Prognosis The periodical of the Harley Street Medical Area Medical Street Harley the of periodical The The periodical of the Harley Street Medical Area Issue 05 / 2019 Issue 05 / 2019

Injury time How professionals and amateurs experience sports medicine Deep brain stimulation A remarkable treatment for Parkinson’s disease Witness protection The vital role played by doctors who appear in court as expert witnesses Crystal ball How the treatment of thyroid conditions is set to evolve

The centre of medical excellence in the heart of London harleystreetmedicalarea.com

prognosis_issue05_coverprognosis_issue03_BC_FINAL.indd PROOF01.indd 56 1 15/12/2017 15:49 08/01/2019 17:44 Rent a property directly from The Howard de Walden Estate

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hsma_prognosis_issue03_website.inddprognosis_issue05_cover PROOF01.indd 1 2 16/12/2017 11:26 hdwe_MJAD_rentaproperty_JUNEJULY2017_02.indd 1 08/01/201924/05/2017 17:4412:54 Prognosis is owned by 36 Injury time The Howard de Walden Estate 36 23 Queen Anne Street Some of the country’s top sports London W1G 9DL medicine experts explain to 020 7580 3163 Prognosis how the treatment of the hdwe.co.uk general public is heavily influenced Estate contact by—but no less important than—that Jenny Hancock of the sporting elite [email protected]

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Prognosis—1

prognosis_issue05_PP1-25 PROOF01.indd 1 10/01/2019 09:32 The current legal system is incredibly expensive, it is very slow, it is not good for doctors, it is not particularly good for those claiming compensation. We need a major overhaul of the whole system

04 A patient approach 60 My Marylebone Simon Baynham, property director of 26 The big interview Dr David Hopkins, consultant physician The Howard de Walden Estate, on how Barrister Anton van and diabetologist at London Medical the HSMA’s challenge is to ensure patient 62 What’s on numbers keep pace with capacity Dellen on medical Cultural events near the Harley Street 09 News court cases and expert Medical Area New arrivals, developments and events 63 Five 10 Crystal ball witnesses Places for a pastry The evolution of the treatment of 32 Oral testimony 64 The guide thyroid conditions A tour of Marylebone’s 11 Harley Street hero Bridging the divide masterclasses and Thomas Horrocks Openshaw between dentistry and workshops (1856-1929) 12 How does it work? medicine In vitro fertilisation 36 Injury time 14 Thinking aloud The thoughts ofMr Rami Alfalahi, How sports medicine director of Green Door Clinic for the general public 16 Profile of a pathogen Influenza is influenced by the 18 How to... sporting elite Deal with cataracts 20 A day in the life 46 Q&A Cat Dowling, matron at medical Mr Erlick Pereira and concierge service Lexihealth 22 Second opinion Dr Dominic Paviour on Should epidurals be available on demand deep brain stimulation during labour? 50 Patient experience How David’s rare heart condition was cured after three complex operations 54 Handsome devil The doctor who used good looks and charm to push a lethal miracle cure

2—Prognosis

prognosis_issue05_PP1-25 PROOF01.indd 2 10/01/2019 09:32 14 20 50

16 26 The case of John St John Long echoes through history, testifying to the enormous power of people’s faith in doctors and, more prosaically, the importance of medicine’s professional bodies

18 36 54

Prognosis—3

prognosis_issue05_PP1-25 PROOF01.indd 3 10/01/2019 09:32 A PATIENT APPROACH Simon Baynham, property director of The Howard de Walden Estate, on how the Harley Street Medical Area’s next challenge is to ensure patient numbers keep pace with its impressive increase in capacity

The HSMA already has many attractions that go beyond its medical credentials—its centrality, its transport links, its proximityto restaurants, shops and green spaces— but there is plenty more that we can do to increase our appeal to patients

Several years ago, when The Howard its historic building stock is a challenge, that I would most like to have join us de Walden Estate began to formulate to say the least. But to judge how here, I would have suggested the Mayo its long-term plan for the Harley Street far we have come in meeting that Clinic and the Cleveland Clinic—the USA’s Medical Area, our primary aim was a aspiration, all I need do is scan the list of highest performing and most forward- simple one: to draw to the area medical attendees for one of the HSMA’s regular thinking non-profit academic medical providers of global repute, whose medical forums, at which clinicians centres. Now, both are coming to the arrival would reinforce the solid base and managers from the area’s medical HSMA. As part of a wider collaboration of highly regarded hospitals and clinics providers meet, share ideas and catch with the University of Oxford, the Mayo already operating here, and in doing up on the latest news. Today, that list Clinic is set to open a screening and so significantly enhance the area’s would include representatives of some diagnostics centre on Portland Place reputation for medical excellence. of the world’s most respected acute in 2019 (a development with which To fulfil this ambition, our challenge was hospitals, as well as leaders in oncology, The Howard de Walden Estate is not to identify world-class organisations orthopaedics, optics, sports medicine, directly involved, but welcomes with whose specialisms would complement mental health, fertility, imaging, great enthusiasm). The Cleveland Clinic and augment the existing mix, and then and a seemingly endless list of other is opening a new hospital on Grosvenor attract them to the HSMA by offering specialisms. Place, but has chosen to locate the state-of-the-art facilities and a clear It is a rollcall that in the next few associated diagnostic and outpatient vision for the area’s future. years is set to become even more facility, where most patients will begin It has not been easy—creating impressive. If at any point in the past and end their treatment journeys, here highly sophisticated modern medical decade you had asked me to identify the in the HSMA—an offer has been made to accommodation in an area defined by two medical groups in the entire world the Estate to take a lease on 24 Portland

4—Prognosis

prognosis_issue05_PP1-25 PROOF01.indd 4 10/01/2019 09:32 Harley Street

Prognosis—5

prognosis_issue05_PP1-25 PROOF01.indd 5 10/01/2019 09:32 Every measure we take who are recuperating from or awaiting treatment and who need to be close to to create a more seamless their clinic, potentially with access to experience for users of the dietary, therapeutic or pharmaceutical area’s diverse services or to services—would be a significant addition sell what we’re doing around to the area. Patients’ families would also benefit from a patient hotel, and there the world will rely upon the are other ways in which the Estate could HSMA’s clinics and hospitals help meet their needs. We might, for working closely with us and example, dedicate some of our residential with each other properties to short-term lets for people who are here to access the HSMA. Along similar lines, we are also looking at ways of providing accommodation at discounted rents for key workers. This could include junior doctors, nurses, technicians and support staff, upon whose skills the area depends, but whose prospects of finding an affordable home close to their central London workplaces are increasingly limited.

Place, which we expect to be confirmed area, The Howard de Walden Estate will Every measure we take to create a imminently. do whatever it can to make sure it does. more seamless experience for users With providers of the calibre of Royal Partly, that means spreading the word of the area’s diverse services or to sell Brompton & Harefield Hospitals, the about what the area has to offer, but what we’re doing around the world Royal Marsden, Moorfields Eye Hospital, it also means thinking hard about will rely upon the HSMA’s clinics and The London Clinic, King Edward VII’s how we can improve the patient hospitals working closely with us and Hospital and HCA either here or on their experience. with each other. A decade ago, before way, together with an exceptional The HSMA already has many the Estate had formulated its medical inventory of specialist clinics, these attractions that go beyond its medical strategy, many of our providers were transatlantic arrivals are the cherry on credentials—its centrality, its transport quite insular in their bearing, uninclined top of an already very impressive cake. links, its proximityto restaurants, shops to even meet each other, let alone Our mission to turn the Harley Street and green spaces—but there is plenty collaborate. Today, things look very Medical Area into a globally recognised more that we can do to increase our different. To give just one quite striking centre of excellence, has, by any appeal to patients. Certainly, there are example, The London Clinic has started measure, been remarkably successful. measures we can take to help patients providing a range of clinical services So, what next? Inevitably, some of our better understand the options available to Schoen Clinic London, including the focus will, I believe, shift from attracting to them and access the facilities that use of its new 3T MRI scanner and other providers to attracting patients. best suit their needs, whether that diagnostic technologies, and access to be through concierge services or the its consultants. Many of our providers One of the great strengths of the HSMA HSMA’s own digital platforms. are also frequently referring patients is the independence with which our We are also looking at ways of using to each other, making use of their operators are able to function. Compared our building stock to host services for respective specialisms. to the purpose-built, centrally organised patients. There is, for example, a good In part, this healthy appetite for medical campuses found in some other case to be made for the creation of a engagement reflects a modernising parts of the world, our hospitals and step-down facility. In some parts of spirit that is now blossoming clinics have a high degree of autonomy. the world, step-down facilities—units throughout the healthcare sector, They have their own cultures, their own for patients who no longer need acute but it is also directly attributable to priorities, their own ways of presenting care but can benefit from an active the work we have done to make our themselves to the world. And while our rehabilitation programme designed to medical occupiers feel part of a wider strategy has been to provide a diversity help them recover from their illness or whole, the collective strength of which of specialisms and services, they are, surgery and get back to full strength— benefits all of its many constituents. The to a certain extent, competitors as well routinely play a crucial role in treatment Harley Street Medical Area may have as neighbours. It is an arrangement pathways, but in the UK they remain spent many years growing in scale and that has done much to stimulate few and far between. Establishing one ambition, but it is also becoming much innovation, encourage openness in the HSMA would give patients the tighter in its bonds and more coherent in and raise standards. But for this to be opportunity to convalesce under the its form. That can only bode well for the sustainable as a model, patients need guidance of experts, while remaining next phase of its development. to be drawn here in sufficient numbers within easy reach of their consultants— for all the providers to thrive. As new particularly useful given the distances The Howard de Walden Estate facilities open and capacity rises, it is many of those patients will have 23 Queen Anne Street essential that the number of patients travelled to get here. London W1G 9DL hdwe.co.uk coming to the HSMA grows at the same Similarly, a patient hotel—offering harleystreetmedicalarea.com rate at least—and as the steward for the comfortable accommodation for people

6—Prognosis

prognosis_issue05_PP1-25 PROOF01.indd 6 10/01/2019 09:32 prognosis_issue05_PP1-25 PROOF01.indd 7 10/01/2019 09:32 prognosis_issue05_PP1-25 PROOF01.indd 8 10/01/2019 09:32 The inaugural Harley Street Medical Private Care at The Royal Marsden, Area Healthcare Conference the private arm of The Royal Marsden NHS Foundation Trust, one of the country’s leading cancer hospitals, has taken a lease on the lower ground NEWS and ground floors of Harcourt House, Cavendish Square, a large, mixed- use mansion block dating from 1907. Comprising around 17,000 sq ft of medical accommodation, The Royal Marsden’s new unit will primarily be used as a diagnostics centre. Building works are expected to be completed by June 2019, with the unit set to open in the summer of 2020 royalmarsden.nhs.uk/private-care

141-143 Harley Street The inaugural Harley Street Medical The Howard de Walden Estate is Area Healthcare Conference took continuing work on a new building place on 31st October. Organised for King Edward VII’s Hospital at by The Howard de Walden Estate and Macintosh House on Beaumont hosted by the Royal Society of Medicine, Street. The redevelopment will the conference saw an exceptional list comprise two basement levels, of speakers addressing topics related to ground and four upper floors, totalling the future of healthcare. The co-chairs, approximately 22,000 sq ft. The facility Rt Hon Professor the Lord Kakkar and will provide the hospital with the space Professor Dame Jane Dacre, supervised needed to enable the expansion of its a programme of lectures and panel outpatient and imaging services. discussions from a cast of experts kingedwardvii.co.uk including Dr Victor Dzau from the US National Academy of Medicine, former NHS medical director Professor Sir Bruce Keogh, Professor Sir John Bell from the University of Oxford and Sir Simon Wessely from King’s College London. harleystreetmedicalarea.com

Work is nearing completion on the The Howard de Walden Estate King Edward VII’s Hospital at Macintosh initial phase of construction of has begun the renovation of House on Beaumont Street a highly advanced proton beam 142-146 Harley Street to provide therapy unit at 141-143 Harley 17,000 sq ft of consulting space. Street. The Howard de Walden Estate Three interconnected Grade II listed expects to be in a position to hand over buildings will be refurbished to create the building to Advanced Oncotherapy a 21st century medical facility. The Plc in June 2019. This particular form basement slab will be lowered to provide of cancer treatment uses beams of an improved floor to ceiling height, and sub-atomic particles, which pinpoint two new lifts will be installed, while tumours with greater power and most of the interior structures, including precision than conventional radiation the period staircases, will be carefully therapies, causing significantly less restored. The Estate hopes to complete damage to surrounding tissues. the project in December 2019.

advancedoncotherapy.com hdwe.co.uk

Prognosis—9

prognosis_issue05_PP1-25 PROOF01.indd 9 10/01/2019 09:32 A probe with an ultrasound head is inserted into the thyroid, allowing the clinician to locate the swollen modules. It is then guided into the centre of the nodule, where a tiny device in the probe generates the radio signals used to destroy the excess tissue

with an enlarged thyroid can be given endocrinologist, a radiologist and an radioactive iodine in pill form, which can ENT surgeon—and a lot of information cause around a 30% reduction in the size has to be communicated between them. CRYSTAL of the nodules. When spread over different clinics, this If we find a malignancy, traditionally can lead to delays and errors. Ideally, we we would remove the whole gland. want to be able to take all the diagnostic BALL However, research has shown that and treatment decisions in one clinic. Thyroid conditions just removing the half of the thyroid I work in one of the very few of those where the tumour is located is usually facilities in the country—if we can move Mr Khalid Ghufoor, effective. This is better for the patient the whole field in that direction, it will consultant ENT and because if you remove the whole make a huge difference to patients. gland, they have to take thyroxine head & neck surgeon at replacement pills for the rest of their life. In the distance Harley Street Medical Looking into the future, one process that On the horizon is being considered very carefully by Centre, on how the One big leap forward in technology some in this field is tissue regeneration, treatment of thyroid for managing small thyroid lumps is both of thyroid tissue and damaged being trialled in the UK at the moment. tissues in the surrounding area. It is conditions is set to evolve Known as coblation or radiofrequency not uncommon for me to see patients destruction, it is a non-heat producing with compromised larynx function process for destroying soft tissue caused by damage, especially to the using radiofrequency energy. This nearby nerve bundles, during thyroid State of play is important because it is a non- surgery. At the moment there is no The thyroid is a butterfly-shaped surgical technique. The issue with single surgical technique which is gland that straddles the windpipe. It surgery is that the thyroid is very considered best for repairing this kind of releases a hormone called thyroxine close to several very important nerve damage, meaning there is a lot of room which controls the body’s metabolism. bundles, which control talking and for improvement. It would be wonderful I generally see people because their swallowing functions, and there is a to be able to apply some type of medium thyroid is overactive, underactive risk that something significant might that would stimulate and promote or swollen, which can be caused by a be damaged. For this new technique, nerve growth, causing the damaged variety of conditions. a probe with an ultrasound head is nerves to regenerate. Looking further Patients with a very overactive inserted into the thyroid, allowing the ahead, I believe that the thyroid has the thyroid gland are prescribed medication clinician to locate the swollen modules. potential to be grown from stem cells, that slows it down, and if it is It is then guided into the centre of the opening the possibility of replacing underactive, they can take medication nodule, where a tiny device in the probe the damaged gland completely with a to boost their thyroxine levels. Both generates the radio signals used to healthy one or implanting one in those these treatments are well understood destroy the excess tissue. born without a thyroid gland at all. and very effective. With a swollen The other big change I can see thyroid, the swelling may be pressing will be structural, not technological. Harley Street Medical Centre on the windpipe or gullet, causing Diagnosis of thyroid disease can be 27 Harley Street difficulty in breathing or swallowing, very laborious for the patient, as there London W1G 9QP 020 7467 6190 in which case we may need to remove can be up to four consultants involved harleystreet-medicalcentre.com the gland completely. Some patients in the process—a cytopathologist, an

