GP INTELLIGENCE THE QUARTERLY MAGAZINE FROM THE HOSPITAL OF ST JOHN & ST ELIZABETH WINTER 2012

INTRODUCING OUR NEW GYNAE UNIT A comprehensive service for assessment and treatment

DEDICATED REFERRAL

HOTLINE FOR GPS Our education programme and annual symposium PIONEERING NEW IMAGING EQUIPMENT The !rst private London Hospital to o"er a 256-slice CT scanner ST JOHN’S HONOURED Hospice receives prestigious Hospice@Home award OUR NEW KNEE UNIT Instant access to some of the !nest specialists in this !eld FOCUS ON PAEDIATRIC CARE Looking at eczema and cardiology problems in children ABNORMAL UTERINE BLEEDING Often the cause of post-natal discomfort for the new mother OUR MANAGEMENT FORGING AHEAD INTO TEAM 2013 INSPIRED BY A VERY SUCCESSFUL 2012 appy New Year and welcome to the Winter edition of GPi. Just before Christmas we completed the Hinstallation of a new 256-slice state-of-the-art CT scanner, which o!ers the very best quality images and more advanced clinical applications. This £1.2million investment in our Imaging Department comes less than a year after we became the "rst private hospital in the UK to have a 3T MRI scanner. As the o#cial medical facility of UK Athletics, we were delighted at the success of the 2012 GB Olympic team after many of the medal-winning track and "eld DR DAVID athletes were treated at the Hospital. Our reputation is growing. A record 293 GPs attended our Annual Symposium GRANT to hear lectures from 15 of our leading consultants. We plan to build on this Medical Director success and the extremely positive feedback by hosting a special Hot Topics Annual Symposium on March 23 (see Pages 6 and 7 for full details). Meanwhile, 266 healthcare professionals attended our Hypermobility Seminar. The Hypermobility Unit, led by Professor Rodney Grahame, is the UK’s only private specialist unit and is already attracting international interest. We are launching a new GP hotline to ensure all referrals are dealt with immediately and also a new Knee Unit and Gynaecology Unit. This will complement our wide range of world-class services – we have hundreds of specialist consultants and boast Spine and Shoulder Units and the fast-growing London Urology, as well as the world-renowned London Foot and Ankle Centre. Our walk-in private urgent care centre has proved to be such a success – with 10,000 patients already treated – that we are now expanding the service. Casualty First is unique in being able to treat adults and children from the age of one for all Carol singers at the St John’s Christmas Fayre which helped to raise £15,000 for the Hospice MRS CHRISTINE minor accidents, illnesses and injuries. The success of the Hospital allows us to fund our on-site hospice, St Johns, MALCOLMSON which recently launched London’s "rst palliative care ambulance service. Our Matron Hospice@Home service scooped the prestigious Domiciliary/Home Healthcare Provider 2012 at the Laing Buisson Independent Healthcare Awards, beating AT THE HEART OF THE LOCAL hundreds of rivals. I thank you for your support last year and look forward to a successful 2013. Kind regards, DAVID MARSHALL CHIEF EXECUTIVE COMMUNITY OFFERING

CONTENTS FIRST CLASS HEALTHCARE ST JOHN’S HOSPICE he Hospital of St John & More than 7,000 local residents units in 2013, including the Knee CASUALTY FIRST St Elizabeth is truly unique. attended the St John’s Christmas Unit and our new gynaecological DR CHRIS The benefits of health At the heart of the As an independent charity, Fayre on St John’s Wood High Street, London Wellwoman Clinic. FARNHAM 4 screening 14 community we are proud to deliver raising £15,000 for the Hospice. All these are designed to help Tultimate standards of private care Our self-pay, walk-in urgent care the Hospital continue to flourish, Hospice Medical EDUCATION DERMATOLOGY Hair loss to our patients. But while doing centre, Casualty First, is proud to allowing us to meet the ever Director Our new GP referral hotline this, all of our profits help fund our sponsor the fayres. growing demand for support from 6 and upcoming programme 16 in women on-site Hospice. In 2013, the Hospital has a the Hospice, which cares for 2,000 GYNAECOLOGY CARDIOLOGY St John’s Hospice provides vital range of exciting expansion plans terminally ill patients and their palliative medicine services free of – starting with Casualty First. Our families for free every year. New Gynae Unit Atrial fibrillation: What charge to the local community and urgent care centre, able to deal We are extremely grateful to 8 Uterine Bleeding 17 are the medical options? beyond. with any minor illness or accident, all those who contributed to our GYNAECOLOGY KNEE UNIT This unique combination has put has already treated 10,000 patients. success in 2012. the Hospital and the Hospice at the Now we are expanding Casualty For full details of all the services High-risk pregnancy counselling Introducing our new heart of the area. First to keep up with demand, provided by the the Hospital please 10 Tackling post-natal problems 18 service and its consultants Our Easter, Summer and ensuring patients enjoy a truly visit www.hje.org.uk. PHYSIOTHERAPY PAEDIATRIC Christmas Fayres partner with local walk-in service without the waiting Alternatively, to find out how schools, groups and businesses to times of NHS A&Es. you can support our Hospice visit Tackling post-natal problems Congenital heart disease raise money to support St John’s. We are also launching new www.stjohnshospice.org.uk. MR GEOFF 11 such as bladder weakness 20 and the General Practioner GREEN IMAGING PAEDIATRIC AMAZING PROGRESS OF CASUALTY FIRST Financial Director Our 5* service introduces Difficult eczema in ! 2 12 pioneering new equipment 22 older children AND OUR EXPANSION PLANS PAGES 4 & 5 3 Casualty First CASUALTY FIRST HAS NOW TREATED MORE THAN 10,000 PATIENTS AND EXPANSION PLANS FORGE AHEAD no time to get to know patients and establish a rapport, much less Capable of win their trust enough to discuss personal matters. ue to its phenomenal Patients don’t always see the detecting success our urgent same doctor in their local practice. care centre, Casualty Many times people do not deem possible First, is currently certain issues as being significant D enough to ‘bother’ their GP about. undergoing expansion. A third problems, consulting room will be created Yet it might be something that has by converting part of the Grove enough of a negative impact on End Road reception. Work is due their lives that they really wish to health to commence early this year. change but feel powerless to do so. Meanwhile, a third full-time For example, erectile screening consultant is being recruited as dysfunction in men, loss of libido we further boost staff numbers to in either sex, urinary incontinence cope with demand. or the discomfort of a vaginal also provides Since the start of our autumn posterocoele might be at the root marketing campaign offering of relationship breakdowns and a safety flu vaccinations and health cause real unhappiness. screenings, there has been an Personality issues may be the net for the average of over 30 patients a day. reason that a patient struggles Despite this growth, waiting at work and at home, and might patient times have been kept to an HEALTH SCREENING need to be gently brought to their absolute minimum and the urgent attention. It might be that someone care centre is winning widespread may want to lose weight, get fit, or and helps praise from the local