Publications by authors named "Jonathan Birns"

43 Publications

Secondary Stroke Prevention Following Embolic Stroke of Unknown Source in the Absence of Documented Atrial Fibrillation: A Clinical Review.

J Am Heart Assoc 2021 07 2;10(13):e021045. Epub 2021 Jul 2.

King's College London London United Kingdom.

Approximately one-third of ischemic strokes are classified as cryptogenic strokes. The risk of stroke recurrence in these patients is significantly elevated with up to one-third of patients with cryptogenic stroke experiencing a further stroke within 10 years. While anticoagulation is the mainstay of treatment for secondary stroke prevention in the context of documented atrial fibrillation (AF), it is estimated that up to 25% of patients with cryptogenic stroke have undiagnosed AF. Furthermore, the historical acceptance of a causal relationship between AF and stroke has recently come under scrutiny, with evidence to suggest that embolic stroke risk may be elevated even in the absence of documented atrial fibrillation attributable to the presence of electrical and structural changes constituting an atrial cardiomyopathy. More recently, the term has garnered increasing interest as a subset of patients with cryptogenic stroke in whom a minimum set of diagnostic investigations has been performed, and a nonlacunar infarct highly suspicious of embolic etiology is suspected but in the absence of an identifiable secondary cause of stroke. The ongoing ARCADIA (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke) randomized trial and ATTICUS (Apixiban for Treatment of Embolic Stroke of Undetermined Source) study seek to further define this novel term. This review summarizes the relationship between AF, embolic stroke, and atrial cardiomyopathy and provides an overview of the clinical relevance of cardiac imaging, electrocardiographic, and serum biomarkers in the assessment of AF and secondary stroke risk. The implications of these findings on therapeutic considerations is considered and gaps in the literature identified as areas for future study in risk stratifying this cohort of patients.
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http://dx.doi.org/10.1161/JAHA.121.021045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403300PMC
July 2021

An update on hyper-acute management of ischaemic stroke.

Clin Med (Lond) 2021 05 4;21(3):215-221. Epub 2021 May 4.

St Thomas' Hospital, London, UK and deputy head of School of Medicine, Health Education England, London, UK.

This article aims to provide a comprehensive overview of key advances on various aspects of hyper-acute management of acute ischaemic stroke. These include neuroimaging, acute stroke unit care, management of blood pressure, reperfusion therapy including intravenous thrombolysis, mechanical thrombectomy and decompressive hemicraniectomy for malignant stroke syndrome. The challenge ahead is to ensure these evidence-based treatments are now being delivered and implemented to maximise the benefits across the population.
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http://dx.doi.org/10.7861/clinmed.2020-0998DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140712PMC
May 2021

Supporting the transition to becoming a medical registrar.

Future Healthc J 2021 Mar;8(1):e160-e163

geriatrics and general medicine, Guy's and St Thomas' NHS Foundation Trust, and deputy head, London School of Medicine for Health Education England, London, UK.

Introduction: Physician training is seeing increasing numbers of doctors adopting the role of medical registrar. Non-clinical as well as clinical responsibilities are a source of great anxiety prior to trainees assuming this role.

Methods: A standardised, blended, 1-day course to address the needs of doctors transitioning to become a medical registrar was designed and delivered across four hospitals. A mixed methods evaluation approach was employed to assess the effect of the course.

Results: Thirty-four trainees approaching the transition to becoming a medical registrar participated. Quantitative and qualitative analysis of participants' written feedback showed a significant pre- to post-course increase in candidates' self-reported confidence in undertaking the medical registrar role along with learning in non-technical skills.

Discussion: This course was shown to be effective in helping to improve the confidence of trainees approaching the medical registrar role. The carefully designed standardised format may facilitate wider expansion of such training.
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http://dx.doi.org/10.7861/fhj.2020-0177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8004318PMC
March 2021

A Springboard for physicians returning to practice.

