; Biography Mr Raj Rai Consultant Obstetrician and Gynaecologist
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Biography Mr Raj Rai Consultant Obstetrician and Gynaecologist


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Mr Raj Rai, Consultant Obstetrician and Gynaecologist and Sub Specialist in Reproductive
Medicine, St Mary’s Hospital, Imperial College Hospitals NHS Trust

Raj Rai qualified from St Thomas’s Hospital Medical School in 1988. He was awarded sub
specialty accreditation in Reproductive Medicine in 2002 following which he was appointed
as Senior Lecturer / Consultant Obstetrician & Gynaecologist at St Mary’s Hospital / Imperial
College London. A recent Wellbeing of Women funded project examined the relationship
between polycystic ovaries and adverse pregnancy outcome. He is currently the Chief
Investigator of the PROMISE trial which is a Euro 2.5 million HTA funded multicentre
placebo controlled study assessing the efficacy of progesterone supplementation in women
with ‘unexplained’ recurrent miscarriages.

St Mary’s has one of the largest dedicated reproductive endocrine units in London (headed
by Professor Stephen Franks) and has a long standing interest in both clinical and laboratory
based research into the aetiology, pathogenesis and treatment of Polycystic ovaries

Mr Raj Rai, Consultant Obstetrician and Gynaecologist and Sub Specialist in Reproductive
Medicine, St Mary’s Hospital, Imperial College Hospitals NHS Trust

Infertility and PCOS

Polycystic ovarian syndrome, the single most common endocrinopathy amongst women of
reproductive age, is an ancient genetic disorder. Descriptions over the last 2000 years
describe a combination of symptoms and signs including menstrual irregularity, masculine
habitus, sub-fertility and possible obesity. The ancestral genes encoding for PCOS are likely
to have selected during the Paleolithic hunter-gatherer era over 10,000 years ago.
Transmission through the generations is likely to be through children conceived between
fertile carrier males and sub fertile affected females; the reduced fecundity of affected
women being offset by their improved energy utilisation and a reduction in the risk of
maternal mortality.

Rotterdam (2003) Consensus:

2 out of the following 3, excluding other aetiologies:
    Oligo- or anovulation
    Clinical or biochemical signs of hyperandrogenism
    Polycystic ovarian morphology

6 – 10% of women. Similar across different populations across the globe

Reproductive consequences of PCOS
Insulin resistance is the key leading to compensatory hyper-insulinaemia is the key
endocrine disturbance leading to abnormal ovarian androgen production, abnormal
folliculogenesis and gonadotrophin production. These effects are amplified by obesity

First line treatment remains clomiphene citrate.
Second line: Ovarian diathermy or gonadotrophins
Third line      IVF – risk of OHSS

Role of Metformin

      ↑Ovulation rate (OR = 2.1)
      ↑ Pregnancy rate BUT
      Does NOT translate to an increase in the livebirth arte

      No effect on BMI
      Decreases fasting insulin but only in non-obese (BMI< 30)
      No effect on lipid profile


Worsens all biochemical and clinical features of PCOS

      Evidence base exists for diet and exercise (5 % reduction in BMI leads to significant
       improvement in biochemical parameters)
      Newer parmacotherapies eg Orlistat and Bariatric Surgery may be of benefit to some
Dr Shane Gordon, GP Commissioning Lead, NHS East of England National Co-Lead, GP
Commissioning Federation, NHS Alliance Chief Executive, North East Essex GP
Commissioning Group

Shane Gordon is the Chief Executive of the NE Essex GP Commissioning Group, formed
from the merger of Colchester Practice Based Commissioning Group (where he was CEO
since 2006) and Tendring Clinical Commissioning Group. They work in partnership with NE
Essex PCT to commission services on behalf of 324,000 patients in North East Essex. He is
also a GP in a busy general practice in Colchester.

Over the last 8 years he has worked for Essex Strategic Health Authority and its successor
NHS East of England. He is currently Associate Medical Director and GP Commissioning
Lead for NHS East of England. He is the National Co-Lead of the NHS Alliance Clinical
Commissioning Federation and provides consultancy and advice to PCTs and GP clusters
across the country.

During 2009-10 Shane’s projects at his surgery and in PBC garnered 6 national awards.