community just wish to change their lifestyle. and beyond. I have worked in both general the general BENEFITS INCLUDE practice and health-screening centres, and have been in the Following the great privileged position to combine practitioner success of our first year the two and offer health screening we can confidently to my GP patients. testing, as well as urine test, body respiratory department where lung offer instant treatment EARLY DIAGNOSIS The process begins with a measurements, visual and hearing function tests and stress ECGs take to all of the following about cardiovascular health and health questionnaire completed tests, stool tests if needed, blood place, as well as echocardiograms. immediately on arrival... the prevention of heart attacks by the patient which asks pressure and ECG. We also have onsite allergy testing  and strokes. about any medical problem The client is given a light and can arrange for someone with A health-screening consultation ever encountered, about stress breakfast then sees the doctor high blood pressure readings to be OAcute illness can be an extremely rewarding and sleep, as well as details of to discuss the questionnaire, fitted with a 24-hour BP monitor on OSports injuries process for both the patient and family medical problems, diet, results of the tests, have a full the same day. O exercise, sexual problems and physical examination which is age There is a distinct advantage Fractures, soft-tissue injuries, DR YUMNAH RAS the doctor. A doctor is in the very psychological issues. appropriate and includes smear to have rapid access to so many sprains and strains Urgent Care Centre doctor privileged position of being able OWounds, wound closure and to ask the patient about many This has the advantage of testing, prostate examination, as well resources in the same place, and burns aspects of their lives, and discuss getting the patient to think as discussing breast and testicular the hospital is so well known for OCuts and grazes t is well known that the their lifestyle in an open and about all of these details before self-examination if needed. Any its friendly atmosphere that health OEar, nose and throat conditions absence of disease does not frank manner. the consultation, and allows the issues can be discussed, whether it is screening at the Hospital of St John O Gynaecological conditions Idefine wellness. Wellness, The old-style family doctor was clinician to hone in on problem a cholesterol-lowering or weight-loss & St Elizabeth is a natural choice ORespiratory and chest or wellbeing, is the feeling someone who knew the entire areas, while at the same time, a plan or referral to a specialist. for many. complaints that physically, psychologically, family, their health concerns consultation of 30-45 minutes At the Hospital of St John & St Some of the best job OStomach, bowel and bladder emotionally and spiritually, a and personal problems, and was helps to build a feeling of trust, Elizabeth we have an onsite lab for satisfaction I have enjoyed is problems person is in a state of harmony available in times of crisis to and of getting to know each rapid results to blood tests, onsite helping someone map their route OEye conditions and balance. provide counselling and advice other. imaging department for same- to optimal health and wellbeing. OEar consultation and ear Health screening can identify on many issues, not all of them After coming for a health day chest X-rays, mammograms, It is even more satisfying knowing syringing problems before they become medical. Unfortunately, with the screening, a nurse or health care or scans such as ultrasound, that downstairs in the Hospice is OFlu vaccines more advanced, and before a pressures of time in which we live, assistant starts by doing fasting CT or MRI. There is also a large the evidence of the charity we all OTravel vaccinations and advice patient even becomes aware that we are not able to do all of this bloods tests for comprehensive physiotherapy department, contribute to with our association there is something wrong, such for our patients, as much as we do haematology and biochemistry dietician, a cardiology and with the Hospital. as detecting high blood pressure, genuinely wish to make a difference Tel: 020 7432 8300 [email protected] www.casualty!rst.co.uk 4 early cancers, or giving advice to people’s lives. We often have 5 Education

JANUARY 2013 " MARCH 2013 e are delighted to announce our new DEDICATED W dedicated referral hotline for GPs. For urgent referrals and admissions call 07736 223344 and one of our team will be on REFERRAL hand to assist you. GPs now have just one number to call to access fast-track appointments with HJE consultants and clinics for All seminars and lectures take place HOTLINE 07736 in the Conference Room, 3rd Floor, both adults and children. Brampton House at the Hospital of St This service is available 24 hours a 223344 John & Elizabeth (60 Grove End Road, FOR GPS day, 7 days a week, 365 days a year. NW8 9NH) unless otherwise stated. OEmail [email protected] to WHY CHOOSE OUR EDUCATION SERVICE book your place at any of the he Hospital events below. of St John & ANNUAL SYMPOSIUM We have a reputation for providing relevant and high-quality St Elizabeth’s education and we welcome all members of the Primary Care GP SEMINARS T teams to attend our varied programme. GP education BECOMES BI!ANNUAL Saturday, February 2 programme continues We offer: 9am-1pm Urology Seminar OTopics of modern-day relevance given by our world- to grow. More and more Last year’s day-long The feedback we received from symposium was held at the the last symposium was fantastic renowned consultants GP SHORT LECTURES GPs are turning to our with GP delegates o!ering warm OConvenient times for GPs to attend the lectures, with lecture and seminar Royal College of Physicians Evening lectures 7.15pm-8.15pm in October and provided a endorsements such as: morning, evening, lunchtime and weekend lectures provided (A bu!et dinner is served from 6.45pm) series to help them keep O‘Seeing di!erent consultants OLectures that are completely FREE OF CHARGE to primary care up-to-date with the fantastic opportunity for teams GPs to gain essential CPD and specialities and learning Wednesday, February 6 latest developments in about what they think is OCertificates of Attendance to count towards your Continuing points and enhance their Evening secondary care. important for GPs’ Professional Development (CPD) Gynaecology Lecture knowledge of conditions they O All those involved in O‘Sessions were really good and The opportunity to network with fellow London GPs Friday, February 8 primary care are advised treat everyday at a primary relevant to GPs’ International Conference on Breast to attend our lectures to care level. It gave them the O‘Excellent and well organised Cancer, Lord’s Cricket Ground hear from our consultants opportunity to meet leading symposium’ 9am-1.20pm on the latest hot topics. experts from an array of O‘Dietary advice for renal stones OUTREACH LECTURES Wednesday, February 27 – the clearest I have ever heard – We ask our speakers to specialities and network Evening # with other GPs throughout fabulous!’ For flexibility we’re happy to provide tbc include referral red ags, O‘Clinically very relevant and case studies and Q&A the capital. free lectures at your practice at a time Wednesday, March 6 useful for everyday practice’ that suits you. Our outreach lecture Evening sessions in their talks to O‘Poster of abnormal LFT programme has been designed especially Paediatrics Lecture ensure that GPs get the algorithms will be placed on my for those healthcare professionals with Wednesday, March 13 " most out of our lectures. Due to the continued o ce wall tomorrow’ exceptionally busy schedules. Evening We have now success and popularity O‘From many of the talks I have These sessions will be arranged Ophthalmology Lecture con$rmed the agenda of our symposia, we two or three skills to take away completely for the convenience of you for our short lecture now plan to hold from the day’ and your colleagues, including practice ANNUAL SYMPOSIA and seminar series in two a year from 2013 O‘Excellent lectures and very nurses and registrars. Saturday, March 23 2013. Please see our onwards, with events useful. Please arrange another All the lectures are of modern-day 9am-3.30pm taking place in both symposium, maybe two per year?’ January-March calendar relevance and are given by our own Royal College of Physicians March and October consultants, who are leaders in their field. Saturday, October 12 for further information. (please see the calendar Thank you to all who attended. Our consultants are also 9am-3.30pm for dates and times). The symposium proved to be our Royal College of Physicians happy to make personal Booking is essential, so biggest and best yet with over appearances to lecture at why not get in early and 290 attendees enjoying a range HOW TO ARRANGE A LECTURE local GP surgeries. If you reserve your place at of topics from kidney stones to You can contact us on 020 7806 4047 or email [email protected] to discuss your preferred topic and these great educational cancer management given by would like to hear about a available dates. We will do the rest and even bring catering along to your practice. Available to GPs in events today? 15 of our expert consultants. topic not included in our London only. series, please contact us to discuss booking a talk 6 at your practice. 7 Gynaecology INTRODUCING OUR NEW GYNAE UNIT

he Gynaecology consultants also treat obstetric Unit – London conditions such as fibroids, Wellwoman Clinic recurrent miscarriage, infertility, Toffers a comprehensive problems following childbirth and assessment and treatment maternal medical disorders. under one roof. Appointments Supported by state-of-the-art are offered to patients within imaging facilities and theatres, 24 hours, with clinics available the multi-disciplinary team at the Monday to Saturday. London Wellwoman Clinic is The London Wellwoman dedicated to o"ering the very best Clinic covers general in private healthcare. Patients can gynaecology checks, abnormal rest assured that they will receive smears, colposcopy, abnormal the utmost care and attention. menstruation clinics, early We have recently invested pregnancy, pelvic pain, infection, in our inpatient and outpatient continence, HRT and all general facilities, so that we can offer gynaecology. as comfortable and relaxing an Our world-renowned environment as possible. BEATING ABNORMAL UTERINE BLEEDING O 30% of all gynaecological outpatient attendances are due to menorraghia O 25% of women feel that their menstrual loss is excessive

O Up to 10% take time off work

Mirena FIGURE 1 Endometrial polyp FIGURE 2 MR EMEKA OKARO MBBS MRCOG 60% of women no abnormality will unsuccessful, removal of the lining cases that do not respond to Consultant Gynaecologist be found and thus a diagnosis of of the womb (endometrial ablation) the treatments above in women dysfunction uterine bleeding is made. should be considered in women whose family is complete. Should of cases the underlying cause is less on ultrasound reduces the t is often difficult to know if 60% of women with menorraghia whose family is complete. menorrhagia be accompanied by benign and in 10% malignant. The pre-test probability of endometrial the menstrual loss is normal will be anaemic. In the remaining 40%, inter-menstrual and/or post-coital commonest !nding being atrophic cancer from 10% to 1%. Overall, an or heavy compared to This is treated with oral conditions such as polyps bleeding it is important to exclude a vaginitis, endometrial or cervical endometrial thickness of 4mm will other women. By definition, medication such as mefenamic (Figure 2), fibroids and pelvic infection and ensure that the polyps. detect 96% of endometrial cancers I and/or tranexamic acid, the oral adnenomyosis are also amenable cervical cytology is normal. Treatment is usually a six-week and 92% of endometrial disease menorraghia is the loss of 80mls of blood or more which clinically can contraceptive pill or progesterone to medical treatment. In some Post menopausal bleeding course of topical oestrogen therapy (polyps, hyperplasia, !broids). It is also be difficult to quantify. tablets. The intrauterine system cases focal lesions such as polyps accounts for 5% of all gynaecological or removal of the focal lesion. An essential to visualise the cervix and A detailed history, pelvic (Figure 1) is also a good !rst choice in and fibroids are removed by outpatient attendances. In 90% endometrial thickness of 4mm or obtain a normal cervical smear. examination and ultrasound scan are women also requiring contraception hysteroscopy. essential to establish a diagnosis. In irrespective of parity. Should these be Hysterectomy is reserved for 8 020 7806 4060 [email protected] www.londonwellwomanclinic.co.uk 9 Gynaecology Physiotherapy Research shows that one in four women experience bladder weakness – and even this is thought to THE GP AND HIGH RISK be an underestimate. Bladder weakness is a key consequence of weak pelvic-"oor muscles and, despite this, 75% of 16 to 24-year-old women have PREGNANCY COUNSELLING never been shown how to locate or exercise their pelvic "oor and one in !ve women don’t know what MISS AMMA KYEI-MENSAH their pelvic-"oor muscles do. MRCP FRCOG WHEN SHOULD PRE"PREGNANCY Consultant Gynaecologist COUNSELLING #PPC$ BE PROVIDED? ! he 2006-2008 UK Con dential Half of pregnancies are unplanned so it is vital that women with Enquiry reported 261 maternal ! POST NATAL pre-existing medical conditions are proactively o ered PPC referral Tdeaths. 154 deaths were whenever they access NHS services. indirect, i.e. due to coexistent Contact opportunities include cervical screening and medical or psychiatric illness. contraception prescribing. Transition from paediatric/adolescent Many of these women received no MUMS AND THE care to an adult clinic for girls with chronic diseases also presents pre-pregnancy counselling (PPC) a timely opportunity to promote discussion of future reproductive therefore opportunities for closer health. surveillance, change in medications etc were missed leading to PELVIC FLOOR suboptimal care. WHO SHOULD PROVIDE IT? he most common form of ! Pre-pregnancy counselling is CLAIRE ANNE HEAD urinary leakage I see is stress Clinical Lead a “Top ten” recommendation in PPC should be provided by a practitioner with suitable training and incontinence. This type of # Women’s Health Physiotherapist the report, requiring a nationwide expertise in pregnancy management of the medical condition. incontinence a ects up to multi-disciplinary response from all T Speci%c criteria for conception with regard to optimal disease a third of all new mums and is most stakeholders involved in maternity control and safe e!ective medication are clari%ed together common in