10—Prognosis

prognosis_issue05_PP1-25 PROOF01.indd 10 10/01/2019 09:32 studies to take up medicine at Durham MUSEUM HARLEY STREET University. He completed his training at the London Hospital in Whitechapel, PIECE HERO gaining Membership of the Royal College The ophthalmoscope of Surgeons in 1882 and a Fellowship Thomas Horrocks in 1886. He was appointed assistant Openshaw demonstrator of anatomy at the London The invention of the Hospital medical college in 1886, and ophthalmoscope by (1856-1929) two years later added the curatorship of Hermann von Helmholtz in Surgeon its Pathology Museum to his list of roles, doing much to develop and catalogue 1851 was an epochal moment Words: Mark Riddaway the collection. In 1890, he was made an in ophthalmology. Before assistant surgeon, and orthopaedics—a this, doctors struggled to new and burgeoning field—became his explain certain types of eye specialism. Openshaw would be central to the foundation of the hospital’s disease because they could orthopaedics department, which he ran not see through to the rear until his retirement. section of the eye. Now, for the Since his youth, Openshaw had been first time, they could examine an enthusiastic member of the British Army’s volunteer force, rising to become a part of the eye called the a surgeon and lieutenant-colonel in fundus, which sits on the For a while in 1888, Thomas Horrocks the Lincolnshire Yeomanry. When the interior surface opposite the Openshaw was, for reasons that gave Second Boer War broke out in October lens and which includes the him no pleasure whatsoever, the 1899, he fulfilled what he considered most famous doctor in the country. to be a patriotic duty by heading off to retina, optic disc, macula, That autumn, over the course of a few South Africa to work in his regiment’s fovea and posterior pole. To months, five women were grotesquely field hospital. Before long, he had been be effective, this new piece murdered and mutilated in the East End taken prisoner by Boer forces, but was of kit needed three elements: of London. On 1st October, a package was released after two weeks as part of a posted to a Whitechapel businessman prisoner exchange. He took up a post as a strong, steady source of involved in the local community’s principal medical officer at a hospital in illumination, a reflecting response to the crimes, containing what Pretoria, where he worked until the end surface to direct light into the purported to be part of the kidney of of the conflict in 1902. eye, and a means of focusing one of the women, Catherine Eddowes, On his return to the UK, Openshaw together with a handwritten letter continued where he had left off, on the fundus. Previous claiming to be from the killer. Openshaw, although rebuilding his private practice attempts had been made to a surgeon at the nearby London on Upper Wimpole Street was no easy build an effective tool, but Hospital, was asked to examine the task after an absence of several years. Helmholtz was the first to tissue, which he confirmed was part of a Resuming his work at the London human kidney. Hospital, as well as several other usefully solve the puzzle. The The 32-year-old doctor suddenly institutions, he became a prolific and widespread adoption of the found himself part of the wild frenzy highly respected surgeon, liked and Helmholtz ophthalmoscope, of press coverage that accompanied admired by colleagues and patients this example of which can the murders. On 29th October, he was alike. sucked even more forcefully into the When war broke out across Europe be found in the Moorfields vortex when another letter arrived, in 1914, the surgeon was too old to be Eye Hospital Museum, led addressed to Openshaw and signed by an active participant, but made himself to a series of new discoveries ‘Jack the Ripper’, who promised to send useful to the military in every way he about the inner workings of “another bit of innerds” soon. It ended could, including taking a post at the with a disturbing (and horribly written) King Edward VII Hospital for Officers. the eye and marked a genuine verse: “O have you seen the devle / with Most notably, he was instrumental in turning point in eyecare. his mikerscope and scalpul / a-lookin the establishment of the Queen Mary at a kidney / with a slide cocked up.” Convalescent Auxiliary Hospital for The ‘Openshaw letter’, as this note the Limbless at Roehampton—a facility became known, would become a that proved pioneering in its use of fundamental part of Ripper lore, prosthetic limbs. When he died in 1929, analysed over and again by police, it was as a highly decorated paragon of writers and amateur sleuths. both the medical and military spheres. It Openshaw’s career amounted to is in the service of these twin passions far more than a tangential encounter that Thomas Horrocks Openshaw with a psychopath. Born in Bury, would have wished to be remembered. Lancashire and educated at Bristol Regrettably, Jack the Ripper, or someone Grammar School, he at first aspired to posing as him, had ensured that be an engineer, but left his engineering wouldn’t happen.

Prognosis—11

prognosis_issue05_PP1-25 PROOF01.indd 11 10/01/2019 09:32 count, sperm motility (the quality of the trophectoderm, which will give rise movement of the sperm) and sperm to the placenta, an internal segregation morphology (how the sperm looks of cells called the inner cell mass, which under the microscope). If the sperm falls will give rise to the foetus, and a cavity below specified parameters, we would filled with fluid. Based on the appearance recommend the use of intracytoplasmic of those three parts, we classify each sperm injection (ICSI) as the preferred embryo as having good, average or method for fertilisation. low morphology. Embryos with low A woman’s eggs are stored within morphologic classification will generally her ovaries in small sacs called follicles. be discarded. In a natural cycle, when ovulation Apart from the traditional occurs, one of these follicles develops morphologic criteria used to determine into the dominant one and releases an the quality of the developing embryo, egg. The key hormones that regulate advances in technology and embryology this process are called gonadotropins: have allowed the introduction of other follicle stimulating hormone (FSH) more accurate methods. These include and luteinising hormone (LH). For time-lapse imaging, which involves us IVF treatment, we use these same introducing the zygote to an incubator hormones in higher than usual doses. that can take pictures of the developing These stimulate the ovaries, causing embryo every few minutes. These them to grow more follicles, allowing pictures are compiled in a video, and us to retrieve more eggs. by observing the mode and timing of The process of oocyte retrieval— embryonic divisions, we can judge the HOW DOES IT egg collection—is normally quite embryo’s reproductive potential. straightforward. It is similar to the The real evolution in determining the WORK? transvaginal scan, but on top of the probe quality of embryos in culture has come In vitro fertilisation (IVF) there is a fine needle that pierces the with pre-implantation genetic screening Dr Apostolos Tsironis from vaginal wall and, under direct sonographic (PGS). This involves a small biopsy— vision, is directed through the ovary and between three and five cells from the the London Women’s Clinic into a follicle. The follicular fluid containing trophectoderm of the blastocyst—being on the mechanics of in vitro the egg is sucked out, before being handed sent for genetic analysis. With PGS, we fertilisation to an embryologist, who will examine it can detect the chromosomal composition under a microscope. The morphological of the embryo with 99% accuracy. Interview: Viel Richardson appearance of the egg (size, cytoplasm Euploid embryos—embryos with a normal integrity, internal fragmentation) number of chromosomes—have a high can provide us with some degree of chance of giving a live birth. Aneuploid information regarding its potential, but embryos—those with an abnormal generally there is no reliable test to check number of chromosomes—are discarded. egg quality. Usually, only mature eggs Assuming that on day five we have are used, but in rare circumstances an embryos with suitable morphology, immature egg will be used. we then either proceed straight away with the embryo transfer or freeze the On the day of oocyte retrieval, the male embryos for future use. Freezing of partner is required to provide us with a embryos is gaining popularity, as it allows In vitro fertilisation (IVF) is the process of fresh semen sample. If semen parameters us to transfer the embryo at the optimal creating an embryo through the fusion are normal, we proceed with standard time in the woman’s cycle, after the of genetic material between an egg IVF, which means that the eggs and effects of ovarian overstimulation have and a sperm outside the human body. sperm are left undisturbed in a petri worn off. It can be the answer in cases of infertility dish to interact. If semen parameters are We sometimes freeze embryos for caused by conditions such as blocked suboptimal, we recommend performing clinical reasons. These can include fallopian tubes, endometriosis, male factor ICSI, which means injecting each egg with detection of endometrial issues, polyps infertility and polycystic ovary syndrome. one sperm. Whichever method we are or fibroids, which will need to be treated. Before we begin IVF, it is vital for the using, we need to wait for 18 to 20 hours One potentially serious reason for a delay patient to undergo an anti-mullerian in order to check whether fertilisation is the risk of ovarian hyperstimulation hormone (AMH) test and a transvaginal has occurred. syndrome (OHSS), an ovarian over- scan. AMH, which is produced within the The fusion between egg and sperm response to stimulation that can make ovaries, is a good indicator of the woman’s creates a zygote, which represents the proceeding with the embryo transfer ovarian reserve and will accurately first day of embryonic life. The zygote dangerous. If OHSS is suspected, the predict her response to IVF treatment. then undergoes successive divisions. transfer is delayed for two or three A transvaginal scan will detect any On day two, the embryo consists of four months in order to allow a full recovery. abnormalities affecting the uterus, such cells—called blastomeres—and on day Embryo freezing is carried out using a as fibroids or polyps, or the ovaries, such three, eight cells. On day five (or, in some method called vitrification—a rapid form as endometriosis. cases, day six or seven), a blastocyst will of freezing that involves removing the Fora male partner, a semen analysis form. The blastocyst consists of three water component of the embryo and is important, as this will reveal his sperm distinct parts: an outer layer of cells called then using liquid nitrogen to keep the

12—Prognosis

prognosis_issue05_PP1-25 PROOF01.indd 12 10/01/2019 09:32 embryo at a very low temperature. The placed in the middle of the uterine cavity. process is safe and highly effective. When With the catheter in place, the embryo we are ready for the transfer, the embryo is released. Hopefully implantation will Anti-mullerian hormone (AMH) A hormone is thawed, a process that takes about 30 happen within 48 hours. produced by small follicles in the ovary, used in the minutes. There is a small risk (less than Following the embryo transfer, the assessment of ovarian reserves and the prediction 2%) that it will not survive the thawing patient is advised to have a pregnancy of response to ovarian stimulation. Ovarian reserve The number of follicles process, but this is seen as an indication test after 12 days. If this is positive, remaining in a woman’s ovaries. that the embryo would not have led to a an early pregnancy scan is booked Intracytoplasmic sperm injection (ICSI) A viable pregnancy anyway. for between six and seven weeks of method of fertilisation used when semen analysis abnormalities are detected. gestation, in which we aim to detect a Follicle The anatomical and functional unit of Before the transfer, the patient’s foetal heartbeat. If this is the case, the the ovary, each of which contains one egg and all endometrial lining is prepared with patient is discharged to her GP with our the necessary supportive cells to ensure correct growth and maturation of the egg. progesterone pessaries in order to warmest wishes in order to arrange the Gonadotropins Hormones produced in the become receptive. The transfer itself is antenatal care. Hopefully the story will human brain that regulate the monthly menstrual relatively simple. The doctor introduces end with a healthy baby at home. cycle. Pre-implantation genetic screening (PGS) a small catheter through the cervix Genetic analysis used to determine embryo while the assistant scans through the The London Women’s Clinic quality by assessing the number of chromosomes abdominal wall, giving the doctor a clear 113-115 Harley Street of the developing embryo. Blastocyst The embryo on day five of view of what is happening. Avoiding London W1G 6AP 020 7563 4309 development, consisting of the inner cell mass, any contact with the uterine fundus is londonwomensclinic.com the trophectoderm, and a fluid-filled cavity. imperative and the embryo needs to be

1. Ovary stimulation Egg 2. Egg retrieved

Uterus 3. Fertilisation

Sperm

Ovary

4. Embryo Cells divide in transferred vitro into uterus

Prognosis—13

prognosis_issue05_PP1-25 PROOF01.indd 13 10/01/2019 09:32 THINKING ALOUD Mr Rami Alfalahi, director of Green Door Clinic

Interview: Ellie Costigan Portrait: Orlando Gili

Addiction is an epidemic that is increasing worldwide. The problem of addiction is the war of our generation.

I spent the first 30 years of my working By 2020, 50% of the world will be able to life in the IT industry, where I saw how Addiction is a symptom converse in English—but for us it is equally information and technology could make and there are many important to understand the client’s significant changes to our daily lives. In lifestyle and culture. We have people on the IT industry, I was trained to identify drivers causing it. The the team who not only speak Arabic but a problem, break it down into component cause could be stressful also understand the culture. The basis of a parts and come up with a solution. Being mental illness is deeply embedded in your the director of a mental health clinic, I see lifestyle, trauma, personality, so your culture and social no difference. depression or anxiety. background have to be taken into account.

This opportunity to develop the Our methods of data gathering help us One of the biggest modern problems clinic was ideal for leveraging IT and determine the underlying root causes is loneliness. Society is moving more mental health to make a difference of each client’s suffering. Addicts are and more in that direction, and it needs in the medical field. The cycle of usually in denial, suffering alone, so our to be addressed. This is bigger than treatment in mental health issues is treatment plans seek to engage the client the medical field: it is sociological and not dissimilar from solving complex in the treatment by working directly with philosophical. We need to start thinking technological problems. parents, families, friends and employers about how we can take better care of as well as the addict. each other.

This in-depth analysis is key to directing Having been involved with One in four people will the treatment. To effectively treat the this mental health clinic, my suffer from mental health addiction, you need to understand the attitude towards many things has full spectrum of issues. Onlythen can changed. I have a young family problems at some stage— you attempt to resolve the cause of and I want my children to do well and there is no health the problem. in their education and their job commitments, but that cannot be without mental health. It at a cost to their mental health or touches every part of life. wellbeing.

Everybody in the health sector talks Addiction is transferable. Some people about wearable devices and big data. have one kind of addiction, then move Based on feedback from digital devices, on to another. It’s very important to we can build a clearer picture of the replace whatever the client is addicted patient. When we have a lot of data, we to with something else that makes them can analyse it, and based on this data happy—sport, yoga, art, theatre, cinema. we can spot an illness early and make Encouraging them to explore things that intelligent decisions. That’s how I see the will stimulate them or help them to relax mental health industry going. We are is an important part of our programme. just at the beginning.

