablation. It is hoped that by providing information on contact
force that success rates will improve further, with early studies suggesting that this is indeed the case. Bupa
Cromwell Hospital uses the very latest in mapping and catheter technologies (Figure 3), and has a very
experienced team managing every aspect of the patients care.
2013 Symposia Series
@ IMAX cinema
Oncology - Saturday, 14 September
Neurology - Saturday, 23 November
9am - 2pm at the Science Museum
Please RSVP by calling 020 7460 5901, registering online at
www.bupacromwellhospital.com/gpeducation or emailing
[email protected]
Figure 3
IMAX Cinema, London Science Museum
Exhibition Road, London SW7 2DD
In summary the outlook for patients with AF is much brighter. Management of patients requires integrated
care however, with appropriate risk assessment of stroke and bleeding risk, thorough assessment of
symptoms with ambulatory and exercise monitoring, cardioversion and assessing whether they are suitable
for AF ablation.
THE NEW
CONSULTANT
DIRECTORY -AVAILABLE
NOW
Twitter
Bupa Cromwell Hospital launched our Twitter account in March. Twitter
is a fantastic way to update patients and healthcare professionals on
new services, events and latest news at the hospital. We will be tweeting
regularly so do follow us and join the conversation!
@BupaCromHosp
MEDIscene - ISSUE 05
cromwell direct 0800 783 9229
Dr Michael
Markiewicz
Dr Michael Markiewicz
BSc MB BS FRCP(UK) FRCPCH
Consultant Paediatrician
The MMR vaccination has been dogged by
controversy. In order to address the fear that
the public holds about the vaccination and any
other misconceptions there might be, we need
to learn the background to the diseases. Fully
understanding these diseases enables us to
reassure parents and immunize patients with no
doubts as to the benefits and possible side affects.
The diseases
Measles, together with chicken pox, is amongst
the most infectious diseases in the western world;
incubation is about 10-12 days having been spread
by fine droplets.
The main features of Measles include a high fever
lasting about seven days, Koplick spots in the
mouth, followed by a very florid rash covering the
face and trunk and extending to the hands and
feet starting abouttwo to four days after the
fever starts. The rash lasts about five to six days
and is often accompanied by coughing, catarrh
and conjunctivitis.
Complications are common, affecting up
to 30% of otherwise healthy patients,
and are most serious in children under
five years old. Pneumonia is a common
complication and this is also the most
common cause of death in young
children. In addition, ear infection
occurs in 10% of patients
and can lead to deafness,
diarrhea occurs in 8%,
1 in 1000 get
The vaccination
The usual routine in the UK (unless an epidemic
is unleashed) is to give the child the first vaccine
at one year and the booster at four years. In some
countries the schedule is more aggressive, with
the first shot given at nine months, which is then
followed by two more vaccines at 18 months and at
school entry.
Why the need to give a booster? In 5-10% of
children the initial vaccination does not lead to
adequate antibody production. In those children
who then receive a second dose well over 90%
produce an adequate response the second time
around. There are no significant side effects for
those children receiving a second dose who have
had an adequate response the first time around.
Regarding the supposed dangers of the vaccination,
Andrew Wakefield has single handedly contributed
more to the morbidity associated with measles in
this country than any other individual. His ill fated
publication in the Lancet in 1988 (based on a total
of only 12 self selected patients) suggested a link
between the MMR vaccine and autism as well
as bowel disease. This article was later declared
fraudulent and retracted, and Andrew Wakefield was
struck off the medical register, but the damage was
done and we are still reeling from the consequences.
There is no evidence for MMR causing autism or gut
disease.
What can you do to reassure patients?
Reassure your patients that there is not one
article published in any peer-reviewed journal that
suggests that there is a real link between MMR
vaccine and autism. On the other hand there are a
large number of publications that show no such link
exists between the MMR and autism.
Yes, autism is still rising and we still do not have any
idea about its cause.
However, it is very important to point out to
patients that autism is often diagnosed around the
same time that the MMR vaccine is administered,
MEDIscene - ISSUE 05
and it stands to reason that with over 600,000
doses of MMR given annually in the UK, there
will be a incidental time similarity between the
administration of MMR and the diagnosis of autism.
No-one has as yet demonstrated any causality
between the MMR and autism. Indeed if one looks
at the graph of incidence of autism against time
it is a steadily rising line. MMR vaccination was
introduced in the USA in the late 1970’s and in the
UK in the mid 80’s. There is absolutely no change
in the incidence of autism in either country after
the respective introduction of the vaccine. In both
countries the incidence continues to increase at
exactly the same rate as before the introduction of
the vaccination programs.
Egg Allergy and MMR vaccination
There is often confusion about egg allergy in
relation to the MMR vaccination. The amount of
ovalbumin contained in the vaccine is in the order
of picograms; this tiny amount is extremely unlikely
to cause any serious adverse reaction. Gelatin and
Neomycin are much more likely candidates in the
event of an allergic reaction.