young women (25-49 HOW TO EXERCISE THE PELVIC FLOOR service provision. with any long-term consequences of pregnancy for the woman. years of age). NICE guidelines (2006) recommend that women with urinary COMMON CONDITIONS REQUIRING The aim is to develop an individualised prospective pregnancy stress incontinence undergo a trial of A combination of fast and slow contractions ensures that both types PRE"PREGNANCY COUNSELLING management plan. ! " supervised pelvic-"oor strengthening of muscle bres found within the pelvic oor are exercised equally OObesity (BMI>30 kg/m2) for a minimum of three months. (Simpson, 2000). O Diabetes Although mums’ and babies’ wellbeing should be equally Slow contractions OEpilepsy considered postnatally, the focus is OAsthma often on the baby. GPs are ideally These work the endurance part of the muscle. The aim is to hold the contraction for 10 seconds. After just a few O Congenital or known acquired heart disease placed to ask postnatal women at their six-week postnatal check about seconds the muscle may tire and start to let go. The contraction ORenal or liver disease " their bladder and bowel function. should be relaxed if this happens. The time that the pelvic oor can OAutoimmune disorders This helps to identify problems be held should be increased gradually. These slow contractions OSevere pre-existing or past mental illness early, prompting women to disclose should be repeated 10 times. symptoms that they may have OHIV infection Fast contractions been too embarrassed to discuss, thereby allowing them to seek THE FUTURE: A “LIFE" appropriate treatment. These work the powerful component of the muscle. COURSE” APPROACH Research shows that pelvic- Rather than holding the muscle, the contraction is let go "oor exercises can strengthen the immediately. This should be repeated 10 times. perivaginal and perianal musculature, These recommendations echo ONICE guidelines (2006) helping to improve bladder and those of a new RCOG Report – recommend exercising the pelvic bowel control. However, Bo (2001) High Quality Women’s Health &oor three times a day. found that 45% of women doing Care: A proposal for change (July pelvic-"oor exercises were doing 2011). It advocates a women’s them incorrectly and therefore a OClaire-Anne Head is an health network with a “life-course” pelvic-"oor assessment should always experienced Women’s Health approach to health care. Every be undertaken to establish pelvic- Physiotherapist who specialises contact with the NHS represents a "oor function and correct technique. in this area. She o#ers one-to-one chance to promote healthy living Women’s Health Physiotherapists sessions for the assessment and as well as disease prevention. from 16% to 24% between 1993 contraception. Consistent messages are ideally placed to do this and can treatment of pelvic-"oor related It aspires to reach all women and 2007. 49% of maternal deaths to teenagers, encouraging healthy individualise pelvic-"oor exercise issues, as well as post-natal pilates throughout their lives. occurred in overweight or obese lifestyle choices, have a greater programmes to account for a patient’s and ‘Life After Birth – Postnatal This approach may help in women. NHS contact opportunities chance of improving long-term lifestyle and motivation. This is the key Recovery’ classes. tackling obesity. Obesity in women for younger women include rubella health outcomes for future mothers to successful outcomes. over 16 years in the UK increased screening, HPV vaccination and and their babies. 10 Tel: 020 7806 4060 [email protected] www.hje.org.uk Tel: 020 7806 4010 ext 3330 [email protected] www.womensphysiotherapy.org.uk 11 Imaging

ur celebrated 3T SERVICES Imaging AVAILABLE ODepartment o!ers patients a 5*service with supreme standards Cartilage Mapping – detect of care and is sta!ed the earliest signs of joint by some of the UK’s cartilage changes seen in leading musculoskeletal various degenerative diseases. Radiologists, Movement Suppression Radiographers and – corrects artefact due Sonographers. Walk- to involuntary patient in appointments are movements, enhancing the Brain Kidney, adult male Heart bypass, female Heart lesion available and in our quality of the study, even latest audit we had zero when the patient is unable to cases of MRSA. co-operate. tional 3D Imaging – software enables CT TVI It’s no wonder so many of London’s leading PIONEERING the fast acquisition of 3D data om other scanners. sets. This enables improved consultants choose to NEW EQUIPMENT quality and faster imaging of d hold their clinics here and the biliary tree (MRCP) and of e why the country’s top pelvic diseases. n athletes and sportsmen age trust the Hospital of Vascular Imaging – Capturing as the St John & St Elizabeth multiple arterial and venous ce in with their diagnosis phase images virtually he anywhere in the body to igh and treatment. We are the medical base for UK ensure rapid examination of best the vascular system. in, Athletics and were proud lvis to support many of our Di"usion imaging of the brain btle, gold-medal-winning – acquisition of data with an be Olympians this summer. the potential for earlier and high more accurate assessment of patients su"ering from OUR FULLY dementia. EQUIPPED The quality of imaging results is excellent with the new 3T MRI scanner 3T breast coil – enhances the IMAGING quality and decreases the DEPARTMENT he Hospital of St John & What the iCT TVI scanner means time taken to acquire breast St Elizabeth has a reputation for our services images. for embracing the latest Head and neck imaging, abdominal T medical technologies which imaging including CT Virtual (ultrasound) – venous and arterial goes back more than 150 years. As colonoscopy and musculo-skeletal assessment of the arms and legs, such we have continued to invest in imaging is now available in greater carotids and aorta using colour our Imaging Department to ensure detail and at faster speeds than Doppler ultrasound. that we remain one of the leading previously. imaging facilities in the UK. The iCT TVI scanner is speci!cally More about our 3T MRI We are pleased to announce that designed to meet the unique needs The new Philips 256-slice CT scanner The incredible detail of the scans we have become the !rst private of vascular imaging from head to achieved by the 3T is particularly hospital in London to install an iCT toe, providing high image quality aortas and pulmonary vessels with OInterventional procedures such as valuable in assessing the brain, TVI 256 slice CT scanner. with low dose and less injected Step & Shoot will also be available. biopsy, aspiration, drain spine, cardiovascular and The department is fully In addition to our state-of-the- contrast. insertion and pain-management musculoskeletal systems. " digital with an integrated art, whole-body 3T MRI scanner, We will be able to o er stroke The department is equipped procedure under X-ray and ! PACS system for all imaging which was installed in 2011, we now imaging as iCT TVI has the lowest and sta ed to provide: ultrasound. This state-of-the-art equipment has have the very best in CT scanning dose brain perfusion protocols in ! O modalities which allows OA full range of plain lm skeletal Routine abdominal and pelvic been designed with the patient’s technology. This innovative new the industry and takes a unique radiography using low-dose digital scans, transrectal prostate scanning, comfort in mind. consultants to