14—Prognosis

prognosis_issue05_PP1-25 PROOF01.indd 14 10/01/2019 09:32 Green Door Clinic 30 Weymouth Street, W1G 7BS 020 7637 5670 greendoorclinic.com

Prognosis—15

prognosis_issue05_PP1-25 PROOF01.indd 15 10/01/2019 09:32

But type A and type B viruses cause enough to the parent for the immune PROFILE seasonal epidemics almost every winter. system to respond. However, these The problem stems from their ability to changes can accumulate to a point OF A mutate, which means they can arrive where the existing influenza antibodies each year as new and very different no longer recognise the antigen as a PATHOGEN looking influenza strains—particularly threat. true of the A virus. The other method of change, which Influenza Influenza A can be divided into is far larger and more abrupt, is called subtypes based on two proteins on the ‘antigenic shift’. This occurs when two surface of the virus: the hemagglutinin or more strains of influenza, often (H) of which there are 18 subtypes. and including those from other animals, the neuraminidase (N) of which there are combine to form a new subtype. When 11, hence the H/N part of the name. The an antigenic shift happens, the global current subtypes of influenza A viruses population has little or no protection found in the general global population are against the new virus. This was the H1N1 and H3N2. These subtypes can in case with 2009 H1N1. turn be broken down even further into These constant mutations are why strains. we need to continually update the flu In the spring of 2009, a new strain vaccine: last year’s formulae may be of of the influenza A H1N1 virus emerged, no use against this year’s virus. Another popularly known as ‘swine flu’, causing complication is that these vaccines don’t the first major pandemic in more than work at all against influenza C viruses, All of you will have heard of influenza, 40 years, with over 6,000 deaths leaving people completely unprotected— or ‘flu’ as it is more commonly known. reported in 206 countries within the but thankfully this is the least dangerous Many of you will also have heard of the first 10 months of its appearance—a of the flu viruses that affect humans. Spanish flu pandemic of 1918-19, which number generally agreed to be a So, while familiarity can sometimes infected around a quarter of the world’s significant underestimate. This strain, breed contempt, complacency about population and, with an estimated death often referred to as ‘2009 H1N1’, is now influenza is not an option. This constantly toll of 20-40 million, was responsible for the dominant form of the H1N1 virus shape-shifting virus has resisted all more fatalities than the world war that circulating in humans. It is no longer attempts to tame it for a century and preceded it. Those fearsome numbers causing such carnage, but the impact of will doubtless continue to do so for many demanded and got a concerted response, its emergence was a sober reminder of years to come. yet despite nearly a century of effort, what this disease can do. the flu season still arrives every year, This relentless shape shifting claiming thousands of lives. happens in two ways. One is called The reason for its continued ‘antigenic drift’. Antigens are Virulence The relative capacity of a pathogen to virulence lies in the nature of the virus biomolecules found on the surfaces of overcome the body’s defences. which, be warned, is rather involved. bacteria or viruses; these are recognised Strain A genetic variant or subtype of a There are four types of influenza by the immune system, thus triggering microorganism such as a virus, bacterium or fungus. Pandemic An outbreak of a disease covering viruses: A, B, C and D. Type C infections the immune response. Small changes several widely-spread countries affecting an generally cause a mild respiratory in the molecular structure of antigens exceptionally high proportion of the populations. illness, while type D viruses are not occur continually as a virus replicates, known to cause illness in people. but usually produce antigens close

16—Prognosis

prognosis_issue05_PP1-25 PROOF01.indd 16 10/01/2019 09:32 prognosis_issue05_PP1-25 PROOF01.indd 17 10/01/2019 09:32 HOW TO... Deal with cataracts Dr Vincenzo Maurino, consultant ophthalmic surgeon and cataract service director at Moorfield’s Eye Hospital

What is a cataract? What are the first signs that people not the new lens—becomes opaque. This The crystalline lens is a biconvex lens should be looking for? is called posterior capsular opacification, that sits behind the iris and is attached They may have difficulty seeing at night or a secondary cataract, and can happen to the inside of the eye by some mini- as well as they once did. Glare, haloes as a by-product of the attempt of the ligaments called the zonula. What and starbursts around light sources may human body to heal. It affects around happens with ageing is that this natural be more noticeable. They may also have 10% of patients and can occur years or lens begins to lose transparency. Once difficulty reading. The usual trajectory even decades after the procedure. It is it becomes cloudy, it is called a cataract. is that the patient goes to the optician more common the younger you are at This loss of transparency leads to a complaining of sight problems. If after the time of the cataract surgery. It can be diminishing in the quality of vision and, an examination the optician confirms treated by a very quick laser treatment if left untreated, loss of useful sight. that one or both crystalline lenses are called YAG laser capsulotomy with losing transparency, this marks the very little risk, and the sight is restored Are there other causes besides age? beginning of the patient’s journey to the immediately. Age is the most common cause, but eye surgeon. cataracts can also be caused by trauma If you have a genetic predisposition to the eye, and there are some people What is the treatment? to cataracts, is there anything you who have a genetic predisposition, which There is no medication-based treatment can do to lower the risk? means this lessening of transparency of available. Cataract surgery is probably Avoiding excessive unprotected the natural lens in the eye may start at the most common surgical procedure exposure to strong sunlight is very a much earlier age. Cataracts in children worldwide—in the UK alone, more than important. As with everything else in are almost always due to genetic causes, 300,000 are performed each year. our bodies, a healthy lifestyle, eating but can be also caused by problems To get access to the lens, we make a well and physical activity will help. during birth. There are also some ocular micro-incision on the cornea, the first conditions that can be associated with transparent structure at the front of the How have things improved during an increased risk of cataracts, such as a eye. Then we create a circular opening at your time in practice? high myopia or glaucoma. the front of the natural lens and remove The surgery has improved the inside using ultrasound energy, tremendously. We have moved from Does the cataract spread evenly which breaks up the cataract. At the incisions of up to 10mm in the cornea, across the lens? same time, we use a sucking device to to incisions of well below 2mm. Also, This can vary a lot, because the lens remove the fragments of cataract. We laser techniques have started to play an is a convex structure around 3-5mm leave the crystalline lens casing in place, increased role. This is very important, in diameter and it is made of different but give it a thorough clean. Finally, we because if the opening is damaged in areas, so it depends where the cataract inject the rolled-up replacement artificial any way there is a much higher risk is localised. The location also determines lens, which expands inside the lens of post-operative complications. But how badly it affects the person’s vision. casing. Sutures are not needed at all in the key factor in our progress is the A posterior sub-capsular cataract—a the vast majority of cases. increasing experience and expertise the very small cataract located at the very surgeon can bring to the procedure. back of the lens—will affect the vision Is this a one-off operation? dramatically and quickly. A nuclear For the vast majority of patients, it is. Moorfields Private Eye Hospital cataract—one located in the centre of But as with any operation, things can 8 Upper Wimpole Street the lens—will progress slowly, with the happen. The most common is that the London W1G 6LH 020 7566 2803 patient becoming aware of the cataract encasing membrane loses transparency. moorfields-private.co.uk after a few years. This occurs if the back of the container—

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prognosis_issue05_PP1-25 PROOF01.indd 19 10/01/2019 09:32 A DAY IN THE LIFE Cat Dowling, matron at medical concierge service Lexihealth

Interview: Mark Riddaway Portraits: Christopher L Proctor

My days here at Lexihealth are very I’m the first port of call for patients who seeing multiple doctors, with all the different to those I’ve been used to contact Lexihealth looking for help. stress and expense that entails. throughout the rest of my working life. We cover everything from pre- My background is as a paediatric nurse— Every morning, I travel in by train conception to the final breath, and from I spent more than 20 years in hospitals from North Acton. I like to get off at the mind to the toes, so every case in London, both NHS and private, as well Queensway and walk the rest of the has the potential to throw up a new as a spell in Australia. As a nurse, you way—having a bit of a stroll wakes you challenge. As a paediatric nurse, I know get used to the night shifts, the long up in the morning, then relaxes you in quite a lot about paediatrics, but I may hours, the weekend work; now I work the evening. As soon as I arrive, I start need some input when it comes to other Monday to Friday, nine to five. I’m used to responding to emails and messages areas of medicine. Having got to know spending time on a busy ward with lots from patients. Most of our interactions the consultants on our medical advisory of children, playing lots of games; now I’m take place over the phone or by email, committee quite well, I can pick up the dealing with a lot more adults. And rather although some people do like to come in phone and say, “I’ve got a patient and I than being in a massive hospital, I’m part and talk face to face. think this is the correct avenue for them, of a small, close-knit team in a quiet office. When a patient makes contact for the but can we discuss the case to make It’s a very different pace of life, but the first time, I start by asking them a set of sure I’m doing it correctly?” Within the work is still demanding and rewarding. standard triage questions, which we’ve business, there is lots of expertise for Lexihealth is a medical concierge refined over time: what has prompted me to draw on. Annabelle Neame, one company. It’s been running now for just them to make contact, who have they of the Lexihealth co-founders, is a over two years, and I’ve been here since seen or spoken to already, what is the nurse by background, and the other, September 2017. Our role is to coordinate specific area they’re concerned about, do Miss Romana Kuchai, is a consultant medical care for our clients. That means they have any other related concerns? ENT surgeon. We also have two patient making sure they are seen by the right That first conversation doesn’t need to liaison managers who are both very consultant, in the right facility, at a time be a long one—usually just 15 minutes knowledgeable and experienced. There that is suitable and convenient to their or so—but I need to glean from them is so much knowledge around me— needs. I’m here in the role of matron—but enough information to ensure that the it’s about utilising that knowledge. not in the Hattie Jacques mode, and consultant or facility we refer them to We are able to refer patients to a long certainly not in the uniform! In fact, this is the right one. The entire premise is list of consultants and specialist facilities, is the first time ever that I haven’t had that we will enable you to be seen by the most of them in London. These have all to wear a uniform to work. In a nutshell, right person straight away, rather than been approved by our medical advisory

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prognosis_issue05_PP1-25 PROOF01.indd 20 10/01/2019 09:32 We cover everything from pre-conception to the final breath, and from the mind to the toes, so every case has the potential to throw up a new challenge

Prognosis—21

prognosis_issue05_PP1-25 PROOF01.indd 21 10/01/2019 09:32 Nursing is all about communication, openness, empathy, understanding where people are coming from and knowing how to draw out of them what it is they want to say. It’s the same in this role

committee, the members of which are better. Once they’ve made their decision, things clearly and honestly, I need to be highly experienced clinicians, and the list we can get things organised very quickly. a good listener. We will all need medical is constantly assessed and expanded. I We have lots of patients who are flying in help at some point in our lives, and we all will quite often go out to visit the facilities and need an appointment then and there. want to be treated with professionalism and see the consultants—it is important Our relationships with the consultants and compassion. for me to build those relationships. and the facilities make that possible. The effects of what we do can be life- The same is true of the patients. changing. We had a case recently where I want to learn about them as people— No two enquiries are the same. For a child had waited a long, long time to see not just a list of symptoms. When we example, we recently had a request a specialist—they had been on a waiting make a referral, we need to find the right for help from a lady who is quite sick list for months. The family contacted us consultant for their medical needs, but but desperately wanted to attend her and we got them seen the next day. also the one most compatible to their only son’s wedding, so we organised an I know the consultant quite well and he personality—some patients like to be ambulance and medical staff to make answered the phone and said, “Fine, get treated firmly and directly, others want it possible. I also spend time looking at them in tomorrow.” That had a big impact their treatment to be warmer and more feedback from patients, seeing what has not just on the child, but on the whole comforting. Getting this right is really worked effectively, working out what family. So much stress and anxiety had important—you want patients to have we need to do to improve. The feedback built up. It affects so many things: eating, the best possible relationship with their we get goes to the consultants as well. school, relationships. One small thing— consultant, to develop real trust. Within nursing you’re always growing seeing the consultant—has changed After we’ve completed the and being challenged, so I’m used to that everything. Mum seems completely assessment, I will send our mindset of constant improvement. Every different now, dad seems completely recommendations to the patient. day is a new day—it’s how it should be. different too, and most importantly the This will include the biographies of In this job, I get to utilise skills I have child is progressing. The part we played consultants, information on facilities, the built up over a long period of time, but in was a small one, but I’m still proud of it. times that are available, the prices—the a very different way. Nursing is all about patients get the same self-pay price that communication, openness, empathy, Lexihealth they would get if they organised the understanding where people are coming 56 New Cavendish Street treatment themselves. We’re really open from and knowing how to draw out of London W1G 8TH 020 7205 2556 and honest about all the options—the them what it is they want to say. It’s the lexihealth.com more informed the patient feels, the same here. I need to be able to explain

22—Prognosis

prognosis_issue05_PP1-25 PROOF01.indd 22 10/01/2019 09:32 prognosis_issue05_PP1-25 PROOF01.indd 23 10/01/2019 09:32

SECOND OPINION Should epidurals be available on demand 1 during labour?

Their sedative effect can remain for assisted birthing techniques, such as There is a place for several days, which may affect the baby’s forceps or ventouse extraction. A natural epidurals, but I believe behaviour in that initial post-partem birth avoids these issues, especially as period. For example, sleepy newborn the mother’s pain can be managed very they can be overused. babies may take longer to suckle at their effectively in other ways. mother’s breast. Perception of pain is strongly linked to An epidural can also neutralise anxiety. If a mother feels safe, supported oxytocin receptors, causing the uterine and empowered, there is clear evidence contractions of labour to slow. This can that she will manage pain much better lead to a woman requiring an intravenous using less invasive methods. Negotiating infusion of synthetic oxytocin to a birthing plan before labour can be hugely Dr Ethel Burns augment her labour—an intervention that helpful. This enables open discussion of An epidural is a form of pain relief closely in turn usually involves the addition of an the pros and cons of the various types of associated with women in labour. It electronic heart monitor machine, which birth and pain relief. With your midwife, involves the insertion of a fine, flexible can inhibit a woman’s ability to adopt an you can lay out the specific circumstances catheter into an area in the lower back optimal position of comfort. under which you wish certain actions called the epidural space. The anaesthetic The anaesthetised pelvic floor to be taken, and that may include the bathes the pelvic nerves, blocking the may also present a complication. This use of an epidural. In the throes of very pain signals’ pathway to the brain. It is hammock-shaped area of muscles has frequent strong contractions, it can be important to remember that an epidural is a firm tone, which enables the baby’s difficult to keep a clear vision of how you a minor surgical procedure with attendant head to pivot forwards, like a tennis ball wanted the birth to progress. issues, and should be approached as in a gutter. If the pelvic floor loses tone, There are good reasons, both physical such: available for use when necessary which can happen with an epidural, and psychological, why an epidural will but not seen as a quick pain fix. there is less tension against which the sometimes be necessary. But it is my As with any drug-based procedure, baby’s head can pivot, making it harder belief that the rush to use it as a quick the knock-on effects must be considered. for it to rotate into position. The Cochrane pain fix can lead to its overuse. There is strong research evidence review of research evidence, published Dr Ethel Burns is senior lecturer showing that the mother’s experience earlier this year, showed that both the in the Department of Midwifery, of labour impacts on how she and her first and second stages of labour can Community and Public Health newborn child bond. The drug used in take longer with an epidural. This may at Oxford Brookes University an epidural is an opioid, and opioids can also be one aspect of an association and a council member of the RSM easily cross the placenta to the baby. between epidurals and the need for Maternity & the Newborn Forum

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2

epidural. Patients can also sometimes options, but one that I believe should be As a doctor I am there to suffer from headaches and back pain. accessible to all women. facilitate the patient’s However, the impact of epidurals on the In recent years, I have seen a lot of woman’s pelvic floor muscles is miniscule women who have felt under pressure wishes if possible. in comparison to nine months of to manage the birth naturally. I know of pregnancy, and the impact on the baby is mothers who see themselves as failures usually minimal and transient. All these having required an epidural—and I think factors need to be weighed up. The failure that is terribly sad. I feel we may have rate also needs to be taken into account: gone too far down the road of trying not all epidurals work with 100% efficacy, to avoid any kind of pain relief, which I and if they don’t, the woman will still feel believe leads to unnecessary suffering. Dr Shree Datta some pain. Pain is exhausting as well as distressing, Like any procedure, an epidural may It is important to remember, though, and you don’t want a woman to be in a not be appropriate ‘on demand’, but I do that the epidural is never our first option. position, when the baby finally arrives believe it should be an option for women To ward off the pain, we always start after hours of contractions, where she is in labour. There can be reasons, some with the safest and easiest options, too tired to be able to push. That is why, clinical and others to do with the progress which include things like walking, if the indications suggest to me that of the labour, that an epidural may not moving, having a bath. We may also call a woman is going to have a very long be either safe or appropriate. However, upon the services of a doula—usually a labour, I may gently suggest that she I think our first thought should always woman with experience of childbirth consider an epidural. be for the woman’s comfort, and unless who has completed some clinical My position is that as a doctor I am there are medical contraindications, training, but is not a midwife—who can here to help the patient. If a woman’s I believe it is my duty as a doctor to grant provide support for the whole family pain threshold has been exceeded, the her wish. throughout the delivery, offering question becomes: how can I possibly Those caveats are important, because flexible, practical and emotional support, deny her effective pain relief? As long as an epidural is a medical procedure and and whose input can often help the it is medically safe for both the baby and with all procedures there is an element of mother to manage her pain. We may the mother, it is my duty to provide an risk. Administering an epidural requires then move on to light pain relief like epidural as part of her care package. careful monitoring, as the patient may paracetamol. Only then do we start Dr Shree Datta is a consultant lose the ability to walk safely or even more serious medication, which also obstetrician and gynaecologist stand up. She may not be able to go to includes gas and air during contractions. and council member of the RSM’s the toilet during and for a while after the The epidural is the last of all these Obstetrics & Gynaecology Section

Prognosis—25

prognosis_issue05_PP1-25 PROOF01.indd 25 10/01/2019 09:32 THE BIG INTERVIEW Witness protection Barrister Anton van Dellen on the increasing complexity of medical court cases and why doctors who appear as expert witnesses play a pivotal role in seeing that justice is done

Words: Viel Richardson Images: Christopher L Proctor

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Prognosis—27

prognosis_issue05_PP26-55 PROOF01.indd 27 10/01/2019 09:34 Coroner An official who presides over inquests into violent, sudden or suspicious deaths. Civil Procedure Rules The procedural code with the overriding objective of enabling the court to deal with cases justly and at proportionate cost. Witness of fact Also known as professional witnesses, these witnesses provide professional evidence based on of their clinical findings, observations and actions. This evidence must be based as far as possible on records and notes made at the relevant time. Supreme Court Established in 2009, the Supreme Court of the United Kingdom is the final court of appeal in the UK for civil cases, and for criminal cases from England, Wales and Northern Ireland. Shoulder dystocia An obstetric emergency in which one of the baby’s shoulders becomes stuck behind the mother’s pubic bone during birth. Informed consent Permission granted for a procedure to take place by a patient who has a full understanding of any possible consequences.