In over 99% of all children having the MMR vaccine
there are no reported side effects directly related
to egg allergy. However, the recommendation for
children who have had anaphylactic or very serious
reactions to egg, or those with chronic active
asthma and significant reactions to ingested egg
such as urticaria, is to administer the vaccine under
hospital supervision with appropriate resuscitation
facilities available.
Single vaccines
As a result of the Wakefield myth the completely
illogical suggestion was made that it would be
much better to use the single component vaccines.
What is wrong with this approach? The argument
that the ‘body can’t cope’ with too many vaccines
at once is completely erroneous and again has
absolutely no scientific basis. In fact studies
that looked at exposure to antibody-producing
antigen found that prior to introduction of the
more modern vaccines, such as the MMR, antigen
exposure was much higher. In addition they did not
find any correlation between antigen exposure and
autism or any other adverse effects.
Furthermore, the efficacy of the single measles
vaccine is not as rigorously tested as the combined
vaccine, and there is a worldwide shortage of the
single mumps vaccine (so anyone going down
this route will remain un-immunized for mumps).
Finally, due to the much longer time taken to
complete the process of single component
vaccines, the child will remain at risk of disease for
much longer.
In summary
It is vital to achieve at least a 95% take up of
the vaccine in order to ensure the safety of our
children. By educating your patients we will be
able to achieve that goal.
Saturn Stills / Science Photo Library
Why is the MMR vaccination
so controversial?
encephalitis, and for patients with vitamin A
deficiency blindness is a common complication.
In 2011 there were 15800 deaths globally from
Measles. Prior to the 1980’s when widespread MMR
vaccination was introduced however, there were
an estimated 2.6 million deaths. The death rate in
the developing world ranges from 5-28%. In the
developed world it is 0.3 %.
Mumps can be quite a benign disease in prepubertal children, however in post pubertal boys it
can cause oophoritis, which in some cases can lead
to sterility. This does not apply to girls.
Rubella is a benign disease for anyone NOT
pregnant, however if contracted by women before
20 weeks gestation it can lead to devastating
consequences for the as yet unborn fetus, causing
blindness, deafness and mental retardation.
Vaccination prevents the devastating consequences
of all three of these diseases
cromwell direct 0800 783 9229
Mr Jeremy
Crane
Mr Jeremy Crane MB ChB MD FRCS
Consultant Transplant and Vascular Surgeon
Kidney transplantation is the renal replacement
therapy of choice for those patients with end
stage renal disease. When compared with either
haemodialysis or peritoneal dialysis, transplantation
confers major survival advantages as well as a better
quality of life. In the UK, there are nearly 7,000 people
waiting for a kidney transplant at any one time and
approximately 2,700 kidney transplants take place per
year, with a third of those kidneys coming from live
donors.
A kidney transplant provides about two thirds of the
function of healthy native kidneys, whereas dialysis
only provides about 5% of native function. A transplant
provides the major advantage of giving freedom
from dialysis and means that all fluid and dietary
restrictions, essential to the renal patient on dialysis,
become a thing of the past. Other advantages of
successful transplantation include enabling patients
to gain employment, giving higher energy levels,
improvements in their sex lives and allowing a more
fulfilling life overall. Women are also more likely to
become pregnant and give birth to a healthy baby.
Which patients are eligible for a transplant?
Nearly half of all patients with renal failure are suitable
for transplantation if a donor kidney is available to
them. As studies suggest that patient survival after
having a transplant is worse the longer a patient is on
dialysis, pre-emptive transplantation is encouraged in
most transplant centres. This means that the transplant
takes place form 6 months before the patient would
start dialysis.
Many units do not have an age limit for transplantation
and each patient is individualized according to the
risks and benefits involved. An age of about 70 is the
normal cut-off, but older patients can be transplanted
depending on their clinical circumstances.
There are contraindications to kidney transplantation,
some absolute but others relative. Examples of
absolute contraindications include active malignancy,
ongoing untreated infections, and irreversible cardiac,
lung or peripheral vascular disease. Psychiatric illness,
substance abuse and a known failure to comply with
medication are examples of relative contraindications.
There are some primary renal diseases that potentially
recur in the transplanted kidney. Examples are
FSGS (focal segmental glomerulosclerosis) or IgA
nephropathy. These need to be discussed carefully pretransplantation but are often more of a problem with a
second transplant. These diseases might contraindicate
a further transplant.
MEDIscene - ISSUE 05
The process of evaluation for a potential
transplant candidate is multidisciplinary, and
involves (amongst others) transplant surgeons,
nephrologists and transplant coordinators. The aims
of this multidisciplinary assessment is to pick up
any contraindications to transplantation, determine
potential immunological problems and screen for
comorbidity that needs to be managed before the
transplant can take place. There are also social and
psychological factors that need to be assessed.