instantly view equipment is perfectly adapted approach to symptom and cause for radiography. transvaginal pelvic scanning, Most studies can be performed images in their consulting to performing the full range of CT stroke diagnosis. OFull !eld digital mammography, musculoskeletal scan, ultrasound with the patient positioned with rooms or at any terminal in examinations and provides a unique We will be introducing dedicated breast ultrasound, !ne needle guided biopsy and ultrasound pain their head outside the scanner the hospital. approach to managing important Cardiac Imaging with Calcium aspiration, breast biopsy and management/joint injections. providing increased space around factors in patient care – a new era score analysis. Full !eld of view, breast MRI. ONon-invasive vascular assessment the patient. /We o"er a full range in low-energy, low-dose and low- prospective cardiac triggered of imaging, including injected-contrast imaging. examinations for coronaries, 020 7806 4030 [email protected] www.londonimaging.co.uk 3T MRI scanner, digital mammography, ultrasound machines and interventional 12 radiology facilities. 13 John’s Hospice THE HOSPICE OF THE CHARITABLE HOSPITAL OF ST JOHN & ST ELIZABETH Hospice OUR HOSPICE AT THE HEART OF THE COMMUNITY PROVIDING 5* QUALITY CHRISTMAS FAYRE JOY MOVING PROCESSION AT LIGHT UP A LIFE OThe unrivalled success of this year’s Christmas Fayre raised t John’s Hospice’s Light Up A Life more than £15,000 for St John’s event brought people together Hospice. St John’s Wood High Swho have lost a loved one or have Street hosted 60 market stalls, someone living in the shadow of a fairground rides and stage terminal illness. They celebrated in a very performances featuring live special way – by remembering their lives entertainment courtesy of The and lighting a candle in their honour. Marylebone Rock Choir, Barrow The event also gave those who Hill School, Punch and Judy and have lost loved ones, in the Hospice or Sylvia Young Theatre School. elsewhere, the chance to come together Eastenders actor Sid Owen and celebrate their memory through switched on St John’s Wood NEW PALLIATIVE CARE AMBULANCE attending our event and dedicating a Christmas lights and he also star on our Wall of Stars. drew the raffle. Noted attendees This service o!ers those of included Angela Harvey, the new dedicated Palliative Care Ambulance, the first of its kind in London, di!erent faiths the chance to come Lord Mayor of Westminster, and has been launched for Hospice patients who can be transferred to together and re"ect while listening Holby City actress Tina Hobley. A and from St John’s Hospice. This new ambulance service will run to testimonials, readings and carols. We are extremely thankful from Monday to Friday between 9am and 5pm and we expect to be able to for the support of all local manage between three and five transfers a day. shop owners, schools and our Steve Barnes, business manager for the Hospice, says, “The new ambulance dedicated volunteers. will minimise waiting times and hopefully reduce some of the anxiety people feel when coming into the Hospice.” PRESCRIBING SYRINGE DRIVERS IN GENERAL PRACTICE

# The most common symptoms in patients HOSPICE HOME AWARDS who are at the end of life are: Therefore, it is usual practice to prescribe the following: t John’s Hospice’s Hospice@ OPain O Home service has scooped O)YLH[OPUNKPMÄJ\S[PLZ 6WPH[LMVYWHPUHUKIYLH[OPUNKPMÄJ\S[PLZ the title of Domiciliary/Home O S O5H\ZLH (U_PVS`[PJMVYHNP[H[PVUHUKIYLH[OPUNKPMÄJ\S[PLZ Healthcare Provider 2012 at the O Independent Healthcare Awards, OAgitation (U[PLTL[PJMVYUH\ZLH beating hundreds of rivals. ORespiratory secretions O(U[PT\ZJHYPUPJMVYYLZWPYH[VY`ZLJYL[PVUZ Judges for the event, organised by healthcare intelligence provider Laing & Buisson, singled FREE “One of the areas I’m asked about most often by GPs is the area of prescribing out St John’s Hospice, highlighting syringe drivers for patients who are no longer able to take oral medication, usually “its highly tailored approach to LEAFLET at the end of life. The most common symptoms in patients who are at the end of the very delicate subject of SPMLHYLWHPUIYLH[OPUNKPMÄJ\S[PLZUH\ZLHHNP[H[PVUHUKYLZWPYH[VY`ZLJYL[PVUZ patients dying in the comfort of INCLUDED Therefore when I’m prescribing syringe drivers for patients at the end of life, I usually their homes”. WYLZJYPILHUVWPH[LMVYWHPUHUKIYLH[OPUNKPMÄJ\S[PLZHUHU_PVS`[PJMVYHNP[H[PVUHUK Hospice@Home service elderly and highly vulnerable members of our IYLH[OPUNKPMÄJ\S[PLZHUHU[PLTL[PJMVYUH\ZLHHUKHUHU[PT\ZJHYPUPJMVYYLZWPYH[VY` provides support by placing healthcare assistants, community. secretions. Initially, patients may not need all four types of drug in their syringe driver, experienced in community work and trained in The awards recognise outstanding quality and but as symptoms can develop over time it is good practice to prescribe all four types palliative care, in the homes of patients who want to innovation in the independent healthcare sector. of drugs on the PRN side of the drug chart ‘just in case’.” remain in familiar and comforting surroundings during Established in 2006, they aim to recognise the the latter stages of their illness. achievements within the sector and to praise the Those benefiting from Hospice@Home are often efforts of those who have achieved excellence. Facts and !gures compiled by Dr Samantha Jayasekera, Consultant in Palliative Medicine. Tel: 020 7806 4050 or 07720 972435 or Dr Chris Farnham (IPU Consultant) 07884 362242. 14 (Telephone numbers should not be passed on to patients.) 15 Dermatology Cardiology HAIR LOSS IN WOMEN ... ANTAB", DR VICKY JOLLIFFE S!ED", MBBCHIR, MA (CANTAB), FRCP, P FRCS(ED), MRCGP Consultant Dermatologist elp, doctor, I’m losing my hair!’ This is a not uncommon cause for H consultation in primary care, and a sympathetic and systematic approach needs to be undertaken in managing such patients. There are several key points in the history which are paramount. A hair fall of short duration may suggest alopecia areata or acute effluvium, ATRIAL DR PIERS CLIFFORD whereas gradual thinning with loss BA MBBS MD FRCP of volume is more suggestive of Consultant Cardiologist Pattern Hair Loss (FPHL). Ask about trigger factors which may cause an trial #brillation is the most FIBRILLATION e"uvium – recent childbirth, stress, common cardiac arrhythmia, What are the medication, illness, or surgery. How Aa!ecting more than 10% of about parents and siblings? Do they patients over the age of 80. It carries medical have normal hair? a risk of stroke and may lead to heart Alopecia Areata (AA) may failure and worsening symptoms of options open occur in families and can also be angina. The primary objectives of associated with other familial treatment are to minimise the stroke to Consultants autoimmune conditions. Is the risk, to control the heart rate or to menstrual cycle regular, is there A DIAGNOSTIC AND restore sinus rhythm. The individual’s and GPs? a history of acne or hirsutism risk of stroke can be estimated using which may suggest underlying the CHADSVAS score. If the score is hyperandrogenaemia, most THERAPEUTIC APPROACH zero no anticoagulation is required. commonly due to Polycystic Ovary A score of greater than 1 is an regrowth), Telogen E!uvium in which Telogen E"uvium. FBC, ferritin, ANA Syndrome? Styling practices may be indication for oral anticoagulation. club hairs are shed in increased and TFTs as a baseline are