“Not always that well,” comes the people, these cases are hugely important, argue their case in front of a judge or a answer, accompanied by a wry smile. life-changing moments. It may be that coroner rather than a jury. To enable Across the table sits Anton van Dellen, they are unable to work again and have a the judge to come to a conclusion, the a barrister at Goldsmith Chambers, family to support, so there is a lot riding lawyers are there to bring clarity to based at Temple, the heart of the legal on the outcome. Being trusted to be their many complex issues, such as what establishment, and I have just asked voice at this critical time is a privilege.” decisions led to the harm or loss how the twin edifices of medicine and When fields as complex as law and suffered, who took the decisions, when law intersect in the courtroom. It wasn’t medicine overlap, having someone who were they taken, and whether someone an answer about which Van Dellen had can provide laypeople with that voice can reasonably be held liable. to think too hard, as his background is vital, as the arguments being laid makes him uniquely placed to out in court can, for the uninitiated, Expert witnesses—independent understand the relationship between be extremely difficult to follow. The experts who have had no personal these two ancient and complex worlds. medical and legal experts in a case involvement in the incident under “I originally studied neurosurgery often discuss the same situation from review—can be called by both and had embarked on a medical entirely opposed but equally esoteric parties and will play a vital role in career,” he explains. “Quite early on, perspectives, using their own distinct these proceedings. Often, they are I found that my administrative duties languages. “From the legal standpoint, consultants whose medical expertise were exposing me to issues involving the first priority is to establish as and professional experience qualify clinical negligence and regulatory law precisely as we can what happened in the them to present informed opinions on and that I was developing a genuine clinical scenario,” Van Dellen explains. the more complex aspects of the case. interest in the area.” It was a discovery “The second is to understand the Their initial task is to write a detailed that left the young medic facing a expected standard of care, then whether report, setting out their position. choice: forge a career in the NHS, or any lapse in the standard of care the Then, during the discussions between else dive headfirst into the legal world. person received caused any harm. When the opposing legal teams, each expert He took the plunge, left the world of people are treated, lots of things can go witness will meet with their opposite medicine and went to law school. wrong, but it could be that even though number, then together they will Relating his story, Van Dellen makes part of the treatment didn’t go to plan, produce a joint statement. This allows this seem like the most natural thing it wasn’t responsible for the harm that them to lay out the areas of the case in the world, but passing the entrance caused the lawsuit to be brought.” in which they are in agreement and exams for both medicine and law takes The medical perspective can be very those in which their opinions differ— a huge amount of drive, passion and different. “It is like looking through the a process that saves time if the case sheer hard work. To abandon one for other end of the telescope,” Van Dellen does go to court, as areas of agreement the other is not a decision to be taken explains. “The clinicians understand can be acknowledged and put aside. In lightly. Clearly, something about the the medicine very well, but don’t these meetings, it is not uncommon for legal side of the medico-legal world had necessarily understand why something a witness to amend their view having an irresistible pull. that they may be very concerned about listened to the opposing witness’s “I’m not sure if I realised it at the time, is not really an issue in the case. An explanation of their position. If the but the ability to give a voice to people example is that the lawyers may be case goes to court, the witnesses will who would otherwise really struggle to focused on the consent process, while be called to answer questions relating grapple with this system is important to the expert witness wants to discuss the to the subjects under dispute. me,” the barrister tells me. “I generally complexities of the procedure.” “Their role is to assist the judge by represent the complainant against an In the types of litigation that Van helping them to understand the core institution or organisation. For a lot of Dellen is involved in, the legal teams issues surrounding the case and reach

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prognosis_issue05_PP26-55 PROOF01.indd 28 10/01/2019 10:46 witness should approach the task of is that so few cases actually get that preparing their report prior to the case far. Most cases are settled out of court. and how they should perform under This means that there are many expert questioning. Anyone doing expert witness witnesses who are very experienced work needs to know those rules very well.” and extremely good at preparing their Most other witnesses in a reports, but who have only been to court case—‘witnesses of fact’, as they are once in perhaps 50 or 60 cases. Despite known—are not generally permitted the title ‘expert witness’, they may be to express their opinions; they must as inexperienced as any of the other stick to objective facts. An expert witnesses when it comes to being cross- witness, on the other hand, is expected examined by a barrister. to draw conclusions. Medical expertise Another challenge is that, when can accommodate a wide variety the trial rolls around, a lot of time of opinions, even within a single has usually passed since the writing specialism, and introducing something of the initial report. Much may have as nebulous as “in my opinion” into a happened in the field since the report system predicated on dealing with facts was prepared, and the witness’s is not an easy task. opinions may have evolved. This “The first thing this does is restrict the means that a lot of preparation is areas in which they can give evidence,” required before going into the witness Van Dellen explains. “They are there box—even if the witness has amended for their expertise on a specific subject, some of their initial views, if the new and no more. Before the case has come to position and reasons are laid out The expert witness trial, the expert witness will have written properly before the legal teams and occupies a very difficult a report detailing their understanding of the judge, it will not be a problem. the situation and laying out their opinion. When I ask for some examples of position. They are Part 35 determines what details should be common mistakes expert witnesses generally instructed, in that report: why they have come to their can make, Van Dellen’s expression opinion, what assumptions they have suggests that the list is long, varied, and therefore paid, by made in coming to that opinion, if there is occasionally amusing and often not one side in the dispute. a range of opinion, and why they sit where for disclosure. After a few moments, they do on the spectrum of opinion.” he answers: “When writing the reports, But their overall duty is Under questioning, if a witness not going through the clinical notes to the court doesn’t follow the rules—for example, a carefully enough and missing something consultant orthopaedic surgeon begins significant. Not using the right language. to discuss a person’s psychological A common mistake is writing, ‘this could state—the judge will intervene and possibly have caused the damage.’ That remind them that they are not qualified is no good to a civil barrister. If it hasn’t to give an opinion. This may reflect ‘probably’ caused the damage, it is not badly on the judge’s perception of going to help me. The expert witness not the witness’s reliability; therefore, making it clear that their view is one of the opposing barristers will, not a range of opinions.” surprisingly, try to coax them into In the courtroom, the witness’s doing just this. bearing is essential. “Another common the level of understanding necessary to To help medical professionals cope mistake, which is very unhelpful, is make a judgement,” says Van Dellen. with the many pitfalls of being called losing their temper under questioning. Crucially, he explains, this is their as an expert witness, Van Dellen runs This is understandable, because often only role—they are there to offer a two-day course at the Royal Society you are talking about eminent clinicians expertise, not advocacy. “The expert of Medicine for any clinicians who who may feel their professional skills are witness actually occupies a very difficult are considering undertaking the role. being questioned. But if you give evidence position. They are generally instructed, “Expert witnesses get paid, so it is a when you are emotional, you look less and therefore paid, by one side in the revenue stream, but the majority of reasonable and are more likely to say dispute. But their overall duty is to the people do it for the interest,” says Van something unhelpful or inappropriate.” court. This can cause some tension, Dellen. “They are studying a set of “Talking too much is another because their duty to the court overrides papers and forming a view, potentially pitfall, something not unique to expert any contractual duty to the people who going to court and giving evidence. witnesses,” Van Dellen continues with instructed them and are obviously They enjoy that intellectual challenge. a hearty laugh. “Generally, the more a hoping they will give evidence that is The course is about equipping them for witness talks, the more likely they are to beneficial to their case.” this task in the same way they would say something deeply unhelpful to your There is, in fact, a very strong legal equip themselves to carry out a new case. As barristers we are trained to let framework to ensure expert witnesses therapeutic procedure.” the witness talk, to not interrupt them, stay true to that duty. “This is all covered A real understanding of what to but they may well end up contradicting by part 35 of the Civil Procedure Rules— expect from a trial is key, as one of the something they said earlier or put in a very prescriptive set of rules that are difficulties, particularly in clinical their written report.” absolutely clear about how an expert negligence and personal injury claims, The role of the expert witness is w

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prognosis_issue05_PP26-55 PROOF01.indd 29 10/01/2019 09:34 The current system is incredibly expensive, Expert Witnesses: Liability to Parties Other Than the Client it is very slow, it is not A van Dellen good for doctors, it is (The Expert Witness, 2017) Difficulties in consent: applying the Mental not particularly good Capacity Act A van Dellen for those claiming (British Medical Journal, 2013). compensation. We need The Aftershock A van Dellen a major overhaul of the (New Law Journal, 2011) whole system

currently under particular scrutiny, literature doesn’t cut the mustard,” their opinions to a panel of appropriately as a result of the recent Supreme Court Van Dellen explains. “If you follow qualified people, overseen by a judge, ruling in the Montgomery case. This the Montgomery case to its logical who will then make their judgement. concerned a woman who had to decide conclusion, I think that makes it very This would mean smaller legal teams, whether to have a caesarean section difficult for doctors to take consent fewer witness to be questioned, and much or a natural birth. Her baby was bigger from that patient at all. Medical shorter wait times.” than average, and one of the risks history, present health, environmental This hypothetical system is one associated with delivering a big baby background, ethnicity—all of these that would be even more dependent is shoulder dystocia, which can lead to combine to make you an individual. on the number and quality of expert the child being starved of oxygen. This means giving generalised medical witnesses, which may in some areas be “The mother was quoted the generally advice based on the literature becomes problematic. However, our barrister agreed risk of shoulder dystocia,” extraordinarily difficult. The answer believes there isn’t really any long-term says Van Dellen. “But there were two then becomes: you have to personalise alternative: at the centre of this whole problems: the first is that when you are every consent process. Montgomery edifice is a person who has suffered trying to guess a baby’s weight from a means that the consent process has harm; the system they turn to needs scan, you end up with a range of weights, become very complex.” to be fit for the job. and this particular baby turned out to “It is an enormous privilege and be right at the top end of the scale. And This is just one instance of the ever- responsibility that people place their the second problem is, if the mother is changing and increasingly complex trust in you to be their voice. When I shorter, the risk of shoulder dystocia medical-legal interface. It is leading represent families at inquests, we see the goes up. Without going into details, the Van Dellen to believe that real change enormous strains this causes. We have woman brought a case that claimed she will be needed for the layman to had clients’ relationships collapse as a wasn’t given adequate clinical advice continue to get justice, and for those result of losing a child. Likewise, when before making her decision.” entrusted with their care to be held representing a professional client before The Supreme Court’s ruling to account if things go wrong. “The their regulator, their livelihood may be stressed the notion that when a current system is incredibly expensive, it at stake. These are very high-stakes,” he clinician is requesting a patient’s is very slow, it is not good for doctors, it is says. “Both medicine and the law need to consent for a medical procedure, the not particularly good for those claiming do their best to ensure that if a person has risks and benefits laid out need to compensation. We need a major suffered because of mistakes in their care, be specific to that individual. This is overhaul of the whole system, because they are not fighting against an opaque creating a real discussion about the I believe it is bursting at the seams,” and confusing system as the result of whole notion of ‘informed consent’. Van Dellen says with some passion. those mistakes. The expert witness is an “If you take a patient for a procedure His solution would require a complete important part of this task—and one like a heart operation and you say to change to the system. “It sounds that I believe can play an increasing role them that the risk is 3%, there may be radical, but I think there’s increasing in ensuring access to justice for anyone various reasons why their risk factor evidence that some kind of alternative who has suffered at the hands of those may actually be a bit higher than that. judicial process is needed. This might entrusted with their care.” Perhaps they had some liver disease involve an early neutral evaluation of or maybe they have had a stroke in the case, leading to some form of judicial Goldsmith Chambers the past. You have to feed in all of mediation, like there is in employment Goldsmith Building those variables when assessing risk. law,” he tells me. “I can see a system where London EC4Y 7BL goldsmithchambers.com Suddenly, saying that the operation each side agrees on a single expert for each carries a 3% risk based on the medical area of the case, and these experts put

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prognosis_issue05_PP26-55 PROOF01.indd 32 10/01/2019 09:34 ORAL TESTIMONY Expertise in oral medicine, which bridges the divide between dentistry and medicine, offers the possibility of early diagnosis of numerous conditions. Specialists from D-Clinic discuss the fundamentals of the field and why they’re so keen to share their knowledge with dentists