Clin Teach 2021 Jun 20;18(3):264-268. Epub 2020 Dec 20.

Health Education England, London, UK.

Background: Many physicians take time out of training and have decreased confidence and poor performance ratings on their return. Courses employing multiple educational methods have been shown to be effective in easing learners into new clinical roles during transition periods but, to date, there is limited evidence for courses to support trainees returning to practice (RTP).

Methods: A 2-day course, named Springboard, was developed, specifically to address the needs of trainee physicians RTP. It employed a blended, multi-modal approach to learning, including lectures, workshops, case-based sessions, interactive panel discussions, small group teaching, peer-led practical advice sessions and simulation training. Springboard was delivered eight times between 2014 and 2019 with a total of 540 doctors attending. We analysed participant pre-and post-course questionnaire feedback.

Results: Reasons for doctors taking time out of training included parental leave, research, fellowships in education and leadership, health-related absence and career breaks. Time out of training ranged between 3 months and 6 years. A significant pre/post-course increase in candidates' self-reported leadership skills and confidence in being prepared to return to practice was demonstrated alongside an appreciation of a multi-modal, 'boot camp' course delivered by expert faculty and a networking experience.

Discussion: Dedicated training courses tailored to the needs of physicians RTP provide an opportunity for improving confidence relating to many areas of clinical and non-clinical practice as well as providing an environment for networking and sharing experiences. Further work would be valuable to establish the potential of providing this on a larger scale.
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http://dx.doi.org/10.1111/tct.13318DOI Listing
June 2021

Training educational supervisors to support physician trainees returning to practice.

Future Healthc J 2020 Jun;7(2):120-124

Health Education England, London, UK and consultant in stroke medicine, geriatrics and general medicine, St Thomas' Hospital, London, UK.

Physicians take time out of training for a variety of reasons and, on their return, they often lack confidence and feel 'out of touch'. These trainees require enhanced support and concerns have been raised about trainers' lack of skills and knowledge in this area. A standardised workshop was developed and delivered to address this with a mixed-methods evaluation approach used to analyse data from participants before and after training. Quantitative analysis showed significant pre- to post-course improvements in trainers' ability to understand, explain and manage issues pertaining to trainees taking time out of training. Qualitative analysis yielded three 'learning' themes surrounding knowledge, understanding and awareness of support needed for returning trainees and three 'action' themes surrounding disseminating information, providing resources and actively supporting returning trainees. Framework analysis of follow-up interviews demonstrated not only retention of topics learned but also positive changes in behaviour.
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http://dx.doi.org/10.7861/fhj.2019-0043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296578PMC
June 2020

Evaluation of training programmes mapped to the new internal medicine curriculum.

Future Healthc J 2020 Jun;7(2):116-119

Health Education England, London, UK.

In preparation for the internal medicine training (IMT) programme introduced in 2019, the core medical training (CMT) programme in London was made 'IMT-ready' in 2018 by creating new rotations that reflected the compulsory requirements of the first 2 years of the IMT curriculum, including provision of the requisite number of critical care placements. Core medical trainees completed posts within the 'IMT-ready' programme between August 2018 and August 2019, during which time the trainee experience was evaluated. A total of 497 responses were received. Of these, 96% of trainees were on an 'acute unselected take' on-call rota, 79% were able to attend outpatient clinics, 80% had the opportunity to practise procedural skills and 88% had the opportunity to apply palliative care skills. Clear areas for improvement were identified that predominantly focused on the need to optimise trainee attendance of outpatient clinics and the number of patients seen during an acute take. With respect to future career intentions, only 63% of trainees planned on applying to a group 1 (with general medicine) higher medical specialty. Thematic analysis of trainees in critical care placements highlighted an appreciation of the level of senior support, feeling well integrated into the team, a positive experience of induction and excellent opportunities for performing procedures.
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http://dx.doi.org/10.7861/fhj.2019-0060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296574PMC
June 2020

Approaches to Eating and Drinking with Acknowledged Risk: A Systematic Review.