Educated at Bishop Vesey Grammar School in Sutton Coldfield, he undertook his medical
training at the University of Nottingham graduating in 1996. He qualified as a general
practitioner in 2002, having also done two years surgical training. He is a member of the
Royal College of Surgeons and the Royal College of General Practitioners and holds a
Masters degree in Information Technology.
Professor John Cleland, Professor of Cardiology, Hull University

Heart failure management in the community

The prevalence of heart failure in primary care is uncertain but is often quoted as about 1%.
However, about 3% of adults in the UK are taking loop diuretics and have a similar
prognosis to patients with heart failure. The prevalence of patients at high risk or with
symptoms that could be attributed to heart failure probably exceeds 5%.

Most patients who develop cardiovascular disease will develop heart failure before they die.
Annual mortality for well-managed patients with heart failure in primary care is about 5-10%.
Most new diagnoses of heart failure occur as a result of an acute event precipitating
hospital admission. Little effort has been made to detect pre-symptomatic major cardiac

Hospital episode statistics for the UK show that about 5% (>250,000 per year) of all
emergency hospital admissions are recorded as due to or complicated by heart failure.
Careful audit suggest that this may only be ~25% of the total disease burden. About 50% of
patients are aged <75 years most of whom have a reduced LVEF (see glossary). Hospital
mortality is about 5% and about 20% of the survivors will die within the following year,
despite widespread use of guideline-indicated therapy. Older patients are more likely to
have a preserved LVEF (HFpEF – see glossary). Their hospitality mortality is about 15% and
about 30% will die within the following year.

These statistics indicate a general failure of the UK and other health systems to address the
problem of heart failure adequately. Most health care costs are due to staff costs.
Technologies and treatments that improve the delivery of care are likely to be effective and


LVEF = left ventricular ejection fraction a traditional measure (not very accurate) measure of
left ventricular contractile performance. It is stroke volume (the volume of blood ejected by
the ventricle in a heart beat) divided by the volume of blood in the left ventricle at the end of
diastole. Please note that blood may be going backwards (mitral regurgitation) as well as
forwards. A normal LVEF is >50%.

LVSD = left ventricular systolic dysfunction – a term that is used to indicated that the LVEF
is reduced – usually to below 40%, but see below………

HFnEF or HFpEF = heart failure with normal or preserved ejection fraction. Used to be
considered largely due to diastolic LF dysfunction (a stiff ventricle). However many of these
patients have long-axis systolic dysfunction (so LVSD with a normal LVEF), valve disease,
pulmonary hypertension and right ventricular disease. A real hotch-potch. Much better
diagnosed with a blood test (BNP/NT-proBNP) than by an echocardiogram.

BNP/NT-proBNP – these are B-type natriuretic peptides (the active component and the
inactive fragment (proBNP) of the pro-hormone – cardiac stress hormones that are the most
powerful medium to long-term prognostic markers available in patients with cardiovascular
disease. Pretty good at diagnosing cardiovascular disease too.

MRA – mineralocorticoid receptor antagonists (spironolactone for women and eplerenone
for men)

Detection & Investigation

Early detection of cardiac dysfunction has been made much more effective in primary care
with development of natriuretic peptides. An elevated plasma concentration always
indicates a serious medical condition (although not necessarily cardiac) and a normal level
excludes serious cardiac or renal disease. The NICE guidelines on the use of natriuretic
peptides are overly complex and should be simplified. In case of suspected thyroid
dysfunction measure thyroid hormone. In case of suspected cardiac dysfunction measure a
natriuretic peptide. It will be elevated in conditions other than left ventricular systolic
dysfunction such as atrial fibrillation and renal dysfunction but tends to be somewhat lower
in the morbidly obese.