valuable. If highly relevant – hair straightening Warfarin has been the mainstay numbers often resulting in loss of hair FPHL is suspected, SHBG, testosterone, and frequent blow-drying may of treatment, aiming for an INR volume in a bitemporal distribution, prolactin and occasionally DHEAS may cause weathering of the hair shaft, between 2 and 3. Newer agents are and Female Pattern Hair Loss, in be performed on days 1-5 of the making it more prone to breaking. now available, such as dabigatran or rhythm (rhythm control) has never control long term is often di$cult which density is reduced over the cycle when the patient is o! the OC Examination should be rivaroxiban, which are more e!ective been shown to be more e!ective and requires the use of powerful crown and preserved at the occiput. pill. Mycology may be indicated in focused on the hair shaft itself than warfarin at preventing stroke than rate control in preventing the anti-arrhythmic drugs such as Scarring alopecia is less scaling, and hair plucks as well as and whether there is a scarring or with a lower bleeding risk. major complications of AF. It may sotalol, %ecainide, dronedarone or commonly seen, but the pattern of scalp scrapings should be sent if non-scarring process underlying They are, however, more achieve better symptom control, amiodarone. All these drugs have scarring should be noted alongside possible. the hair loss. Note the skin type. expensive, have less of a track but at the cost of a greater number signi#cant side-e!ects, including other features such a perifollicular Telogen e"uvium should resolve Patients with Afro-textured hair record in clinical practice and are of hospitalisations when patients life-threatening arrhythmias, and erythema and scaling, styling such as after any correctable factors have may have some speci#c causes of di$cult to reverse if bleeding %ick back into AF. Therefore the vast should be prescribed only with corn-row braiding or straightening been modi#ed, e.g. stopping relevant scarring alopecia such as Central becomes a problem. Most majority of elderly patients can be specialist advice. and pigmentary changes such as drugs,correcting ferritin, alleviating Centrifugal Cicatricial Alopecia or guidelines now do not advise well controlled using beta-blockers Ablation of AF is also a possibility hypopigmentation commonly seen stress etc. AA may warrant specialist Acne Keloidalis Nucheae which are using aspirin for stroke prevention or rate-slowing dihydropyridines in highly symptomatic patients with with Discoid LE. All cases of scarring referral but it is reasonable to start not seen in patients with Fitzpatrick in AF, as it carries a bleeding risk, (verapamil or diltiazem). paroxysmal AF, with successful cure alopecia should be referred to a superpotent topical steroid at night skin types 1-4. especially in elderly patients, Digoxin can be added to achieve being achieved in 65-85% of treated dermatologist as biopsy is usually for up to six weeks to the a!ected Common non-scarring causes but is not nearly as e$cacious as a resting heart rate of 80 beats per patients. Rhythm control in itself is indicated, and many scarring patch in primary care . FPHL may of hair loss include Alopecia areata oral anticoagulation. The risk of minute but should not be used as not a substitute for anticoagulation processes progress rapidly, leaving warrant oral therapy and specialist (annular clearly demarcated non- bleeding can be assessed using mono therapy unless the patient and patients need to remain on permanent alopecia. investigation but topical Minoxidil scarring non-scaly patches of hair the HASBLED score and caution is is largely sedentary because it warfarin according to their risk Investigation in primary care can can reasonably be started pending loss, with exclamation mark hairs advised if this score exceeds the does not prevent heart-rate rises score long term in case AF returns be helpful, especially for patients with review by a Dermatologist. peripherally and very often white CHADSVAS score. Restoring sinus on exercise. Achieving rhythm unnoticed. 16 Tel: 020 7806 4060 [email protected] www.londondermatologyunit.co.uk Tel: 020 7806 4080 [email protected] www.thecardiacunit.org.uk 17 OUR CONSULTANTS: Knee Unit

Mr Raj Bhattacharya FRCS (Tr & Orth) MBBS MRCS (Ed) MRCS (Glas) MSc After starting his medical career in Lanarkshire and the North-East of England, he completed basic surgical training, Masters degree and registrar training. He undertook Fellowships in Knee Surgery and Trauma in Edinburgh, then Knee Surgery at Southampton Knee Unit before becoming Consultant at Imperial in 2010. His clinical interests include mainly complex trauma and knee injuries as well as hip and knee joint replacements. He also has active research interests in these areas, is widely published and has presented his work internationally. He is heavily involved INTRODUCING in the teaching and training of medical students at Imperial College Medical School. OUR NEW KNEE UNIT

Mr Nicholas Garlick MBBS FRCS (Edin) FRCS (Eng) FRCS (Orth) Having quali!ed at St Bartholomew’s Medical School, he completed registrar Visit our new Knee Unit website: training at St George’s www.londonkneespecialists.co.uk Hospital, Royal Free and Royal National Orthopaedic Hospital Contact: 020 7432 8297 Rotations. His lower-limb specialist training took place at the OOur new Knee Unit Mr Nicholas Goddard MBBS FRCS Royal National Orthopaedic Following graduation from St Bartholomew’s Hospital and the Charnley Mr Nimalan Maruthainar brings together many FRCS (Tr & Orth) MBBS BSc (Hons) Medical School which included further training Joint Replacement Unit, of the country’s leading He quali!ed from the Royal Free followed at the University of Vancouver, he undertook Redhill. He undertook further lower-limb specialists by basic surgical training at Norfolk and diplomas in Microsurgical Techniques and specialist training in shoulder Norwich. Further training at RNOH included Surgery of the Hand and Upper Limb at the surgery at the Royal National to provide unparalleled one year as Clinical Lecturer at the Institute of University of Paris VI. Orthopaedic Hospital, a access to top surgeons. Orthopaedics, UCL. His fellowships included He started his consultancy at the Royal Free speciality which he maintains. Our consultants are the Joint Reconstruction Unit, RNOH and Knee in 1990 where he remains. He is an honorary His main NHS consultancy Unit, University of Southern California, then consultant for several organisations including Surrey County is at the Royal Free Hampstead available every consultant at the Royal Free since 2005. Cricket Club, Dispensaire Français, London and the Royal where he is Clinical Lead in weekday plus Previously an Honorary Senior Lecturer at UCL, he is Associate Ballet School. Orthopaedic Surgery. He Saturdays, with urgent Editor Orthopaedics and Trauma Specialist Collection, NHS Evidence He has published over 90 articles and book chapters and 2,000 teaches students at the Royal medicolegal papers. He is an examiner for IMRCS (RCS), European appointments available & Trust Speciality Training Director for Trauma & Orthopaedic Surgery, Free and University College Royal Free. He has special interests in hip and knee arthroplasty and Diploma in Hand Surgery and MB BS (University of London). Medical Schools. on the same day or the orthopaedic aspects of lysosomal storage diseases. within 24 hours.