Dysphagia 2021 02 1;36(1):54-66. Epub 2020 Apr 1.

Department of Speech and Language Therapy, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.

Background: Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, risk/benefit discussions, patient wishes, their capacity and best interests.

Objective: This study aimed to establish if EDAR protocols improve care through a systematic literature review with a secondary aim to explore important factors for the development and success of a protocol.

Methods: PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May 2019 with terms related to EDAR, dysphagia and end of life. Articles were agreed for inclusion by three independent reviewers. Levels of evidence were assessed using the modified Sackett scale. Study themes were identified and discussed.

Results: 8 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study). Most were limited to patients with dementia, stroke, in older person's wards or residential homes. Three articles described a systematic approach to EDAR for in-patients, reporting reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Five papers explored the views and knowledge of staff, patients and families/carers relating to EDAR and complex feeding decisions. Formal meta-analysis was not possible due to the level and mix of methodology.

Conclusion: There is a paucity of evidence to determine if EDAR protocols improve care. However, support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; training and communication within teams is essential, together with incorporating feedback from patients and carers, and this justifies further work.
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http://dx.doi.org/10.1007/s00455-020-10107-0DOI Listing
February 2021

Stroke warning syndromes.

Br J Hosp Med (Lond) 2020 Jan 28;81(1):1-5. Epub 2020 Jan 28.

Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.

It is important for physicians to be aware of stroke warning syndromes because, although rare, there is a high associated risk of subsequent ischaemic infarction. Stroke warning syndromes present as stereotypical, recurrent transient episodes of focal neurological deficit, in the absence of cortical signs, occurring within a short period of time. They are broadly divided into two main subtypes, based on vascular territory: capsular warning syndrome and pontine warning syndrome. The exact underlying pathophysiology related to stroke warning syndromes is incompletely established, but proposed pathophysiological hypotheses for cerebral hypoperfusion include micro-atherosclerosis (cerebral small vessel disease) and haemodynamic instability (e.g. hypotension). Atherosclerotic disease involving small perforating arteries in the anterior circulation (e.g. lenticulostriatal arteries) gives rise to capsular warning syndrome and subsequent risk of capsular infarcts. Conversely, involvement of the posterior circulation pontine perforator arteries gives rise to pontine warning syndrome, which can result in paramedian pontine infarcts. Although the evidence is limited, recommended treatment modalities include permissive hypertension, intravenous recombinant tissue plasminogen activator, dual antiplatelet therapy and statins.
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http://dx.doi.org/10.12968/hmed.2019.0222DOI Listing
January 2020

The management of infective endocarditis complicated by stroke.

Int J Clin Pract 2020 04 17;74(4):e13469. Epub 2020 Jan 17.

Department of Aging and Health, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1111/ijcp.13469DOI Listing
April 2020

FORWARD (Feeding via the Oral Route With Acknowledged Risk of Deterioration): evaluation of a novel tool to support patients eating and drinking at risk of aspiration.

Age Ageing 2019 07;48(4):553-558

Department of Geriatric Medicine, Guy's and St. Thomas's Hospital, UK.

Background: care of patients with a permanently unsafe swallow who are inappropriate for tube feeding is challenging. Eating and drinking with acknowledged risk (EDAR) may be an appropriate strategy but without clear decision making and communication patients may spend unnecessarily long 'nil by mouth' (NBM), they or their family may experience significant anxieties and advance care plans may not be made.

Methods: the FORWARD (Feeding via the Oral Route With Acknowledged Risk of Deterioration) care bundle was sequentially co-designed and embedded across different in-patient clinical services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD's implementation was evaluated using a time-series analysis of 305 'EDAR patients' (19 in 6 months pre-FORWARD; 42 in a 12-month 'pilot'; 244 patients in the subsequent 27 months).