Patients with an NT-proBNP <200ng/L can be reassured and alternative diagnoses sought.
NT-proBNP 200-400ng/L indicates some cardiac stress but unlikely to cause symptoms or
require specific therapy. It is a call to tighten up on blood pressure and lipid control. Patients
with values >400ng/L should be investigated (standard haematology and biochemistry
should usually be sent at same time as BNP/NT-proBNP) including an ECG and an
echocardiogram. If the LVEF is normal, the patients is in sinus rhythm and eGFR is
>40mls/minute then the patient either has right sided disease or LV diastolic dysfunction


The treatment of HFpEF is based on management of comorbidity such as AF (digoxin, beta-
blocker and anti-coagulant) or hypertension (ACEi/ARB/MRA/MRA/beta-blocker) and fluid

Patients with moderate or severe valve disease should be evaluated for repair or

Patients with LVSD should be considered for triple therapy with ACE inhibitor (or ARB),
beta-blocker and MRA.
Titrate dose of ACEi or ARB to target unless limited by hypotension or renal dysfunction.
Titrate beta-blockers to target doses unless limited by bradycardia or hypotension. Aim for a
resting heart rate of 50-60bpm. Patients who reach target doses, are in sinus rhythm and
still have a resting heart rate >70bpm should receive ivabradine – a sinus node inhibitor. It
has few side effects and may be an alternative to beta-blockers when contra-indicated or
not tolerated.
MRA should be titrated to achieve serum potassium of 4.2 & 5.2mmol/L (4.5 is ideal).
Diuretics are used to control fluid retention.
Digoxin and anti-coagulants are reserved for patients with atrial fibrillation.

For patients with severe persistent LVSD should be considered for an implantable
defibrillator if preventing sudden death is considered a risk worth avoiding. Patients who
have moderate or severe symptoms and a QRS duration >120msec and are in sinus rhythm
should be considered for atrio-bi-ventricular pacing (cardiac resynchronisation therapy or

Patients with severe symptoms or recent hospitalisation should be considered for home

Recent trials targeting coronary disease in patients with heart failure have been
disappointing. Rosuvastatin failed to improve prognosis in two large trials. Two trials of
revascularisation failed to demonstrate an important impact on prognosis. Finally, two
randomised trials have shown that aspirin is associated with a substantial increase in
hospitalisation for heart failure. Whether clopidogrel is a better anti-platelet agent in patients
with heart failure is currently being tested in the CACHE (Clopidogrel versus Aspirin in
Chronic HEart failure) trial; funded by the NHS HTA and enrolling patients from primary &
secondary care. It’s a simple, pragmatic, open-label, low-hassle study. If you are interested
in participating please contact Cara Gittus Cara.Gittus@hey.nhs.uk or Mike Lammiman
Dr Miriam Johnson, Reader in Palliative Medicine, Hull-York Medical School

Miriam Johnson is a Reader in Palliative Medicine at Hull-York Medical School. Her research
interests include the management of breathlessness, particularly in heart failure, and venous
thromboembolism. She is a member of the NCRI palliative care clinical study group, the
chair of its breathlessness research sub group and is an elected member of the Association
for Palliative Medicine (UK)’s science committee. She holds three current NIHR grants
(oxygen for people with chronic heart failure, clinical decision making in VTE in people with
advanced cancer and breathing training programmes in lung cancer) and has just completed
a SuPaC funded project in non-pharmacological management of breathlessness. She is a co-
director of the Thrombosis Research in Advanced Disease (TRAD) Alliance. She is lead
palliative care research clinician for her cancer network and is local specialty group lead for
palliative care research for the North East Yorkshire North Lincolnshire region. In conjunction
with the local cardiologists, she has developed one of the first joint services for heart
patients in the UK at St Catherine’s Hospice in Scarborough where she is an Honorary
Consultant Palliative Physician.

Dr Miriam Johnson, Reader in Palliative Medicine, Hull York Medical School

Palliative care for non-malignant conditions

Palliative care services in the UK have grown up alongside oncology services, often based in
the voluntary sector and funded by cancer charities. This has led to an inequity of services
and generic support provided for people with non-malignant conditions. Publications over
the past 10 – 15 years, however, have highlighted the symptom burden experienced by
patients with other life shortening illnesses, and their carers.

Despite this, many services across the UK have been slow to systematically respond to this.
There is also a relative dearth of research to help provide an evidence base in symptom
control or service provision for supportive and palliative care non-malignant disease.

This presentation will:
     present some barriers and solutions in providing supportive and palliative care for
       patients with non-malignant conditions
     give an overview of the evidence base for the management of breathlessness as an
       exemplar symptom in non-malignant disease
     summarise the main features of advance care planning for end of life care

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