Mr James Youngman MBBS FRCS (Tr & Orth) Mr Robert Marston MBBS FRCS (Eng & Edin), FRCS (Orth) Graduating from Middlesex and UCL, he worked in major trauma at Whipps Cross and Obtaining his MD from St Thomas’ Hospital, he completed fellowships at the RNOH the Royal London before becoming consultant at UCLH, experienced in adult and with Johnson & Johnson as Zimmer Hip Fellow and BOA Travelling Fellow in the paediatric trauma. United States and Australia. He has a major interest in treatment of knee problems, including complex trauma, His main NHS post is at Imperial with honorary positions at St Luke’s Hospital and sports injuries and degenerative conditions, and advanced arthroscopic techniques Ravenscourt Park NHS Treatment Centre. ! with complex ligament reconstruction using hamstring, patella tendon or allograft. His speci c interest and expertise is lower-limb trauma and he runs the 24-hour His deformity work includes correction of long-bone deformity, either by trauma unit for the elderly at St John & St Elizabeth’s. osteotomy or acute correction using Ilizarov or Taylor spatial frames. Performing and His orthopaedic subspecialty interests are primary, complex primary and revision teaching knee-replacement techniques including complex knees with severe deformity, he carries out hip surgery. He performs knee arthroscopy, anterior cruciate ligament reconstruction, degenerative hip reconstruction and revision arthroplasty. 18 knee replacement and some foot and ankle. 19 Paediatric Cardiology Characteristics of an Indications for referral to a innocent murmur Paediatric Cardiologist The murmur is soft with no Previous child with Similar lesions CONGENITAL HEART DISEASE diastolic component Background risk of CHD is congenital heart higher in view of previous more likely to ! There is a normal second heart disease a ected child recur sound AND THE GENERAL PRACTITIONER Family history of A Hx of genetic cardiac Cardiomyopathies It may vary with position but heart disease or disease should prompt Marfans Syndrome Heart defects are the most common congenital problem seen in babies, occurring in seven to does not radiate referral eight of every 1,000 live births. Congenital Heart Disease comprises of genetic heart disease and structural abnormalities of the heart or great vessels. There are no other signs of FHx of sudden or This is particular important Long QT, symptoms of heart disease early death for arrhythmias or in cases Brugada of syncope syndrome Why one-third of babies with life-threatening Dysmorphisms or Down syndrome (T21) AVSD, VSD, Tetrology DR SHANKAR SRIDHARAN CHD leave UK Hospitals undiagnosed be missed. This is in part due to genetic / MRCPCH MBBS BSc the fact that mild defects such as a chromosomal Turner syndrome (45XO) Coarctation, bicuspid Consultant Paediatric Cardiologist Limitations in Limited (4-Ch view only) cardiac imaging at small VSD produce a loud murmur, disease aortic valve antenatal care 20-week anomaly week scan whereas larger haemodynamically Noonan syndrome (Chr 12) Pulmonary stenosis more important septal defects may HOCM espite advances in fetal Physiological Duct dependent lesions often manifest in give rise only to a very soft gentle medicine, antenatal changes at birth neonatal period after arterial duct closes – murmur as a consequence of the Williams syndrome (Chr 7) Supravalvar AS and PS # Dscreening and the these lesions missed on one-week checks ow characteristics (the diagnosis – Elastin gene mutation) implementation of postnatal baby is always easier with an echo checks in the UK, approximately Lack of awareness Di"culty in identifying cause of illness in machine!). Prematurity At any gestation ASD, PDA one-third of infants with life- of CHD as a di!erential infants due to clinical overlap of signs threatening CHD leave hospital Presentation with heart failure Maternal ill health SLE Congenital Heart Block undiagnosed (Wren, C et al 2008. If a heart defect is undiagnosed Arch Dis Child Fetal Neonatal Ed. where up to 60% of patients have from a fetal to postnatal circulation. and the circulation is insu"cient, Antenatal Infection Rubella Pulmonary Stenosis Twenty-year trends in diagnosis some form of heart disease. Urgent referral is warranted if an infant may present later with of life-threatening neonatal A family history of heart problems there is associated heart failure symptoms or signs of heart failure. Postnatal infection Viral mediated Viral myocarditis cardiovascular malformations). in siblings or relatives, or genetic (poor feeding, tachypnoea or These include: cardiac conditions should also hepatomegaly) and/or cyanosis, OBreathlessness, particularly when Bacterial Endocarditis These infants then often !rst prompt referral. These include as an emergency if necessary. If a crying for feeding present to front-line NHS health conditions such as: murmur is heard and the baby is OTachypnoea with or without services including General otherwise well, review again a week tachycardia Practitioners and A&E departments. Cardiomyopathies where there is an later to assess for ongoing presence. OFailure to thrive and/or di"culty An awareness that illness in a young underlying problem with the heart If still present, refer to paediatric feeding Signs and symptoms of heart disease in children child may be due to cardiac disease muscle. cardiology. OHepatomegaly Signs Cyanosis (perioral cyanosis is common in is a valuable clinical aid during Connective tissue disorders such OWeight increase due to #uid young infants) assessment as, often, clinical signs as Marfans Syndrome and Ehlers Presentation with a murmur in retention Murmur overlap in young infants and it can Danlos Syndrome. infants and children Tachycardia be di"cult to discern the underlying Inherited arrhythmic conditions Murmurs are a common !nding in The most likely causes of heart Tachypnoea/respiratory distress (young infants) aeitiology. including chanellopathies such as childhood. Most of these murmurs failure in neonates include left heart Weak femoral pulse Long QT Syndrome and Brugada are innocent murmurs and not due lesions such as severe aortic stenosis Hypertension Who should be referred? Syndrome that may present with to congenital heart disease. These and coarctation of the aorta. In Patients are often referred to tachycardia or syncope. murmurs are usually generated as a older infants and children, large Symptoms Breathlessness a paediatric cardiologist for consequence of the blood #owing VSDs, patent ductus arteriosus and Failure to thrive assessment following the suspicion Common Signs and Symptoms at speed around tight corners and ASDs may cause heart failure. Chest pain (older children) (check if upon exertion) of heart disease from either clinical Clinical history, examination and bends in a relatively smaller heart Exercise intolerance signs such as cyanosis, following