Results: median (IQR) days patients were NBM without an alternative feeding route reduced significantly from 2 (1-4) pre-FORWARD to 0 (0-2) in the 'pilot' and 0 (0) post-'pilot' (P < 0.05). G-chart analysis demonstrated sustained performance across time and different clinical settings. Implementation of FORWARD significantly improved documentation of capacity assessment (42%→98%), discussions with next of kin (47%→98%) and onward communication of feeding plans (67%→81%). In wards where FORWARD was introduced, rate of aspiration pneumonia (a 'balancing measure' sensitive to harm associated with EDAR) increased at half the rate of dysphagia (0.8%/year versus 1.6%/year).

Conclusion: the FORWARD care bundle supported complex decision-making around EDAR in patients with persistent dysphagia. The benefits of FORWARD were shown to be sustained over time and in a wide in-patient context.
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http://dx.doi.org/10.1093/ageing/afz050DOI Listing
July 2019

Improving the Management of Post-Stroke Spasticity: Time for Action.

J Rehabil Med Clin Commun 2018 21;1:1000004. Epub 2018 Sep 21.

Rehabilitation Medicine, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.

Objective: To identify barriers to appropriate referral and treatment for patients with spasticity and present solutions that address these in a pragmatic way.

Methods: Using the findings of interviews conducted with UK healthcare professionals on the management of post-stroke spasticity, a consensus meeting was held involving 7 UK spasticity experts. The panel identified barriers to timely identification and referral of patients in the acute and post-acute care settings. Barriers were prioritized using a consensus framework based on impact and resolvability and a series of final recommendations were agreed.

Results: High-priority barriers broadly related to: insufficient awareness of spasticity symptoms and benefits of treatment, limited access to spasticity services and lack of standardized pathways for post-stroke spasticity identification. Potential solutions included the appointment of an experienced member of the acute team to gain expertise in spasticity identification, patient education of spasticity symptoms and a greater utilization of training resources for healthcare professionals.

Conclusion: To address the barriers identified, we provide a series of consensus recommendations. As a key recommendation, we propose a set of indicators for the identification of stroke patients requiring specialist assessment and the use of the associated acronym "ACTION".
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http://dx.doi.org/10.2340/20030711-1000004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011679PMC
September 2018

Improving the care of patients feeding at risk using a novel care bundle.

Future Healthc J 2017 Oct;4(3):202-206

Guy's and St Thomas' NHS Foundation Trust, London, UK.

Feeding with acknowledged risk is appropriate for patients unsuitable for tube feeding who have an unsafe swallow that is unlikely to improve. However, without excellent multidisciplinary decision making and communication, patients may spend unnecessarily long 'nil by mouth' (NBM) and advance feeding/care plans may not be made or communicated. The FORWARD bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) was sequentially co-designed and embedded across different services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD was evaluated using a time-series analysis of 80 patients who had been risk-fed. Time NBM without tube feeding improved from 2 to 0 days (p=0.02) with significantly better documentation of capacity assessments and discussions with next of kin. There were sustained trends to improved rates of best interest discussions and communication of feeding plans to downstream care providers. The significance and applicability of these findings is discussed.
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http://dx.doi.org/10.7861/futurehosp.4-3-202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502578PMC
October 2017

Trials and tribulations of the annual review of competence progression - lessons learned from core medical training in London.

Future Healthc J 2017 Jun;4(2):92-98

London School of Medicine, London, UK.

The annual review of competence progression (ARCP) was introduced as a way of keeping records and reviewing satisfactory progress through a medical curriculum for doctors in training. It provides public assurance that doctors are trained to a satisfactory standard and are fit for purpose. A routine external review of the core medical training (CMT) ARCPs in London revealed documentation of satisfactory progression of trainees to the next level of training without the evidence to support their completion of the curriculum. An internal review and series of process interventions were subsequently conducted and implemented to improve the quality and standardisation of the ARCPs. This paper reviews these interventions, discusses the lessons learned from the internal review and highlights issues applicable to any ARCP process.
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http://dx.doi.org/10.7861/futurehosp.4-2-92DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502634PMC
June 2017

Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery.