Words: Viel Richardson

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prognosis_issue05_PP26-55 PROOF01.indd 33 10/01/2019 09:34 “Oral medicine is a fascinating specialty, chronic inflammatory disease of the which sits at the interface between intestine, can cause mouth ulceration Some of the changes dentistry and medicine,” says Professor and persistent, disfiguring lip swelling. that occur in the mouth Stefano Fedele, a professor of oral In the early stages of the disease, it medicine at the UCL Eastman Dental is not unusual to see young patients may not be solely related Institute who practises at D-Clinic in who are seeking attention for their lip to the teeth. Instead, the Harley Street Medical Area. swelling. Only through an investigation Dentistry and medicine have for of the symptoms do they become aware they may signal that a centuries been treated as almost of having Crohn’s disease in their more systemic issue is entirely separate fields. They are intestine.” taught on different courses, overseen For Prof Fedele’s colleague, developing elsewhere in by different professional bodies, Dr Dejan Dragisic, founder of D-Clinic, the body located in different buildings. But the practice of oral medicine and the the human body, in all its limitless delivery of oral health services were complexity, doesn’t recognise such always going to be fundamental parts neat distinctions, so a significant of the clinic’s offering, together with degree of overlap is inevitable. It is all the usual services you would oral medicine, one of the 13 specialties expect of an oral surgery practice: of dentistry recognised by the complex tooth extractions, implants, General Dental Council, that provides soft tissue grafting, restorative an important—and occasionally treatments, bone augmentation, life-saving—bridge between the two. bridges. “During my training in oral Some of the changes that occur in surgery in Germany, the fields of oral the mouth may not be solely related health and oral medicine were much to the teeth. Instead, they may more integrated into general dentistry, signal that a more systemic issue is not taught separately as they are here,” developing elsewhere in the body. he tells me. “When I thought about By understanding what these signs setting up my own practice, it was clear are, the oral medicine specialist can to me that oral medicine was going to often spot something that might be central to the surgical and dental otherwise not have been noticed services we offered.” by a doctor until it was much more symptomatic, meaning that an Despite the popular perception earlier diagnosis can be made and that a fear of dentists keeps people treatment can begin. away, millions of us still manage to “Many general medical conditions see one every year, and this regular can manifest themselves through contact means that dentists with an signs in the mouth, including in the understanding of oral medicine have oral mucosa—the lining of the a real opportunity to spot problems mouth—the salivary glands, the jaw early and make a substantial bones, and the associated muscle difference to the disease path. and nerves,” Prof Fedele explains. “Diseases such as systemic lupus “For example, Crohn’s disease, a erythematous, scleroderma,

34—Prognosis rise”, with current figures indicating cases. As a result, Dr Dragisic and that new cases of mouth cancer in the his team have developed very close UK have reached 8,302 annually—an relationships with a wide network of increase of 49% in the last decade dental practitioners, and through this and 135% compared with 20 years network, they have started to teach the ago. “Diagnosis and management of fundamentals of oral health and oral potentially malignant disorders—oral medicine to interested clinicians. precancer—is always challenging,” “This educational aspect is a key part Prof Fedele continues. “Only a of what we do. We organise lectures minority of mouth cancers are currently and seminars and run workshops,” diagnosed at an early stage when they Dr Dragisic explains. “The idea is are highly treatable. The vast majority for our colleagues in general practice of patients are referred to cancer clinics to become more aware of changes in when their disease is already advanced the mouth that may be signposts for and more difficult to treat.” developing or underlying problems.” “What I find gratifying is that I see Oral medicine specialists can play very little resistance from the dentists an important part in aiding early we work with, in a field that can be diagnosis. Among the potential quite conservative,” Dr Dragisic says early warning signs of oral cancer are with a smile. “They see us as having white patches, which typically appear an additional skillset they can offer on the inner parts of the cheeks or on to their patients and they are also tuberculosis, sarcoidosis, hepatitis C, the tongue. These white patches may very interested in expanding their HIV—all of these are areas where turn out to be of little note, or they knowledge and learning as much as oral medicine can play a crucial role may be an indication of an they can. Quite often dentists who in diagnosis and management,” autoimmune condition called lichen have referred a patient will come in Prof Fedele says. So too is Sjögren’s planus, which affects the skin, hair, to watch or assist on the patient’s syndrome, the second most common nails and mucus membranes—but surgical procedure to get a greater form of rheumatic disease. This can they can also represent precancerous understanding of the condition or the cause chronic dry-mouth, due to a tissue. Potentially malignant procedure.” lack of salivation, causing associated mucosal lesions are not necessarily Dr Dragisic explains that their discomfort such as difficulty with white—sometimes they are red close relationship with patients puts chewing and swallowing and an velvety patches surrounded by darker the general dental practitioner in a increased risk of oral and dental margins, making them very obvious, great position to make a real infection. If more dentists were trained some can be mildly pale, others can be difference in the world of oral to recognise these signs, the potential elevated from the surrounding tissue. medicine, but that not many British for alleviating the discomfort of All should be thoroughly investigated, dentists have had much exposure people suffering in ignorance could be often with a surgical biopsy. to the field. For him, this is a shame, significant. Most patients are typically especially as one of the real pioneers Another important area of oral managed with long-term clinical in the field was a British oral surgeon, medicine practice is the diagnosis surveillance. However, should an Professor Crispian Scully, former and management of chronic initial biopsy show the presence emeritus professor of oral medicine neuropathic pain disorders such of certain cellular changes, some at University College London. as burning mouth syndrome. of which carry a very high risk of “What we are trying to do here is These are conditions for which the progression to cancer, those patients create a hub where people who wish to multi-disciplinary approach of oral will require the patches to be surgically pursue their interest in oral medicine health comes to the fore. “These removed. Such interventions have can come,” says Dr Dragisic. “Dentistry patients typically report persistent saved lives. The key to saving even is not a single field anymore but includes painful symptoms to the lining of the more lives is increasing the skill levels many specialties. It is the combination mouth, jawbone, teeth or face, but of those dental professionals best of these that defines the practice of oral there is an absence of any obvious placed to spot potential problems medicine and oral health. We want to abnormality on clinical inspection early. “There is definitely work to be build a community where the various or scans,” Prof Fedele explains. “The done,” Prof Fedele says. “I would like practitioners can meet, work and treatment of this group of disorders is to see more progress in the early share ideas. Some of the early pioneers extremely collaborative, requiring the diagnosis of oral cancer, which has the of oral health were British, so being a coordinated efforts of oral medicine potential to save lives, reduce morbidity part of expanding that knowledge base specialists, clinical psychologists and save money for the NHS.” through cooperation between dentists and physiotherapy specialists with D-Clinic is seeking to play its part here is hugely rewarding, as well as experience in managing chronic pain.” in propagating an understanding being very exciting work.” Among the most serious of of oral medicine. It functions as a conditions upon which oral medicine referring practice, which means that D-Clinic has the potential to make a significant as well as treating its own patients, 55 Wimpole Street impact is oral cancer. The incidence it takes referrals from general dental London W1G 8YL d-clinic.uk of oral cancer has been undergoing practitioners whose patients have what Prof Fedele calls a “worrying presented with complex or difficult

Prognosis—35 The world’s top athletes exist on an entirely different plane to the rest of us when it comes to physical gifts and psychological strength, but their route back from injury is fundamentally the same as that of the average Sunday league clogger. Some of the country’s top sports medicine experts explain to Prognosis how the treatment of the general public is heavily influenced by—but no less important than— that of the sporting elite

Words: Clare Finney REUTERS / ELOY ALONSO ALONSO ELOY / REUTERS INJURY 36—Prognosis TIME prognosis_issue05_PP26-55 PROOF01.indd 36 10/01/2019 09:34 REUTERS / ELOY ALONSO ALONSO ELOY / REUTERS w INJURY TIME Prognosis—37

prognosis_issue05_PP26-55 PROOF01.indd 37 10/01/2019 09:34 This Girl Can A National Lottery funded initiative designed by Sport England to promote sport among women and girls of all ability levels. Bone mass A measure of bone density, reflecting the strength of bones as represented by their calcium content. Quads Short for quadriceps femoris, a large muscle group that includes the four prevailing muscles on the front of the thigh World Economic Forum Founded in 1971 as a not-for-profit organisation, the WEF gained formal status in January 2015. Its stated mission is to “improve the state of the world by engaging business, political, academic, and other leaders of society to shape global, regional, and industry agendas”.

In 2016 the managing director of British society,” Davison continues. rebuilding muscles and bones in athletes the Isokinetic Medical Group, Mike “The legacy of the 2012 Olympics and after injury.” Indeed, this continuum Davison, walked into the waiting room campaigns like This Girl Can, which is one of the main reasons he and his to greet a new patient: a 71-year-old is run by a friend of mine, has been to colleagues try to see both elite athletes woman called Judy. In tow was an increase participation rates—and and ‘normal’ people during the course elderly man, fast asleep—her husband, that is something that sports medicine of any day. “If you treat elite athletes and it turned out. “When I was 21, I thought and professional sports people actively become familiar with the approaches marrying a 42-year-old with a sports need to support and encourage.” and techniques associated with their car was cool,” she announced, with That, he says, is why making cutting treatment, then you will tend to use a smile. edge sports medicine available to those approaches and techniques Judy had a major concern. “She keen amateurs, and even occasional for everyone.” came into my room and said, ‘Mike, dabblers, means as much to him as Like Prof Haddad’s surgery, if you don’t get me back to playing treating the superstars. Isokinetic’s rehabilitation sessions mixed doubles tennis, my life is over. In fact, drawing any distinctions at mix athletes of all levels and abilities I’ll be stuck at home all day looking all between Linda, the septuagenarian together. “The professional may come after him,’ she gestured to the waiting mixed doubles tennis player, and for four hours a day, five days a week, room,” Davison recalls. In their Roger Federer, while not unreasonable, while someone else might come for two day-to-day work at the group’s sports would do little to facilitate what the hours for five days and another person medicine and injury rehab clinic on orthopaedic medical director of HCA just once a week—but the content of Harley Street, his team see “every UK, Professor Fares Haddad, calls the these sessions is essentially the same type of sporting and active person, “continuum from the elite athlete, to the for everyone,” Davison explains. from the general public to Royal Ballet aspiring amateur, to the person in the Amateurs, he says, are inspired by dancers, West Indies cricketers and street”. In fact, this continuum works the dedication and professionalism Premier League footballers”—but Judy both ways, explains Prof Haddad. of the elite athletes, while they in sticks out as an example of a non- “There’s a lot we can learn from treating turn enjoy the company. “You can be professional for whom recovery—full elite athletes that we can apply to the quite isolated, socially, by the nature recovery—mattered just as much as it normal patient, but there are also some of an elite sport.” From a medical would to any finely-tuned athlete. things we can learn the other way.” perspective, “elite athletes are no Being able to exercise is vitally The latter, he says, include strategies different to you or me. They are human important. “Inactivity is a killer. used to help patients recover muscle beings. The only differences are the It is the equivalent of plastic in the and bone mass after intensive care. demands of their sport and their oceans when it comes to the health of “We can apply those theories to dedication to it.”

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prognosis_issue05_PP26-55 PROOF01.indd 38 10/01/2019 09:34 In their day-to-day work, the Isokinetic team see every type of sporting and active person, from the general public to Royal Ballet dancers, West Indies cricketers and Premier League footballers

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prognosis_issue05_PP26-55 PROOF01.indd 40 10/01/2019 09:34 THE PROFESSIONAL MAY COME FOR FOUR HOURS A DAY, FIVE DAYS A WEEK, WHILE SOMEONE ELSE MIGHT COME FOR TWO HOURS FOR FIVE DAYS AND ANOTHER PERSON JUST ONCE A WEEK—BUT THE CONTENT OF THESE SESSIONS IS ESSENTIALLY THE SAME FOR EVERYONE

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prognosis_issue05_PP26-55 PROOF01.indd 41 10/01/2019 09:34 Physios are very good at taking on new information, but not as good at getting rid of old information they think has worked in the past, like applying ice for reduction of inflamation

“They are stronger and faster to make its way into the mainstream. taking on new information, but not as than your average person and they “You’ll probably have seen footballers good at getting rid of old information are psychologically quite different,” or tennis players on the sidelines they think has worked in the past, Prof Haddad adds, “but a lot of their with a compression pack strapped like applying ice for reduction of treatment translates to everyone else.” to their knee,” Davison says. “Now inflamation, or taking anti- So too does the financial investment we’re seeing it used post-operatively in inflammatories within 48 hours for that goes into keeping them at their hospitals around the country, as well initial healing.” Some responses are peak—just as much of the technology as at amateur sports level.” It’s a big so ingrained, they kick in despite the we now use in everyday life originated improvement on the age-old frozen lack of robust evidence to suggest from within the military or NASA, so peas approach to Sunday league they have any positive impact at the abundance of money and expertise sprains and swellings. all. “There is extremely little, if any, in elite sport leads to innovations that evidence to suggest ice does anything will filter out into the wider world. “Consumer see what’s happening in beneficial for swelling. The elite teams “The demands of these environments elite sport, and they want access,” use it less and less.” and the economy of these environments Davison explains: a theory as true for For Delahunt, the greatest change at means new technology and techniques the prevention of sports injuries as it an amateur level has been in attitudes are road-tested before becoming is for treatment. Gary Delahunt, clinic toward managing load. ‘Load’, to the commercialised,” says Davison. manager at the ESPH physiotherapy uninitiated, is the amount of perceived What’s more, he argues, “the science centre, tells me that one of the biggest exertion and the period of time for and research in sports medicine is more positive changes he has seen is in the which that exertion is taking place— robust than it has ever been”. pre-game stretching routines of team and it is very easy to monitor. “Even if In the “pressure cooker sports, “at the level of elite and general you have a predisposition to a certain environment” of elite sport, devices players—even of underage groups”. injury—and most of us have certain like the Butterfly iQ can be developed: Gone are the days of static warm ups; of predispositions, be that a stiff shoulder a portable ultrasound that connects players stood in a line, stretching their or a weak muscle—it doesn’t mean to a phone and uses machine learning quads on a frosted pitch. The extra an injury will take place, provided and AI to interpret the results. To academic and financial resources you don’t overload that structure. refine it, they needed to start with a in sports science and medicine and In other words, provided you don’t group that has an extraordinary level the level of access the internet has increase your acute load compared to of muscle and muscular demands— afforded to “views that are cutting edge your chronic load by more than 15% a group like an NBA basketball team. in their field, has enabled physios to per week, your risk of an overloading “If they can get it to work within the conduct metanalysis of studies, and injury will remain low. If you increase demands of an NBA team on location, revise what was previously anecdotal that by more than 15%, your risk then they have passed a significant evidence,” continues Delahunt. of an overloading injury increases test,” Davison tells me. The dream, Today, teams of all standards prepare exponentially”—so there’s no point ultimately, is to provide access to with what’s called a dynamic warm leaping from six-mile runs at 10mph quality muscular screening to anyone up, centred on movement—a very to 12-mile runs at 10mph when you’re who wants it, for little more than £100. successful approach to reducing training for a marathon. Of course, While widespread use of Butterfly injury. FIFA has even created a measuring load has been made much iQ may be some way off, an innovation template that can be downloaded and easier with the advent of Apple Watch called Game Ready, which uses used across the country. and apps like Strava, “but it is quite compression and cold therapy to Of course, some misconceptions easy to get patients to manage their load reduce swelling and pain, is starting remain. “Physios are very good at and its increase without having that