suspicion that a heart problem may (as compared to an adult). Innocent Presentation with cyanosis Palpitations or syncope (check FHx) the detection of heart murmurs in be present are key factors in making murmurs become more apparent Cyanosis in babies is uncommon children, or due to symptoms such a diagnosis. during times when the heart works and usually indicates a serious issue. as breathlessness and poor weight a little harder (producing more Low oxygen saturations may be gain. Chest pain is a common Presentation with a heart murmur turbulence) such as during fever di"cult to assess in a GP surgery. complaint in older children at the 6-8 week check or exertion. Later presentation in infancy is Is it always awful news? in children may often be managed and review can often exclude a Approximately 45% of cardiac Patients are often referred mostly due to cases of important Con!rming that a child has a heart in the clinic without the need for cardiac pathology and provide malformations are detected before to a Paediatric Cardiologist for pulmonary stenosis or tetralogy of problem is upsetting for any parent. interventional procedures or child reassurance. a child’s !rst birthday. Around assessment following the !nding Fallot. Perioral cyanosis can be a It is important to remember that heart surgery. A rapid and accurate 50% of murmurs heard at the 6-8 of a cardiac murmur. Many common !nding in young children there is a huge variation in the diagnosis, together with a kind Babies or children with a syndrome, week check re#ect an underlying clinicians feel uncomfortable about and may be due to environmental severity, impact and management empathic approach, best serves the or proven chromosomal problem, structural cardiac issue. Murmurs classifying a murmur as ‘innocent’ changes in temperature. of lesions. Congenital heart disease child, family and GP. are often at much higher risk of may not manifest initially as until formal paediatric cardiac having a coexisting heart problem pulmonary pressures but may take a review as they are concerned that 20 e.g. Downs Syndrome (Trisomy 21) few days to fall following transition an underlying cardiac problem may Tel: 020 7078 3831 [email protected] www.thepaediatricunit.org.uk 21 Paediatric ST JOHN & ST ELIZABETH’S SPECIALIST UNITS BREAST UNIT SPINE UNIT Telephone: 020 7266 4272 Tel: 0844 589 2020 Fax: 020 7432 8264 Fax: 0844 589 6060 DIFFICULTDIFFICULT email: [email protected] email: [email protected] ECZECZEEMAMA www.thebreastunit.org.uk www.thespineunit.org.uk STROKE UNIT HYPERMOBILITY UNIT Telephone: 020 7806 4075 Telephone: 020 7806 4010 ININ OLDEOLDERR Fax: 020 7806 4003 Fax: 020 7806 4009 email: [email protected] email: [email protected] CCHILHILDRENDREN www.thestrokeunit.org.uk www.thehypermobilityunit.org.uk PAEDIATRIC UNIT LONDON UROLOGY Telephone: 020 7078 3831 Telephone: 020 7432 8297 Fax: 020 7806 4001 Fax: 020 7806 4008 email: [email protected] email: [email protected] www.thepaediatricunit.org.uk www.londonurology.org.uk Treating this distressing problem when traditional steroids are not working RAST GI UNIT SHOULDER UNIT Telephone: 020 7432 8253 Telephone: 020 7806 4004 less likely (but not impossible) it is Skin-prick testing or speci!c DR LEE NOIMARK Fax: 020 7432 8251 Fax: 020 7806 4008 for food allergy to be related. The IgE (RAST) testing can be MRCPCH MBBS MSc BSc email: [email protected] email: [email protected] eczema treatment needs to be performed and once the Consultant Paediatrician www.theshoulderunit.org.uk reviewed, making sure that regular allergens are isolated e.g. www.thegiunit.org.uk 12-year-old girl comes moisturising is taking place, a soap house dust mite, measures to see you with eczema substitute and bath emollient are can be put into place above not responding to potent in place and an appropriate steroid and beyond just the eczema steroids. The distribution has been prescribed. The steroid treatment to help the patient’s " should be used in a su#cient symptoms improve, adopting CARDIAC AND Aa ects her arms and legs with GYNAE UNIT general sparing of her body. Her amount to cover the skin and leave a more holistic approach. RESPIRATORY UNITS face is also a"ected. Her eczema it nicely covered. Too sparing an Advice should be given to the Telephone: 020 7806 4060 treatment has been changed application is a common problem patient as to how to minimise Telephone: 020 7806 4080 Fax: 020 7806 4001 several times with no improvement. for treatment failure. the environmental impact of Fax: 020 7806 4081 email: [email protected] The eczema started in the past Once the eczema treatment has the allergens on their eczema. email: [email protected] www.hje.org.uk 18 months. She tells you that the been reviewed, allergy needs to Rhinitis should be treated www.thecardiacunit.org.uk eczema is especially bad in the be considered. A thorough history symptomatically with nasal www.therespiratoryunit.org.uk summer and winter. She has allergic asking about both immediate and douching, anti-histamine and rhinitis but not asthma. The family delayed reactions to food is taken steroid spray as needed. are convinced that food allergy is and tests taken depending on OPHTHALMOLOGY VARICOSE VEINS causing her eczema. the history. What is important to UNIT Telephone: 020 7078 3822 This remains a common problem recognise in the older age group is the impact of aeroallergens Fax: 020 7078 3877 that is being increasingly faced in Telephone: 020 7806 4060 on eczema. The rhinitis history is email: [email protected] primary care with children with Fax: 020 7806 4045 often helpful and knowing when www.varicoseveins.co.uk eczema. While there is little doubt email: [email protected] that food allergy plays a part in this causes a problem can help www.theophthalmologyunit.org.uk eczema in children under the age you with likely environmental of one, with children developing allergens which are responsible. eczema later in life this is less The distribution of the eczema common. It is important here to also only occurring on exposed LONDON FOOT & ANKLE CENTRE KNEE UNIT ! nd out when the eczema may non-covered areas of skin hints Common eczema sites in Telephone: 020 7078 3800 Telephone: 020 7432 8297 older children have started, and the older a child that this may be caused by Fax: 020 7078 3801 Fax: 020 7806 4008 is when the eczema started the environmental allergens. email: [email protected] email: [email protected] www.londonfootandanklecentre.co.uk Tel: 020 7078 3831 [email protected] www.londonallergyspecialists.co.uk www.londonkneespecialists.co.uk O Our pro!ts help support St John’s Hospice, which cares for more than 2,000 terminally ill 22 people and their families every year for free PRIVATE SELF!PAY WALK!IN URGENT CARE CENTRE AVOID NHS A&E QUEUES _ 10,000 PATIENTS ALREADY TREATED

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