Clin Med (Lond) 2016 Dec;16(6):535-540

Department of Ageing and Health, St Thomas' Hospital, London, UK.

It is increasingly common for physicians and anaesthetists to be asked for advice in the medical management of surgical patients who have an incidental history of stroke or transient ischaemic attack (TIA). Advising clinicians requires an understanding of the common predictors, outcomes and management of perioperative stroke. The most important predictor of perioperative stroke is a previous history of stroke, and outcomes associated with such an event are extremely poor. The perioperative management of this patient group needs careful consideration to minimise the thrombotic risk and a comprehensive, individualised approach is crucial. Although there is literature supporting the management of such patients undergoing cardiac surgery, evidence is lacking in the setting of non-cardiac surgical intervention. This article reviews the current evidence and provides a pragmatic interpretation to inform the perioperative management of patients with a history of stroke and/or TIA presenting for elective non-cardiac surgery.
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http://dx.doi.org/10.7861/clinmedicine.16-6-535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297334PMC
December 2016

Where did the acute medical trainees go? A review of the career pathways of acute care common stem acute medical trainees in London.

Clin Med (Lond) 2016 Oct;16(5):427-431

School of Medicine, Health Education England, London, UK.

Acute care common stem acute medicine (ACCS AM) training was designed to develop competent multi-skilled acute physicians to manage patients with multimorbidity from 'door to discharge' in an era of increasing acute hospital admissions. Recent surveys by the Royal College of Physicians have suggested that acute medical specialties are proving less attractive to trainees. However, data on the career pathways taken by trainees completing core acute medical training has been lacking. Using London as a region with a 100% fill rate for its ACCS AM training programme, this study showed only 14% of trainees go on to higher specialty training in acute internal medicine and a further 10% to pursue higher medical specialty training with dual accreditation with internal medicine. 16% of trainees switched from ACCS AM to emergency medicine or anaesthetics during core ACCS training, and intensive care medicine proved to be the most popular career choice for ACCS AM trainees (21%). The ACCS AM training programme therefore does not appear to be providing what it was set out to do and this paper discusses the potential causes and effects.
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http://dx.doi.org/10.7861/clinmedicine.16-5-427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297300PMC
October 2016

Secondary prevention of stroke.

Br J Hosp Med (Lond) 2015 Jul;76(7):C104-7

Consultant in Stroke Medicine, Geriatrics and General Medicine in the Department of Ageing and Health, St Thomas' Hospital, London SE1 7EH.

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http://dx.doi.org/10.12968/hmed.2015.76.7.C104DOI Listing
July 2015

Interprofessional learning on a stroke unit.

Clin Teach 2015 Oct 5;12(5):315-9. Epub 2015 Jun 5.

Department of Ageing & Health, St Thomas' Hospital, London, UK.

Background: The importance of a collaborative approach to patient care in improving safety and outcomes has been highlighted by medical regulatory organisations. The World Health Organization has advocated that future health care professionals should be 'collaborative practice ready', and there is a global drive to incorporate interprofessional learning into health education. Interprofessional learning promotes the development of effective teamworking skills and improves the understanding of roles in the multidisciplinary team. This article outlines the development of a practice-based interprofessional learning initiative on a stroke unit. The World Health Organization has advocated that future health care professionals should be 'collaborative practice ready'

Methods: A half-day seminar was developed by King's College London in conjunction with an interprofessional clinical team from the Stroke Unit at St Thomas' Hospital. Students were assigned discipline-specific supervisors who allocated them to care for a patient within the confines of their usual professional role. They were asked to present the patient to a mixed-discipline group of students within the seminar from the perspective of their individual disciplines. This was followed by supervisor-led group discussions concerning the care of the patient and interprofessional working.