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prognosis_issue05_PP26-55 PROOF01.indd 43 10/01/2019 09:34 quicker, whereas your average person While master athletes might be better off with slower, physio- maintain a health status based treatment.” Something that is clearly recognised similar to their 35-year- in sporting circles, but which has only old selves until their recently started to trickle down, is the idea that pain is not always indicative late 70s, the health of of injury, a learned pain if you will— an average member of what Delahunt describes as “the pain the brain arbitrarily decides you feel, the population declines based on previous experience of that steadily over the years particular activity, your environmental and tissue stresses”. “If I tell you you’re until they die finally healed after hurting your back six months ago and you feel pain when you touch your toes, you might think there’s still something wrong, even though there’s not,” Delahunt continues. An elite athlete, on the other hand, “will have a therapy team and surgical team to guide them,” says Prof Haddad. They’ll know when to stop and rest, and sort of kit,” he says. You just need to be late 70s, after which they can decline they’ll know when to push on through mindful of the intensity and duration quite rapidly, the health of an average the pain. “This is where early diagnosis of your exercise. member of the population declines and streamlined pathways of care are steadily over the years until they die. so important. If you have runner’s knee Delahunt, Davison and Prof Haddad Their life spans are roughly the same, and you rest and take Ibuprofen, the all agree about the vital role that but the amount of time a master pain will come back again the moment sports medicine can play in enabling athlete, or former master athlete, has you start running again. If you see a us all to enjoy physical activity. as a healthy individual is significantly specialist and get a diagnosis, we can These are sports medics at the top greater.” That’s Davison’s aspiration resolve the problem”—be it through of their game, treating sportsmen for us all: to retain physical and mental strengthening exercises or surgery to and women at the top of their game, health for as long as possible. remove damaged cartilage. but they feel a strong sense of social Like Davison, Prof Haddad sees There are some signs that messages responsibility. “If you look at the impact it as his job to “fit treatment to the about the importance of exercise are of exercise compared to drugs and aspiration of the individual”, as far getting through. “There are more people other interventions on public health, as is medically possible. “There are engaging in sport. There are more people getting everyone moving could improve 30-year-olds happy to give up the rugby engaging at a higher level of activity,” the health of the nation more than they played as teenagers—and there reports Prof Haddad. The number of anything else being trialled,” explains are 60 and 70-year-olds desperate to over-50s pursuing sports is the highest Prof Haddad. “Part of the plan when get back to tennis, or runners who are it has even been, as is the number of we set up the Institute of Sport, Exercise deeply passionate about continuing to women. “In 2014, when we opened this and Health”—of which he is clinical run.” Patients must learn to ask the right building, we built our changing rooms director—“was to translate elite care to questions and demand the most up-to- on the basis of two-thirds men, one-third the general population and introduce date treatments, and doctors need to women, which was how it was when we the idea of exercise as medicine. Our provide more individualised support. started. Now it’s 57% men, and 43% aims here at HCA, meanwhile, are “A person here can come and be treated women,” grins Davison. In order for threefold: firstly, delivering the best care like a professional athlete, if they want,” this wave to continue unbroken, we and preparation to elite athletes so they Davison tells me. “There is nothing in the need sports medics like Prof Haddad, can win medals and championships; market which elite sportspeople use that Davison and Delahunt—and we need secondly, extending that knowledge and isn’t available to the general population.” our elite athletes to continue to be treatment to anyone who is interested On the flipside, cautions Prof trailblazers for new techniques and in getting back into an activity; and Haddad, “you do have to be careful treatments, as well as sporting records. thirdly, getting everyone active.” not to assume everyone will respond It’s a philosophy that resonates like an athlete to treatment”—either with Davison, who wants us all to physically or psychologically. “The Isokinetic 11 Harley Street, W1G 9QJ “age like an athlete. I have a favourite key differences are their demands, 030 0061 6161 chart, of health index and age span, which for athletes are often more short isokinetic.com commissioned by The World Economic term, and their unwillingness to accept The Princess Grace Hospital Forum. It shows we all start at roughly limitations.” Elite athletes are not 142-152 Nottingham Place, W1U 5NY 020 7486 1234 the same level—though it depends a bit thinking about the lifetime of their hcahealthcare.co.uk on environmental and socio-economic joint, so much as the next World Cup or ESPH factors—but while master athletes Olympics. “These time pressures might 42 Harley Street, W1G 9PR maintain a health status similar to justify an intervention like soft-tissue 020 7907 1900 their 35-year-old selves until their repair that will get them back to activity esph.co.uk

44—Prognosis

prognosis_issue05_PP26-55 PROOF01.indd 44 10/01/2019 11:09 Untitled-1 1 17/12/2018 11:19:03 prognosis_issue05_PP26-55Untitled-1 1 PROOF01.indd 45 17/12/201810/01/2019 11:19:03 09:34 Deep brain stimulation What is deep brain stimulation (DBS)? Q+A Mr Erlick Pereira: It involves using an artificially generated Consultant neurosurgeon Mr Erlick electrical signal to modify abnormal electrical activity in the brain. With DBS, we implant electrodes deep inside the brain Pereira and consultant neurologist and use a pulse generator to deliver electrical signals designed Dr Dominic Paviour on a remarkable to control abnormal brain rhythms. The pulse generator is implanted in the patient’s chest, with leads running up treatment that can change the lives of through the neck to the head. These are connected to fine patients with Parkinson’s disease and wires that are fed into the brain, at the end of which sit the other movement disorders electrodes we use to deliver the stimulation signals. What is the mechanism by which the treatment works? Interview: Viel Richardson EP: When you want to move a part of the body, there is Portrait: Christopher L Proctor electrical circuitry deep in the brain that deals with the process of turning the thought about moving into the physical movement. In some conditions, this circuitry can transmit faulty signals or be constantly transmitting, giving the patient constant and potentially severe tremors. If you put an electrode in the right part of the brain, you can pass a high frequency electrical current in a waveform that effectively jams or modifies these abnormal signals.

What conditions has it been developed to treat? Dr Dominic Paviour: The main one is Parkinson’s disease, which causes problems of tremor, rigidity and difficulty or slowness of movement. This is usually managed by medicines, but some patients’ symptoms can be improved significantly with DBS. Other movement disorders include tremor and dystonia, where sustained or repetitive muscle spasms can result in twisting or an abnormal fixed posture in the neck. Carefully selected patients with chronic pain syndromes may also respond to DBS.

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prognosis_issue05_PP26-55 PROOF01.indd 46 10/01/2019 10:46 Mr Erlick Pereira and Dr Dominic Paviour

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prognosis_issue05_PP26-55 PROOF01.indd 47 10/01/2019 09:34 What are the efficacy levels? generator and programme in what we feel are the optimal EP: We see some excellent results. For Parkinson’s, you settings for the patient. Then we ask them questions about will usually be able to halve the amount of medication the how they are feeling, their movements, their emotional patient is taking while cutting the severity and durations state. We make adjustments depending on their responses. of their symptoms by 50%. In dystonia, we see significant Conventionally, in the first year the neurologist would improvements in controlling spasms and relaxing the see the patient three or four times to check things over overactive muscles. It is also very effective in conditions and make any necessary adjustments. With a progressive involving tremors. disease like Parkinson’s, as the years pass you would need to adjust the settings to account for the continuing Does it work for everyone? deterioration. DP: Not everybody with these conditions is a good candidate for DBS and not everyone with these conditions Is DBS a difficult surgical process? would have symptoms severe enough to make the surgery EP: It does require some specialist equipment and it is worthwhile. For Parkinson’s disease, there are some very complex. The challenge is placing the electrodes to within effective tablet-based treatments for controlling symptoms. a millimetre of the target. The brain has the consistency of For dystonia, initial treatment would be a combination a stiff blancmange and the wire connected to the electrode of tablets and an injection of botulinum toxin into the will bend under its own weight, so you need to get a pliable overactive muscles. In the case of tremor syndromes, wire through soft tissue to a specific location with high DBS is typically much more effective than medical levels of precision. This represents both an engineering therapy. and a surgical challenge. For the procedure, we place the patient’s head into a frame that can hold it securely and How do you assess who is suitable? position it extremely precisely. I then make a hole a couple DP: Assessing which patients are suitable for DBS is a team- of millimetres wide and insert a less pliable probe I can based multidisciplinary procedure. The team typically control, which I guide to the target area. This probe creates includes a neurologist, a neurosurgeon, a psychologist and a track in the brain through which I then feed the DBS wire a clinical nurse specialist. The patient needs to have their with the electrode on the end. The procedure is called movements assessed. They need to have a comprehensive stereotactic neurosurgery. medical assessment of their symptoms as well as a test of their response to medication. If they have a good response Does the patient have a role to play in the procedure? to a particular drug, that may guide us as to whether they EP: Historically this operation was done with the patient will respond well to the surgery. They also have a brain scan awake, so we could test if the movement problem went away to ensure the brain fibres we are targeting are structurally when we stimulated the electrode. Because of the quality intact and accessible to the surgeon. of modern CT and MRI scans, we can now locate the target It is also extremely important to establish what the fibres very precisely and place the electrode accordingly. patient’s expectations are from the procedure. What This means we no longer need to test the electrode as part of aspects of their symptoms do they wish to see improved? the procedure, so the patient can have the whole operation If there is a disconnect between what the patient hopes under a general anaesthetic, which is much more pleasant for and what DBS can provide, it will not be a successful for them. procedure. Are there any side effects? What happens after the surgery? DP: There can be side effects on speech and some unwanted DP: Between two and four weeks after the procedure, after movement. There can also be effects on the patient’s mood ensuring the healing has gone well, I will switch on the pulse and emotion. We will look for these at the patient’s first

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prognosis_issue05_PP26-55 PROOF01.indd 48 10/01/2019 09:34 The London Clinic 20 Devonshire Place London W1G 6BW 020 7935 4444 thelondonclinic.co.uk

pulse generator programming session, and then continue to a neurologist saying “all movement is thought in action”, monitor them. which points to the close relationship between the two EP: The nice thing about deep brain stimulation today processes. is that it is reversible. Historically you were deliberately DP: When assessing a patient for DBS, we screen for creating a brain lesion in order to jam the signals, and psychiatric or psychological issues such as anxiety, this was irreversible. Today if there are side effects which depression, impulsive and compulsive behaviours, because the patient is struggling with, the electrical settings can we know that DBS can have an impact on this once the be altered, or as a last resort they can be switched off or pulse generator is turned on. A very detailed assessment removed entirely. is undertaken by a psychologist trained to work with DBS therapy, which contributes to the decision as to whether or Will the range of conditions DBS is applied to expand? not a patient is suitable for the procedure. EP: In short, yes. It is a very exciting area for research. We now have the opportunity to study a group of people with Is there much innovation in the field? brain implants, to record those brain signals. This generates EP: There is a lot of innovation, split over several exciting opportunities to increase our understanding of categories. There is innovation in how patients are this very complex area. Combined with the real increase assessed and selected. For example, they might be given in what we can see with the latest scanning technology, we wearable devices to measure their movements, which are learning a great deal. This can be seen in the increased can be fed into a computer and analysed as part of their success of DBS for some psychiatric disorders. My colleague assessments. The brain scans are getting increasingly Professor Tipu Aziz, who is a leader in this field and sophisticated—we are able to use a form of MRI scan called pioneered DBS in the UK in the 1990s, is doing a trial with diffusion tractography to see the brain pathways and see anorexia nervosa, which is showing very promising results. exactly which fibres we want to target. Some surgeons use I can see this technique expanding to treat other physical robots in the procedure. The devices we use are becoming and psychiatric conditions. more sophisticated and miniaturised. My research is DP: There is medical literature covering a number of other involved in developing adaptive stimulators—so-called areas where it could be applied, such as degenerative ‘smart stimulators’. dementias, cognitive impairment in Alzheimer’s disease, One area that is really exciting is what I would call and in the disorders that bridge neurology and psychiatry, neuro-restorative technology. This involves molecular, like Tourette’s syndrome. But there is not literature cellular and biological therapies like stem cells or gene establishing proven efficacy as yet. therapy, where you alter the natural history of the disorder. EP: There is increasing evidence that it can help mitigate So, you could potentially inject something deep into some psychological disorders such as obsessive-compulsive the brain that might stop the dopamine neurones in behaviour and depression. Research in this area is ongoing, Parkinson’s from degenerating, or even actually help them but it is currently available to some patients in certain to regrow. Our present stimulation technique does not situations. impact on the rate of degeneration, it just improves the symptoms. Is the mechanism for treating psychological disorders the same as for physical ones? What drew you to this operation? EP: There is electrical circuitry for thoughts and emotions EP: With a lot of degenerative diseases, there are no as well as physical movement, and that circuitry can treatments available that can profoundly improve also malfunction. The actual way in which it impacts on someone’s life immediately. The notion that with the mental processes is less understood than with the neurosurgery one can improve function and quality of movement conditions, but I recall reading a quote from life straight away is very satisfying, as well as exciting.

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Patient experience How David’s rare heart condition was cured after three complex operations

Interviews: Clare Finney

I think a serious illness does make you When no one came up with a reason cardiac surgery, and he specialises appreciate your own mortality and for my having it—it is most often seen in re-dos. Having a second heart understand what is important in life. in people who have had heart surgery operation in less than a year is far from I took a philosophical approach to my or radiation therapy—they had to straightforward: my blood pressure illness and treatment because there assume it was viral. I had my first was low, my kidney function was is always someone worse off than you pericardiectomy operation to remove abnormal, and I was more susceptible in this world. Royal Brompton and the pericardium at the end of that year. to developing infections than I had Harefield Hospitals specialise in the Unfortunately, it didn’t seem to been before the first pericardiectomy. treatment of broad spectrum of heart do the trick. Over the next couple of Dr Vazir worked closely with me to and lung conditions, so they see a lot months after the operation, the low prepare me for the operation, and to of children as well as adults—and I blood pressure and fluid retention help me recover afterward. remember thinking, just imagine associated with CP started to return, being a child with a serious heart or and I realised I needed a second One of the advantages of Royal lung disease, or the parent of that opinion. I was introduced to my cardio Brompton and Harefield Hospitals child. How sad that must be, with all physician Dr Ali Vazir in spring 2017. is their combined team approach, their lives ahead of them. I felt lucky in Someone I know had recommended which enables them to tackle each that respect. I’m also a glass-half-full his colleague Mr Rosendahl, a surgeon problem as it comes to them. Surgeons, person: there were low moments, make who Dr Vazir worked with at Royal pulmonologists, gastroenterologists, no mistake about that, but I always Brompton. dietitians and so on all sit down thought I would recover, somehow. I liked Ali immediately. We had and come to a decision about an In August 2016, I was diagnosed good chemistry, I liked his demeanour, individual patient in a team-based with constrictive pericarditis, a and he spoke in terms I could fashion: something that doesn’t often condition in which the sac that understand. After taking a look happen in private hospitals, because surrounds the heart sticks to the and considering my symptoms— the physicians come from various outside wall of the heart muscle. low blood pressure, fluid retention different institutions. I’d been feeling quite breathless for in the legs and lungs—they After the second pericardiectomy, a while. I wasn’t too concerned at concluded the pericardium had been the doctors at Royal Brompton found first—I thought it was old age finally incompletely removed and offered fluid on my right lung, which would catching up with me—but after a series me a second pericardiectomy, or what not respond to tablets and was too of tests and investigations the doctors Mr Rosendahl calls a ‘re-do’. He has thick to be easily drained. I had to have at my first hospital finally came to a significant technical and clinical another operation to scoop out the diagnosis. It’s quite rare, apparently. experience in advanced complex infected material, as it was impeding w