Immunology; finding the right kidney
Immunological evaluation starts with the identification
of potential prior antigen exposure. This could have
occurred from previous transplants, blood product
transfusions and pregnancies. Testing of blood types
and human leukocyte antigen (HLA) typing is carried
out to detect both potential matches and, conversely,
donor-recipient pairs that would not have a good
immunological outcome.
Matching the blood group is more straightforward than
matching the tissue type and follows certain principles,
similar to blood transfusions (see table 1). In some
transplant centres a sophisticated means of removing
blood group antibodies pre-transplantation enables
donor-recipient pairs with mismatched blood groups
to go ahead and donate a kidney. This is known as
antibody incompatible transplantation.
PATIENT
DONOR
Group O
Group O
Group A
Group A or O
Group B
Group B or O
Group AB
Any Group
As there are so many possible tissue types, matching
the donor tissue type to the recipient is highly
complex. Essentially, the more of these tissue type
characteristics that are similar in both donor and
recipient, the higher the chance that the transplant
kidney will work. Due to the large number of tissue
types, it is rare to get an exact match, however if
the patient and donor have three or more of the
major HLA tissue type characteristics in common,
the transplant will be offered. The matching of tissue
type in living donors is slightly less important and so
a less satisfactory match is acceptable for successful
transplantation.
Live versus deceased donor kidney transplantation
A deceased donor transplant, (formerly known as
a cadaveric donor), is the term used to describe an
organ used for transplantation that has been retrieved
from someone who has died. In the UK about two
thirds of kidneys transplanted come from these
donors, who have most often died from intracerebral
haemorrhages and are brain stem dead. A smaller
number of organs are retrieved from patients who have
died but do not fulfill brain stem death criteria and
have no hope of recovery. Life sustaining treatment is
withdrawn, after which the organs are retrieved; this is
referred to as donation after circulatory death. Due to
the shortage of organs in the UK a growing number of
transplants are from this source.
When a deceased donor organ becomes available,
coordination within NHSBT (NHS Blood and
Transplant) offers the organs out to recipients that are
highest on the waiting list. Factors that would push
a patient to the front of the list include how close
the tissue type is to the donor, blood type, age and
age match, and time on the waiting list. Due to these
factors patients from ethnic minorities, particularly
Afro-Caribbeans and Asians, tend to wait longer than
Caucasians.
Live donation is when a relative or someone close
to the patient with renal failure donates one of their
kidneys. Kidneys from live donors have better longterm patency than deceased donor kidneys, and
there are other major benefits from living related
transplantation. Waiting times tend to be shorter and
this is particularly relevant in renal failure patients from
ethnic minorities who would otherwise have a longer
wait on the deceased donor renal transplant list. Also,
unlike a deceased donor transplant, which is on an
emergency basis with no prior warning, live donation
is a planned elective procedure. Live donation is much
more likely to allow for preemptive transplantation.
Live renal donation, which is performed at Bupa
Cromwell Hospital, is increasing as the procedure
becomes more widely accepted. Risks to the donor are
minimal and most renal units aim to perform as many
as possible in the knowledge that it provides the best
results.
The surgical procedure
The incision for a kidney transplant is usually an
oblique incision in the iliac fossa. The renal vein is
anastomosed to the external iliac vein and the renal
artery to the external iliac artery. Often there are
multiple vessels. The ureter is attached to the bladder
(ureteroneocystostomy), and a ’jj’ stent is placed from
the ureter to the bladder to help keep this anastomosis
open and patent.
Complications of renal transplantation
In the early phase post transplantation, there are
certain complications to be aware of. These include
post-operative haemorrhage and vascular thrombosis
that must be identified immediately. Delayed graft
function (where the patient needs dialysis before the
transplanted kidney starts to make urine), rejection
and side effects of the long-term immunosuppressant
regimen should all be recognized, and the recipient
counseled as to these potential complications.
Very careful follow-up after discharge continues
for 12 months after transplantation, after which the
frequency of visits to the transplant clinic is tailed off.
GP management at this point is crucial; any changes in
plasma creatinine and other aspects of renal function
must be reported to the transplanting centre. Many
units have ‘walk-in’ rapid assessment units for renal
and transplant patients.
This image - Spare kidneys - Victor De Schwanberg / Science Photo Library
Background image - Dr. Barry Slaven / Visuals Unlimited, Inc. / Science Photo Library
Considering the benefits
of kidney transplantation
Preparing for a transplant
cromwell direct 0800 783 9229
New
consultants
Mr Jeremy Crane
Vascular Surgeon
Dr Yousef Daryani
Cardiologist
Dr David Wyn Davies
Cardiologist
Mr Michael Douek
Breast Surgeon
Miss Penelope Law
Gynaecologist
Mr Hilali Noordeen
Paediatric Spinal Surgeon
Mr Vassilios Papalois
Transplant Surgeon - renal
Mr Parthi Srinivasan
HPB Surgeon
To make an appointment with
one of our consultants, please
call Cromwell Direct on
0800 783 9229
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Alison Taylor-Smith
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