Results: Sixty-seven students from different disciplines participated in nine seminars over a 2-year period. Thematic analysis of participants' comments revealed an improvement in the students' awareness of: the varying roles and responsibilities of professionals; how differing disciplines share functions; and the importance of effective communication. All students stated that they would recommend the seminar to other students.

Discussion: Effective interprofessional learning programmes are imperative to promote collaborative practice amongst health care professionals. Stroke units are ideal learning environments for practice-based interprofessional education.
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http://dx.doi.org/10.1111/tct.12321DOI Listing
October 2015

Evaluation of a simulation training programme for geriatric medicine.

Age Ageing 2015 Jul 6;44(4):677-82. Epub 2015 May 6.

Department of Ageing and Health, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, UK.

Background: geriatrics encompasses diverse medical, social and ethical challenges requiring a multidimensional, interdisciplinary approach. Recent reports have highlighted failings in the care of older people. It is therefore vital that trainees in geriatrics are afforded opportunities to develop skills in managing this complex population. Simulation has been adopted as a teaching tool in medicine; however, evidence for its use in geriatrics has been limited to small, single-site studies primarily involving role-play or discrete clinical skills training.

Methods: a standardised, two centre, multimodal, interprofessional, geriatrics simulation training programme was developed using curriculum-mapped scenarios in which the patient perspective was central. Simulation techniques used included high-fidelity patient manikins, actors with integrated clinical skills using part-task trainers and role-play exercises. A mixed-methods evaluation was used to analyse data from participants before and after training.

Results: eighty-nine candidates attended 12 similar courses over 2 years. Thematic analysis of candidate feedback was supportive of simulation as a useful tool, with benefits for both technical and non-technical skills. Candidates commented that simulation was a valuable training modality addressing curriculum areas rarely taught formally including continence assessment, end-of-life decisions and multidisciplinary situations. Quantitative analysis of pre- and post-course questionnaires revealed a significant improvement of self-reported confidence in managing geriatric scenarios (mean improvement 11.5%; P < 0.001).

Discussion: this study demonstrated the feasibility of a standardised simulation training programme across two sites in geriatrics. Simulation training affords situational learning without compromising patient safety and is an exciting and novel method of delivering teaching for geriatrics that could be integrated into national training curricula.
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http://dx.doi.org/10.1093/ageing/afv049DOI Listing
July 2015

Simulation training for geriatric medicine.

Clin Teach 2014 Aug;11(5):387-92

Department of Ageing & Health, St Thomas' Hospital, London, UK.

Background: Geriatric medicine encompasses a diverse nature of medical, social and ethical challenges, and requires a multidimensional, interdisciplinary approach. Recent reports have highlighted failings in the care of the elderly, and it is therefore vital that specialist trainees in geriatric medicine are afforded opportunities to develop their skills in managing this complex patient population. Simulation has been widely adopted as a teaching tool in medicine; however, its use in geriatric medicine to date has involved primarily role-play or discrete clinical skills training. This article outlines the development of a bespoke, multimodal, simulation course for specialist trainees in geriatric medicine.

Methods: A 1-day multimodal and interprofessional simulation course was created specifically for specialist trainees in geriatric medicine, using six curriculum-mapped scenarios in which the patient perspective was central to the teaching objectives. Various simulation techniques were used, including high-fidelity human patient manikins, patient actors, with integrated clinical skills using part-task trainers, and role-play exercises. Debriefs by trained faculty members were completed after each scenario.

Results: Twenty-six candidates attended four similar courses in 2012. Quantitative analysis of pre- and post-course questionnaires revealed an improvement of self-reported confidence in managing geriatric scenarios (Z = 4.1; p < 0.001), and thematic analysis of candidate feedback was supportive of simulation as a useful teaching tool, with reported benefits for both technical and non-technical skills.