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prognosis_issue05_PP26-55 PROOF01.indd 51 10/01/2019 09:34 my ability to breathe properly. Royal Brompton’s combined expertise in the WHAT IS heart and lungs meant they were able to take a joined-up approach to looking CONSTRICTIVE after me, and I could stay in the same place. PERICARDITIS? One of the hardest things about being in hospital for such a long time, Dr Ali Vazir, consultant unable to eat or exercise properly, in cardiology and critical was how much weight I lost. I don’t think anyone can prepare you for care at Royal Brompton & that. I have always been a reasonably Harefield Hospitals fit man: I ran marathons when I was younger—I was still regularly running 5km before going into hospital—and I love fishing and skiing. After three major operations, my weight had dropped to 50kg, and the muscles around my chest had wasted to the point where I was too weak to expand my chest and fill my lungs properly. This meant I had an abnormally high breathing rate—about 26 breaths Constrictive pericarditis is a condition kidney function was abnormal and per minute instead of the usual whereby the sac that surrounds the his bone marrow was more susceptible 16—as I was breathing more rapidly heart—the pericardium—becomes to infection. Yet the alternative was to compensate for how little air one inflamed, causing it to stick to the living with a limited life expectancy breath could take in. outside wall of the heart muscle. The and significantly reduced quality of pericardium contains lubrication fluid, life. Having accepted the risks involved, Eventually I was advised that it which allows the heart to squeeze he underwent the operation with would be almost impossible to get and relax in a well-oiled manner, and Mr Ulrich Rosendahl, a consultant enough calories to rebuild the lost also acts as a membrane to protect the cardiac surgeon who specialises in muscle by eating naturally, so for six heart from the lungs. With constrictive this sort of complex operation. In the months my diet was supplemented pericarditis, the heart can’t function end, the operation had two steps, with a feeding tube that went straight properly: not enough blood gets in, not because the surgeon discovered an into my stomach. I also had physio enough blood gets pumped out, and a infected breastbone, so had to remove to help build muscle. Again, Royal patient will feel breathless—to the point that before removing the rest of the Brompton’s combined approach, where they struggle with even climbing pericardium. incorporating physiotherapists and a flight of stairs. Their blood pressure gastroenterologists and dietitians, drops significantly, leading to a It’s not uncommon to see patients made a big difference, for all the build-up of fluid in the stomach area, retain fluid around the body after discomfort of having a tube in my legs and lungs. heart operations. Sometimes this stomach for six months. I’m still a lot Often we can’t explain why can be dealt with by tablets, but in this lighter than I was when I went into constrictive pericarditis happens, case the patient did not respond to hospital, but then on the plus side, I as indeed was the case with David. the tablets. The fluid was trapped and can fit into some pretty smart Italian When he came to us, he had already was impacting his ability to breathe. suits. undergone a pericardiectomy—the We put a drain inside the chest, but Taking up marathons again is surgical removal of the pericardium— that still didn’t work because the fluid probably not on the horizon, but I’m but his condition hadn’t improved. was too thick, so we referred him to the keen to get back to jogging, a bit of golf He still had low blood pressure and surgeon, to scoop the infected material and fishing—perhaps even the odd trapped fluid, so he was seeking a and fluid out. blue ski run. I’m easing back into work. second opinion. We had a look, and David may not be quite the same man I was CEO of the company I founded, concluded the pericardium must he was before he was unwell, but he is but I’ve returned in a deputy chairman have been incompletely removed. certainly a lot better than when we first capacity. Two major heart operations A pericardiectomy is a risky procedure, saw him. He is a remarkably determined and a lung operation in a 12-month and sometimes the surgeon doesn’t individual, who has been through a period is a lot for anyone, and there strip away as much of the pericardium lot and is very grateful for what we are pretty major risks associated with as they need to for fear of injuring were able to do for him—and so long that, but I think being interested in the heart muscle. That was what had as he keeps up the motivation, he will every process and what was involved happened, so we offered David a second continue to improve. was really important. I learnt a lot operation to remove the remainder from about medicine and the body in that his heart. RB&HH Specialist Care time and it helped me to rationalise The risks of a second operation are 77 Wimpole Street in my mind just how, thanks to that invariably greater than with the first, London W1G 9RU rbhh-specialistcare.co.uk exceptional medical team, I was going and in this case, the patient was more to get through it. frail, having lost a lot of weight. His

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prognosis_issue05_PP26-55 PROOF01.indd 52 10/01/2019 09:34 Constrictive pericarditis

Inflammation of the pericardium

Heart

Prognosis—53

prognosis_issue05_PP26-55 PROOF01.indd 53 10/01/2019 09:34 HANDSOME DEVIL

Long before Harley Street had become synonymous with medicine, a self- styled doctor used his good looks and charm to gull patients into believing in a wildly dangerous “miracle cure”. His ability to do so says much about the importance of regulated healthcare

Words: Sasha Garwood

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WELLCOME COLLECTION w

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prognosis_issue05_PP26-55 PROOF01.indd 55 10/01/2019 09:34 In the summer of 1830, 24-year-old rubbing an equally mysterious lotion Catherine Cashin came to London from into her chest. The case of John St John her home in Dublin, together with her Harmless enough, one might Long echoes through mother and her 16-year-old sister, Ellen. think, but the rubbing was deemed Ellen was suffering from tuberculosis, insufficient unless it produced a history, testifying to so while in the city Mrs Cashin sought running, weeping sore, which Long the enormous power of treatment from fashionable Harley claimed would enable the disease to Street physician John St John Long. leave the body. In Catherine’s case, this people’s faith in doctors The Harley Street of the 1830s wound became so obviously infected and, more prosaically, was very different from that of today. that Mrs Roddis, the Cashins’ landlady, Doctors only began arriving in any wrote to Long and “humanely urged the importance of great numbers in the second half of the that danger might arise from symptoms medicine’s professional century, and the street’s townhouses— which appeared so violent”. Long, modest in style and scale compared however, “laughed at her apprehension, bodies with those on many of the nearby declared that the wound was going on streets and squares—were as likely remarkably well, and that he would give to house artists as they were medical a hundred guineas if he could produce men, JMW Turner being one notable similar favourable signs in some other of early-19th century resident. In fact, his patients”. Even as Catherine began the entire field of medicine was, like to vomit constantly, Long declared Harley Street, standing on the cusp that the sore was “in a beautiful state” of a significant change, with formal and that Catherine’s “recovery” was structures for training and professional proceeding just as it should. Mrs Cashin oversight a few decades away and many begged him for “a composing draught” doctors still clinging onto medieval to help her daughter’s sickness, but assumptions about the human body, Long declared that he hated “physic” despite the era’s rapid advances in and recommended a tumbler of mulled science. Long, whose clients included wine instead, which (like everything politicians, generals and members of else) Catherine failed to retain. the aristocracy, seemed on the surface The Newgate Calendar for 1831 tells to be the very model of the modern us that, as “every day brought new physician. He proved to be nothing symptoms”, a respected doctor, Mr of the sort. (later Sir) Brodie, eventually came to Upon seeing the Cashin sisters see the patient. This eminent surgeon together, Long pronounced that “took every step possible for Miss Cashin, not only did Ellen have terminal but all his efforts were useless”—after tuberculosis, but the apparently what Mrs Roddis later described as “a hale and hearty Catherine carried terrible night”, the landlady found her within her “the seeds of consumption”. charge dying. She tried to administer He insisted that Catherine begin a brandy, but “her jaws were quite set and course of his patented treatment: the [Catherine] was dead”. inhalation of a mystery substance, The Cashin family, understandably accompanied by his female assistants appalled at the callous destruction

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prognosis_issue05_PP26-55 PROOF01.indd 56 10/01/2019 09:34 A contemporary engraving of John St John Long, in which the devil is saying to the doctor: “Rub away, my fine fellow, ‘tis a long time since I found a more promising pupil” WELLCOME COLLECTION

of their healthy daughter, asked the treatment, and of the virtues of his “When I went into the room there surgeon, founding editor of The Lancet lotion for curing various complaints”. appeared to me to be two cabinet pianos. and future MP Thomas Wakley to He is also known to have treated Each lady took a pipe about a yard and represent them at the inquest. Perhaps Sir Francis Burdett, Lord Anglesey, a half long, put it into an orifice in the unsurprisingly, this concluded and the Marchioness of Ormond. machine and put the other end into her that Long had been responsible for This was a far cry from his rural Irish mouth. I should think there were eight Catherine’s death, and brought a childhood. Born the son of a basket- or 10 ladies in the room.” While the criminal charge of manslaughter weaver in 1798 in Newcastle, in the west ladies inhaled, their backs or chests against him. Several eminent medical of County Limerick, the young John were scrubbed with sponges soaked in practitioners testified at the trial. These St John Long showed considerable Long’s lotion to produce the sores that included: “Dr Alexander Thompson, artistic talent in childhood—so much Long claimed allowed disease to leave who had examined the body of the so that friends, neighbours and local the body. The idea was that after five to deceased, Mr Thomas King, surgeon, gentry clubbed together to pay for him 10 days of running with pus, the wound Mr Wildgoose, surgeon, Dr John Hogg, to go to Dublin Academy to study fine would be covered with cabbage leaves Dr Thomas Goodeve, Dr James Johnson, art. Upon completing his studies, Long and allowed to heal, and the patient Mr John Maclean and Mr Thomas supported himself by teaching, before would be pronounced cured. Evans.” All had been present at the moving to London in 1822. Here, he Catherine Cashin wasn’t the only post-mortem examination, and all studied with John Martin, painter of apparently healthy patient within concurred that Catherine had been several Last Judgement canvases. Long whom Long suggested he could see “a perfectly healthful subject, beautiful produced his own selection of mostly hidden disease. Moving in increasingly in form, and free from all disease, save religious artworks, including a version high-class circles, he claimed to be that occasioned by the wound in the of The Temptation in the Wilderness able to diagnose “seeds of illness” back”. They declared that “few people that remains in the collection of Tate simply by looking at someone, and would have recovered after such a local Britain, and exhibited at the Society frequently did so at parties, obviously injury, which appeared to them perfectly of British Artists and the British proceeding to invite the concerned unjustifiable”. Long was tried and Institution. To make ends meet, he also subject to his consulting rooms for convicted—much to the foot-stamping assisted other artists and collectors, treatment. By 1830, Long’s extensive joy of many doctors crowded into the like Sir Thomas Lawrence and William patient list included those suffering courtroom—but sentenced only to pay Young Ottley, but struggled to keep from disorders such as pulmonary a fine of £250. This he promptly did, himself in the style to which he very disease, debility, swelling of the glands, then walked free to treat (and torment) much wished to become accustomed. gout, rheumatism, cancer, smallpox, further patients. Instead, by utilising the traditional measles, and various mental illnesses. artist’s training in anatomy with his Long’s followers believed him a How did a working-class artist undoubted good looks and personal persecuted martyr, attacked by a with no medical training and fewer charm, he decided to strike out in a new medical profession that resented scruples end up a doctor to the great direction. At first, he advertised his his evident genius, and pointed to and the good? By 1830, Long’s social services as a chiropodist, but in 1826 he old medical wisdom about counter- capital was considerable: those found a new niche, announcing that he irritation to justify his treatment. testifying to the coroner and court on had found a cure for consumption. This principle—of creating irritation in his behalf included “the Countess of This was the patented process one location on the body to lessen it in Buckinghamshire, Mr Prendergast, through which Catherine Cashin another—was usually applied through MP, and Mr Higgs, the brewer”, all of met her death. One visitor described poultices or blisters. But as the medics whom “spoke in high terms of Mr Long’s the scene at Long’s treatment rooms: testifying at the Catherine Cashin trial w

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in the illustrious (and probably Long’s famous liniment, contemptuous) company of medical the formula to which was pioneers such as Richard Bright (physician-extraordinary to Queen bought by an Irishman for Victoria, for whom Bright’s disease an immense sum at his was named); Sir Anthony Carlisle; Sir James McGrigor (Wellington’s chief death, was tested many of medical staff); and Dr Thomas years later and found to Wakley, he who had testified against Font 2 Long at the Cashin trial. Long’s famous consist of turpentine, liniment, the formula to which was Wigmore Hall's renowned Learning programme Our 'Sense of Home' festival in February 2019 egg yolk and vinegar bought by an Irishman for an immense gives people of all ages, backgrounds and celebrates Wigmore Hall as a home away from home. sum at his death, was tested many abilities opportunities to take part in creative Highlights include: years later and found to consist of turpentine, egg yolk and vinegar— music making. although in 1831 a Dr James McCabe Tuesday 12 February, 10.00am – 2.30pm speculated, probably accurately, about We work in partnership with a range of health and the regular addition of quicklime to social care organisations to connect people who produce the corrosive effects crucial Big Sing! are experiencing isolation as a result of a medical to Long’s treatment. We invite you to join vocal leader Charles MacDougall The case of John St John Long condition or trauma, including activity with people echoes through medical history, to explore a range of music before having a Big Sing! living with dementia; young people with Autism pointed out, its application in a healthy Benjamin Brodie, but it was too late. testifying to the enormous power together on the Wigmore Hall stage. The event features patient was entirely contraindicated Three painful weeks later, she died. of faith (some would say gullibility) Spectrum Disorders; blind and partially sighted special guest soloists as well as Singing with Friends, even by its most devoted adherents. The coroner’s jury were staunch in in medicine, the powerlessness of children and their families; and children with complex Nevertheless, lengthy defences, their attribution of blame. After only humanity before illness for much of our choir for families living with dementia. including one written by “a graduate half an hour, the foreman declared that our history, and also, more prosaically, emotional, behavioural and mental health problems. of Trinity College, Cambridge, and “having attentively and deliberately the importance of medicine’s member of the Middle Temple”, considered their verdict, [the jury] professional bodies. Regulation of represented Long as a pioneer, unfairly can come to no other verdict than medical practice would begin a couple Thursday 21 February, 11.00am – 12 noon maligned out of jealousy. manslaughter against John St John of decades after Long’s demise, with A death and a guilty verdict Long… on the ground of gross ignorance, the establishment of the British Relaxed Concert: Soraya Mafi did nothing to chasten Long. On and on other considerations”. Long was Medical Association in 1856 and the Wednesday 10th November 1830, two tried for manslaughter a second time General Medical Council in 1858. This relaxed concert is open to everyone and welcomes months after his conviction for the at the Old Bailey on the 19th February Why was Long acquitted after people who could benefi t from a more informal concert death of Catherine Cashin, a highly 1831, with several “elegantly dressed the death of Mrs Lloyd? Partly respectable coroner’s jury led by ladies” accompanying him in the his popularity and social status, environment, including people with Autism Spectrum JH Gell assembled at the Wilton Arms dock. Again, the question of counter- undoubtedly, but also the general Disorders, sensory and communication disorders, and in Knightsbridge. They were there to irritation was brought up. Brodie, helplessness of most doctors before inquire into the death of Mrs Colin on the stand, was asked, “Wasn’t it illness in an age before vaccinations, learning disabilities. There is a relaxed attitude to noise Campbell Lloyd, aged 48, the wife of true in orthodox medicine that the disinfectants, antibiotics or and movement, house lights remain up, and there is a Edward Lloyd, a captain in the Royal same counter-irritant might benefit anaesthetics. The 19th century designated quiet area. Navy. This worthy lady had consulted one patient but harm another?” and would see the medical sciences take Long about a sporadic cough, and she responded with impressive restraint several giant leaps forward, but Long too underwent the patented treatment that although orthodox medical managed to thrive at the tail-end of that had proved fatal to Catherine. practitioners may sometimes misjudge an era in which faith and folklore had Within days, she developed violent the degree of counter-irritation, he yet to be demolished by evidence burning pains in the wound in her couldn’t recall a case where the result and empiricism. His confidence and chest, accompanied by shivering, had been death. The jury, however, seemingly efficacious treatments— thirst and nausea. Her husband perhaps overawed by Long’s client list producing as they did visible, tangible testified that the sore induced by and smart feminine escort, returned effects, however unpleasant—were Long had been “discharging a dirty, a verdict of not guilty. probably reassuring to those who felt white-ish, thick kind of substance”. helpless before encroaching death. Sense of Home is Discolouration and inflammation Perhaps fortunately for the population Perhaps it’s unsurprising that many generously supported by spread down her arms. When at large, Long himself died aged 35, women—and it was mostly women— The Howard de Walden Estate consulted, Long (as with Catherine) only three years after being acquitted to whom he had offered a glimpse of declared Mrs Lloyd’s state to be of the death of Mrs Lloyd. Rumour hope defended him vigorously against absolutely normal, recommending no has it that he died of consumption, charges of quackery. But reading the medications save “brandy and water” refusing his own treatments to the trial transcripts of those who died so and suggesting only that she put her last, although the Lancet suggests horribly at the hands of somebody head under the bedclothes. After two that it was a rather more prosaic riding who professed the knowledge to heal Box Offi ce: 020 7935 2141 days of increasing agony, Long was accident. He is buried in Kensal Green is a resounding argument in favour wigmore-hall.org.uk/learning banned from seeing the patient and cemetery, beneath an elaborate and of medical training, regulation and other doctors were called in, again defensively adulatory monument the miraculous technologies of The Wigmore Hall Trust, 36 Wigmore Street, London W1U 2BP, Director: John Gilhooly OBE, Registered Charity Number 1024838 including eminent figures like Sir funded by his former patients, and modern medicine.