Discussion: Simulation is an exciting and novel method of delivering teaching for specialist trainees in geriatric medicine. This teaching modality could be integrated into the training curriculum for geriatric medicine, to allow a wider application.
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http://dx.doi.org/10.1111/tct.12156DOI Listing
August 2014

Endovascular stroke therapy.

Eur J Intern Med 2014 Sep 14;25(7):584-91. Epub 2014 Jul 14.

Department of Ageing & Health, St Thomas' Hospital, London, United Kingdom; Department of Stroke Medicine, King's College Hospital, London, United Kingdom; Department of Health and Social Care Research, King's College London, London, United Kingdom.

Background: Following the development of intravenous thrombolysis as a successful treatment for ischaemic stroke, advances in neurointerventional radiology have facilitated endovascular approaches to treatment. This article reviews the available endovascular therapeutic options and their evidence-base.

Summary: Initial studies demonstrated that endovascular treatment of ischaemic stroke with intra-arterial thrombolysis and/or the use of clot-retrieval, thrombus aspiration and stent-retriever devices produced early recanalisation and reperfusion and improved neurological outcome. More recent randomised trials, however, have failed to show translation of recanalisation into successful clinical outcome with 'time to treatment' proving crucial. In this rapidly evolving field, combined therapy incorporating intravenous and intra-arterial thrombolysis in combination with endovascular clot-retrieval has been developed and further studies are expected to yield better evidence to guide the optimal treatment of acute cerebral ischaemia.
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http://dx.doi.org/10.1016/j.ejim.2014.06.025DOI Listing
September 2014

Syringomyelia in an older patient.

Age Ageing 2014 Nov 17;43(6):880-1. Epub 2014 Jul 17.

Ageing and Health, Guy's and St Thomas' Hospital, London, UK.

We describe the case of an 80-year-old man who presented with lower limb upper motor neurone weakness and spinothalamic tract sensory deficit secondary to previously undiagnosed syringomyelia. The case highlights the need for methodical history, examination and investigation in elderly patients to achieve diagnostic accuracy.
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http://dx.doi.org/10.1093/ageing/afu097DOI Listing
November 2014

Autonomic failure following deep brain stimulation for Parkinson's disease.

Br J Hosp Med (Lond) 2012 Mar;73(3):170-1

Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London.

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http://dx.doi.org/10.12968/hmed.2012.73.3.170DOI Listing
March 2012

Telemedicine versus face-to-face evaluation in the delivery of thrombolysis for acute ischaemic stroke: a single centre experience.

Postgrad Med J 2012 Mar 19;88(1037):134-7. Epub 2012 Jan 19.

Department of Ageing & Health, Guy's and St Thomas' Hospitals, St Thomas' Hospital, London SE1 7EH, UK.

Background: Telemedicine is increasingly used in the UK to deliver thrombolysis. It is primarily used to enable assessment of people presenting with an acute stroke by a remote specialist in stroke care, and to determine eligibility for thrombolysis with alteplase (recombinant tissue plasminogen activator). This study aims to evaluate the process of acute stroke care, safety and outcome profiles when comparing face-to-face evaluation and telemedicine in the delivery of thrombolysis.

Methods: This was a retrospective single centre cohort study, evaluating patients thrombolysed from July 2007 to December 2009 inclusive. All patients were given treatment within a 3-hour window from onset of symptoms. Of the 97 patients thrombolysed, 45 (46%) were evaluated by telemedicine. Process times of the steps taken to deliver thrombolysis for the two groups were compared. The authors include the rates of symptomatic intracranial haemorrhage (SICH). Outcome data include 3-month mortality and functional status.

Results: Process times were significantly better in face-to-face: Admission to CT (p=0.001), CT to treatment (p≤0.001) and admission to treatment (p≤0.001). SICH occurred in four patients (7.7%) in the face-to-face group compared with the two patients (4.4%) in the telemedicine group (p=0.7). Favourable outcome: a modified Rankin score of 0-2 was observed in 19 patients (36.5%) in the face-to-face group compared with 19 patients (42%) in the telemedicine group (p=0.9).

Conclusions: This analysis shows that the use of telemedicine compared with face-to-face evaluation is feasible in the delivery of thrombolysis during out of hours. There are several areas of our emergency process of hyper-acute stroke care that need improving when using telemedicine.
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http://dx.doi.org/10.1136/postgradmedj-2011-130060DOI Listing
March 2012

Simulation training for hyperacute stroke unit nurses.

Br J Nurs 2011 Nov 24-Dec 7;20(21):1352-6

Stroke Unit, Department of Ageing & Health, St Thomas' Hospital, London, UK.

National clinical guidelines have emphasized the need to identify acute stroke as a clinical priority for early assessment and treatment of patients on hyperacute stroke units. Nurses working on hyperacute stroke units require stroke specialist training and development of competencies in dealing with neurological emergencies and working in multidisciplinary teams. Educational theory suggests that experiential learning with colleagues in real-life settings may provide transferable results to the workplace with improved performance. Simulation training has been shown to deliver situational training without compromising patient safety and has been shown to improve both technical and non-technical skills (McGaghie et al, 2010). This article describes the role that simulation training may play for nurses working on hyperacute stroke units explaining the modalities available and the educational potential. The article also outlines the development of a pilot course involving directly relevant clinical scenarios for hyperacute stroke unit patient care and assesses the benefits of simulation training for hyperacute stroke unit nurses, in terms of clinical performance and non-clinical abilities including leadership and communication.
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http://dx.doi.org/10.12968/bjon.2011.20.21.1352DOI Listing
February 2012

Recreational drug misuse and stroke.

Curr Drug Abuse Rev 2011 Dec;4(4):286-91

Department of Ageing & Health, St Thomas' Hospital, London, UK.

Stroke is the third commonest cause of death and single largest cause of adult disability worldwide. Whilst the majority of strokes in older individuals are due to large or small vessel arterial disease or cardiac disease in association with classical vascular risk factors, strokes occurring in younger individuals may have atypical etiologies. Recreational substance misuse is on the increase worldwide, particularly in young adults in developed countries with commonly used substances including cocaine, amphetamines, heroin and other opiates, marijuana and gammahydroxybutyrate (GHB). Adverse vascular sequelae of inappropriate use of these substances is well recognized but the link between acute stroke and substance misuse is often underestimated. Both ischemic and hemorrhagic strokes may be caused by recreational substance misuse and this paper reviews the available evidence and discusses the potential pathophysiological links.
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http://dx.doi.org/10.2174/1874473711104040286DOI Listing
December 2011

Pulmonary and paradoxical embolism with platypnoea-orthodeoxia.

Br J Hosp Med (Lond) 2011 Nov;72(11):652-3

Department of ageing and Health, St. Thomas's Hospital, London.

This article outlines the case of a 62-year-old man who presented with a deep vein thrombosis, pulmonary embolus and right middle cerebral artery territory ischaemic stroke in association with a patent foramen ovale with right-to-left shunting. Despite anticoagulation, he was noted to have desaturation and tachypnoea when upright, without other symptoms or cardiovascular compromise, that resolved on lying down. The article describes the syndrome of platypnoea-orthodeoxia, characterized by breathlessness, hypoxia and/or cyanosis while in the upright position that improves on lying down, its relationship to this case, and its resolution by closure of the patent foramen ovale.
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http://dx.doi.org/10.12968/hmed.2011.72.11.652DOI Listing
November 2011

Telestroke: a concept in practice.

Age Ageing 2010 Nov 10;39(6):666-7. Epub 2010 Sep 10.

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http://dx.doi.org/10.1093/ageing/afq125DOI Listing
November 2010
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