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Font 2 Wigmore Hall's renowned Learning programme Our 'Sense of Home' festival in February 2019 gives people of all ages, backgrounds and celebrates Wigmore Hall as a home away from home. abilities opportunities to take part in creative Highlights include: music making. Tuesday 12 February, 10.00am – 2.30pm We work in partnership with a range of health and social care organisations to connect people who Big Sing! are experiencing isolation as a result of a medical We invite you to join vocal leader Charles MacDougall condition or trauma, including activity with people to explore a range of music before having a Big Sing! living with dementia; young people with Autism together on the Wigmore Hall stage. The event features Spectrum Disorders; blind and partially sighted special guest soloists as well as Singing with Friends, children and their families; and children with complex our choir for families living with dementia. emotional, behavioural and mental health problems.

Thursday 21 February, 11.00am – 12 noon Relaxed Concert: Soraya Mafi This relaxed concert is open to everyone and welcomes people who could benefi t from a more informal concert environment, including people with Autism Spectrum Disorders, sensory and communication disorders, and learning disabilities. There is a relaxed attitude to noise and movement, house lights remain up, and there is a designated quiet area.

Sense of Home is generously supported by The Howard de Walden Estate

Box Offi ce: 020 7935 2141 wigmore-hall.org.uk/learning

The Wigmore Hall Trust, 36 Wigmore Street, London W1U 2BP, Director: John Gilhooly OBE, Registered Charity Number 1024838

prognosis_issue05_PP26-55 PROOF01.indd 59 10/01/2019 09:34 full page.indd 1 08/01/2019 16:50 especially the upstairs area. For coffee and pastries, I particularly enjoy Paul on MY Marylebone High Street. We are regular shoppers at the Marylebone farmers’ MARYLEBONE market on Sundays: it is so Dr David Hopkins, consultant physician wonderful to get farm-fresh and diabetologist at London Medical produce in the middle of a big city. Favourite traders are Riverdale Organics—they have a fantastic range of organic vegetables—and The Potato Man. He’s a real character. Supplementing that is The Ginger Pig butcher and La Fromagerie, with its Marylebone farmers’ market Left: Daunt Books range of breads and cheeses. They are our local bakers: all their breads are baked in London, and they are really very good.

Culture Our favourite local cultural institution is The Wallace Collection. We go there a few times a year, and know it well. It’s a wonderful place to kill half an hour.

Fresh air We have a key for the Live to various other health to sense blood glucose levels gardens in Park Square and I have been living in issues, and having other and can make adjustments Park Crescent. It’s a nice focal Marylebone for 14 years. For specialists in the area means to the insulin administered point for the area, and you me the attraction of the area, patients can always get accordingly. We are moving meet people who live in the and the reason we’ve stayed quick treatment for eye, toward a closed-loop system, vicinity. When my daughter for so long, is how vibrant it kidney, liver or heart related or semi-artificial pancreas, was younger, we spent a lot is, particularly along the high complications. The key aim which means the system has of time in Regent’s Park. It street. It is a great place to at London Medical, and the an intelligence to dictate the is beautiful. These days it is live, and live well. Even in the London Diabetes Centre therapy. That is very exciting. where I run, around the lakes centre of a busy metropolis, within that, is to create My other areas of clinical and the perimeter. Having it retains its local village treatments tailored to each research include wearable that on your doorstep is a feel. We’ve got to know the person’s needs. technology to prevent type big plus for the Marylebone various shop owners over One of the things I like to 2 diabetes and developing area. It is certainly one of my the years. As for my working emphasise is the benefits new treatments to set the favourites of the London life, it is marvellous to be able of insulin pump therapy for condition back a few years. parks. to pop in and check up on my people suffering from type patients at London Medical as 1 diabetes. It is used in the Shop I’m making my way home. NHS, but there are relatively I love the range of interesting Marylebone is a few private clinics which shops in Marylebone. As great place to live, Work can support it. Living with an avid reader, I love Daunt I am a consultant specialising an insulin pump requires Books with its old library feel and live well. Even in diabetes. My NHS work the support of specialised and excellent programme in the centre of a is based at King’s College nurses and dietitians, as of lectures. I frequent those busy metropolis, Hospital, and my private well as a consultant, and regularly. It’s also a lovely it retains its local practice is at London Medical you need a big enough clinic place to simply browse. on Marylebone High Street. to manage that. This is village feel As a place to work, London one of the key advantages Eat Medical is very exciting, of London Medical being We eat out at various because my colleagues multidisciplinary. Insulin places—there is such choice cover such a great range of pump therapy is a key area in Marylebone—but we are specialisms. The nature of of research for me: the latest big fans in particular of The diabetes is that it relates generation of pumps are able Providores and Tapa Room,

60—Prognosis

prognosis_issue05_pp60-64 PROOF01.indd 60 10/01/2019 09:34 The Providores and Tapa Room

Prognosis—61

prognosis_issue05_pp60-64 PROOF01.indd 61 10/01/2019 09:34 WHAT’S ON

MUSIC and pianist Jeremy Denk French Riviera. Grace Kelly HENRY MOORE: performing Bach and plays the love interest. THE HELMET HEADS BBC MONDAY LUNCHTIME Schubert. 6th March—23rd June 2019 CONCERTS FOOD The Wallace Collection Every Monday, 1pm FILM Hertfort House Wigmore Hall NIGHTBIRD Manchester Square 36 Wigmore Street MATINEE CLASSICS 22nd—26th January London W1U 3BN London W1U 2BP Every Wednesday, 12pm Carousel wigmore-hall.org.uk & 3:30pm 71 Blandford Street Henry Moore was Regent Street Cinema London W1U 8AB Every Monday, Marylebone’s 309 Regent Street carousel-london.com one of the most famed chamber music London W1B 2UW celebrated sculptors venue Wigmore Hall hosts regentstreetcinema.com Since opening Nightbird of the 20th century. hour-long lunchtime concerts in San Francisco in 2016, While perhaps featuring international February sees the return to chef-proprietor Kim Alter has artists young and old, the beautiful and historic earned widespread critical best-known for his up-and-coming and well Regent Street Cinema of acclaim for her tasting menu, expansive, semi- established, in a performance a programme of weekly which celebrates Californian abstract bronze that is broadcast live to a Wednesday screenings of old produce, manipulated with friezes, Moore also worldwide audience on BBC film favourites, with a live great skill and inventiveness. Radio 3. The new season’s organ prelude introducing In her January residency produced a series of highlights include violinist the first of two afternoon at Marylebone’s rotating helmet sculptures— Leila Josefowicz and pianist sittings. The 2019 season restaurant, Carousel, Kim and recent research John Novacek performing kicks off on 13th February offers a taster of her flair reveals that the Sibelius, Prokofiev, with Alfred Hitchcock’s for flavour and love of fresh Knussen, Mahler and To Catch a Thief, which ingredients: think quail’s egg Wallace Collection’s Zimmermann; pianist Sophie sees reformed jewel thief topped with brown butter armoury directly Pacini performing Liszt, John Robie, played by Cary aioli and caviar, on a bed of inspired their Mendelssohn and Schumann; Grant, fighting to prove his fried leeks; scallops with creation. Presented The Quatuor Arod string innocence by catching the turnip and mushrooms; and quartet and violist Timothy copycat criminal who has chocolate, pear and coffee in collaboration with Ridout performing Mozart; been robbing tourists on the pudding. The Henry Moore Foundation, these Leila Josefowicz To Catch a Thieftbc sculptures will be on show alongside a collection of original sketches and maquettes in an exhibition that explores the artist’s fascination with armour.

62—Prognosis

prognosis_issue05_pp60-64 PROOF01.indd 62 10/01/2019 09:34 EXHIBITION SOURCED MARKET Alain Coumont, a Belgian 68-72 Wigmore Street who came from a long line of THE WANDERING WOMB: London W1U 2SD chefs and bakers and who WOMEN’S HEALTH sourcedmarket.com learnt the art of tarts, bread NURSING PAST AND and pastries from his aunt PRESENT The clue’s in the name Simone. We’re particular Until 22nd March at Sourced Market, a fans of the blueberry swirl, Royal College of Nursing popular shop-cafe-bar while the croissant—dipped Library and Heritage Centre premised entirely on the in Le Pain Quotidien’s famous 20 Cavendish Square scrupulousness of its bowls of rich, creamy hot London W1G 0RN sourcing. Its suppliers are all chocolate, as per French rcn.org.uk artisans: small, independent and Belgian tradition—is a and usually local producers thing of unadorned beauty. Women have long been whose methods and “My idea was simple,” says seen to be at the mercy of ingredients are of the Alain Coumont—“having their biological functions. highest ethical standards a place where I can feel at It was once believed that and quality. The pastries home, away from home.” a ‘wandering womb’—or Of the best places to come from Yeast Bakery, a displaced uterus—was the root enjoy a pastry bakery under a railway arch BONNE BOUCHE of many pathological medical near Broadway Market, east 2-3 Thayer Street troubles. Menstruation and London, which specialises London W1U 3JD childbearing were thought in hand-made viennoiserie, bonnebouche.co.uk to make women weaker and produced using the finest less rational than men. In this Normandy butter. Gobble down a raspberry tart exhibition, the RCN explores or an almond croissant from the assumptions, myths and MAISON KAYSER Bonne Bouche, and you’ll find generalisations that have 8 Baker Steet yourself in fine company. long surrounded women’s London W1H 6AZ Harrods, Peter Jones, the health, and shows that, while maison-kayser.com Royal Opera House and many some of those misconceptions other illustrious British have been overturned, we’ve The doors of the first Maison establishments have all still a long way to go. Kayser opened in Paris in been known to have a 1996—but its credentials lie penchant for the brand’s THEATRE as much with its founder as locally-baked pastries. with its Parisian provenance. Its bijou Marylebone shop is OUR TOWN Born into a family of the perfect place to try them: 16th May—8th June French bakers dating back a small, cosy monument Regent’s Park four generations, Eric to the cafes of times past, Open Air Theatre Kayser started his baking sweet-smelling, buzzy Inner Circle apprenticeship at the and warm. London NW1 4NU prestigious Les Compagnons openairtheatre.com du Devoir at the age of 14 FISCHER’S before going on to become 50 Marylebone High Street When American playwright one of France’s most admired London W1U 5HN Thornton Wilder’s Our bakers. Each new bakery fischers.co.uk Town debuted in New he opens has its own local Jersey in 1938, it defied character but all share the On those occasions when genre categorisation. same meticulous attention you want to nibble delicate Set in the quiet, fictional to detail as the first: additive- viennoiserie like a princess, town of Grover’s Corners, free flour, natural leavening sipping a china cup of teapot Maison Kayser New Hampshire, it tells a agents, pure French butter— tea, one pinkie stuck out like simple tale of two lovers and the Baker Street store is a sentinel, you need to visit and the bonds that tie their an Aladdin’s cave of lozenge- Fischer’s on Marylebone High community together, but like eclairs and flaky golden Street: a cafe and konditorei does so while constantly pastry. owned by Corbon and breaking the fourth wall, King, inspired by the grand with the main character LE PAIN QUOTIDIEN cafes of Vienna in the 1920s. purporting to be the stage 72-75 Marylebone High There are dark oil paintings, manager of the theatre in Street even darker wood panelling, which it’s being performed. London W1U 5JW gleaming gilded mirrors, The play, which takes place lepainquotidien.com fine crockery and pastries on a mostly bare stage and of such finesse, you are without the use of props, will Le Pain Quotidien, whose forced to quietly contemplate be a fascinating addition to name means ‘the daily their beauty before greedily the Open Air Theatre’s bill. bread’, was founded by tucking in.

Prognosis—63

prognosis_issue05_pp60-64 PROOF01.indd 63 10/01/2019 09:34 Le Vieux Comptoir put together a beautiful bouquet—then take your THE spoils home with you. THE GINGER PIG 8-10 Moxon Street GUIDE London W1U 4EW A tour of Marylebone’s thegingerpig.co.uk masterclasses and For foodies who don’t mind workshops getting their hands dirty, The Ginger Pig—a high welfare butcher known for the exceptional quality of its produce (and massive sausage rolls)—runs classes that cover almost every element of basic butchery: learn how to make your own bacon; discover what to do with feathered and furred game; or de-bone and roll your own lamb shoulder.

LULULEMON 74-75 Marylebone High Street London W1U 5JR lululemon.co.uk

Short of a poky hotel gym, finding somewhere to exercise that doesn’t cost the earth or require some sort of LA CUCINA CALDESI In the winter, we example, have a crack at membership is no mean feat. 4 Cross Keys Close candle making, put together Luckily, Lululemon offers London W1U 2DG can think of few your own terrarium, or brush complimentary yoga classes caldesi.com nicer ways to while up on your calligraphy—then, and mindfulness workshops away a cold evening ideally, head upstairs for in store: no commitment, no Giancarlo and Katie Caldesi than a tour of Le some top-notch dinner and obligation to buy anything, opened their popular Italian drinks from Carousel’s own just rock up in your gym gear restaurant Caffe Caldesi on Vieux Comptoir’s lunch menu, or feast on fare and join in. Marylebone Lane in 2002. finest tipples, under from an internationally Some years later, they the expert guidance acclaimed chef. LE VIEUX COMPTOIR decided to share their wealth 26-28 Moxon Street of cooking experience by of its oenophiles JANE PACKER FLOWER London W1U 4EU founding a cookery school. and sommeliers SCHOOL levieuxcomptoir.co.uk It is open to all ages and 75 George Street abilities, whether you “know London W1U 8AQ In the warmer months, your spaghetti from your Jane-packer.co.uk Laurent Faure’s restaurant, spatula” or not. Look out for deli, wine bar and wine shop appearances from celebrity If like us, and probably is the perfect place to pick chefs, food writers and everybody else who’s not a up some cheese, charcuterie wine experts, who are often professional florist, you like and a bottle of something invited in to run the show. flowers but never manage delicious before heading to to make them look quite as nearby Paddington Street CAROUSEL good at home as they do in Gardens for a picnic. In the 71 Blandford Street the shop, head to Jane Packer winter, though, we can think London W1U 8AB Flower School, which offers of few nicer ways to while carousel-london.com a fun and accessible way to away a cold evening than a learn the basics of flower tour of Le Vieux Comptoir’s As well as a restaurant and a arranging, in one hour, one finest tipples, under the gallery space, Carousel hosts day, or three day workshops. expert guidance of its a roster of guest events to Learn how to put together oenophiles and sommeliers— suit even the most out-there a traditional hat box, weave and often, visits from the of interests: you might, for a Christmas wreath, or producers themselves.

64—Prognosis

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