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Cheng DK, Ullah MH, Gage H, Moineddin R, Sud A. Chronic pain trials often exclude people with comorbid depressive symptoms: A secondary analysis of 346 randomized controlled trials. Clin Trials 2023; 20:632-641. [PMID: 37345528 PMCID: PMC10638851 DOI: 10.1177/17407745231182010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND Chronic pain and depression are common comorbid conditions, but there is limited evidence-based guidance for management of the two conditions together. In recent years, there has been an increase in the number of chronic pain randomized controlled trials that collect depression outcomes, but it is unknown how often these trials include people with depression or significant depressive symptoms. If trials do not include participants representative of real-world populations, evidence and guidance generated from these trials risk being inapplicable for large proportions of the target population, or worse, risk harm. Thus, in order to identify pathways to improve the conduct of clinical trials, the aims of this study were to (1) estimate the proportion of randomized controlled trials evaluating chronic pain interventions and reporting depression outcomes that include participants with significant depressive symptoms; and (2) assess the variability of inclusion proportions by pain type, intervention type, gender, country of origin, and publication year. METHODS Studies were extracted from an umbrella review of interventions for chronic pain that reported depression outcomes. Screening and data extraction were completed in duplicate and conflicts were resolved by a third author. Randomized controlled trials with at least 50% adult participants and validated depression scales were included, and randomized controlled trials with populations whose mean scores were at or above depression thresholds at baseline were considered to have included participants with depression. RESULTS Of the 346 randomized controlled trials analyzed, 142 (41%) included participants with depression. Eight pain-type groups and nine intervention types were identified. Randomized controlled trials investigating fibromyalgia and mixed chronic pain had the highest proportion of participants with depression, whereas studies of arthritis and axial pain had among the lowest. Randomized controlled trials from the United States had a significantly lower inclusion proportion compared with non-US studies, especially for studies on arthritis. The increase in inclusion proportion by publication year was driven by the increase in fibromyalgia studies. DISCUSSION AND CONCLUSION This study highlights opportunities to improve the conduct of chronic pain clinical trials. The majority of randomized controlled trials s analyzed evaluated participants without significant depressive symptoms at baseline, thus the findings synthesized in systematic reviews and subsequent guidelines are most applicable to the subset of real-world populations that do not have significant depressive symptoms. As well, systemic biases around psychological conditions and gender may be important contributors to differences in the study of depression in fibromyalgia compared with common conditions such as arthritis and axial pain. In order to better inform clinical practice, future research must intentionally include individuals with comorbid depression in trials of common chronic pain conditions, and consider methods to mitigate biases that may distort study design.
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Affiliation(s)
- Darren K Cheng
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
| | - Maarij Hannan Ullah
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Henry Gage
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Rahim Moineddin
- Department of Family & Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Abhimanyu Sud
- Department of Family & Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Humber River Hospital, Toronto, ON, Canada
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Cheng DK, Lai KSP, Pico-Espinosa OJ, Rice DB, Chung C, Modarresi G, Sud A. Interventions for Depressive Symptoms in People Living with Chronic Pain: A Systematic Review of Meta-Analyses. PAIN MEDICINE 2021; 23:934-954. [PMID: 34373915 PMCID: PMC9071227 DOI: 10.1093/pm/pnab248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This review investigated the effectiveness of clinical interventions on depressive symptoms in people with all types of chronic pain. METHODS We searched seven electronic databases and reference lists on September 15, 2020, and included English-language, systematic reviews and meta-analyses of trials that examined the effects of clinical interventions on depressive outcomes in chronic pain. Two independent reviewers screened, extracted, and assessed the risk of bias. PROSPERO registration: CRD42019131871. RESULTS Eighty-three reviews were selected and included 182 meta-analyses. Data were summarized visually and narratively using standardized mean differences with 95% confidence intervals as the primary outcome of interest. A large proportion of meta-analyses investigated fibromyalgia or mixed chronic pain, and psychological interventions were most commonly evaluated. Acceptance and commitment therapy for general chronic pain, and fluoxetine and web-based psychotherapy for fibromyalgia showed the most robust effects and can be prioritized for implementation in clinical practice. Exercise for arthritis, pharmacotherapy for neuropathic pain, self-regulatory psychotherapy for axial pain, and music therapy for general chronic pain showed large, significant effects, but estimates were derived from low- or critically low-quality reviews. CONCLUSIONS No single intervention type demonstrated substantial superiority across multiple pain populations. Other dimensions beyond efficacy, such as accessibility, safety, cost, patient preference, and efficacy for non-depressive outcomes should also be weighed when considering treatment options. Further effectiveness research is required for common pain types such as arthritis and axial pain, and common interventions such as opioids, anti-inflammatories and acupuncture.
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Affiliation(s)
- Darren K Cheng
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health
| | | | | | | | | | - Golale Modarresi
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto
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van Staveren I. Migraine and stress-an exploratory cross-country study of external stress factors. BMC Res Notes 2021; 14:174. [PMID: 33964985 PMCID: PMC8105928 DOI: 10.1186/s13104-021-05587-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/24/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The data collected by the Global Burden of Disease 2016 project indicate that migraine ranks second in high-income countries with very competitive and flexible labour markets, and first in low- and middle-income countries suffering from civic unrest and conflict. This raises the question whether external stress factors may be correlated with migraine years lived with disability per 100,000 inhabitants (YLD). The objective of this exploratory study is to test the hypothesis that external stress factors are correlated with the prevalence and severity of migraine at the country level. The analysis uses two country groups: developed and developing countries. For the first group, the proxy variables for stress are labour productivity and unemployment rate. For the second group, the proxy variables measure conflict-related deaths and share of migrant/refugee population. RESULTS The results show a positive relationship between the stress variables on the one hand and migraine YLD on the other hand for both country groups. Almost all results are statistically significant at p < 0.01. These exploratory findings suggest that societal stress factors may be potential candidates for modifiable factors for the prevalence and/or severity of migraine at the country level.
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Affiliation(s)
- Irene van Staveren
- Institute of Social Studies, Erasmus University Rotterdam, Kortenaerkade 12, 2518 AX, The Hague, The Netherlands.
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Interrelationships between job demands, low back pain and depression: A four-way decomposition analysis of direct and indirect effects of job demands through mediation and/or interaction. J Affect Disord 2021; 282:219-226. [PMID: 33418370 DOI: 10.1016/j.jad.2020.12.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 11/28/2020] [Accepted: 12/19/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Psychosocial work stressors may lead to low back pain (LBP) through depressive symptoms or to depression through LBP. Depressive symptoms or LBP may also modify these associations. METHODS We examined prospective interrelationships between job demands, LBP and depressive symptoms. We used comparable data from three consecutive biennial surveys in 2010-2016, from the Swedish Longitudinal Occupational Survey of Health (SLOSH) and the Work Environment and Health in Denmark (WEHD) cohorts, broadly representative of the working populations in Sweden and Denmark. We conducted multivariate counterfactual based mediation analyses allowing for four-way decomposition of the total effect of job demands, on incident LBP (N=2813, 2701) and incident major depression (N=3707, 5496). The four components estimated direct and indirect effects through mediation and/or interaction. RESULTS We observed no association between job demands and incident LBP four years later, but job demands was associated with later major depression (relative risks=1.88, 95% confidence interval=1.45-2.31 in SLOSH and 1.64, 1.18-2.11 in WEHD, adjusted for age, sex, panel (SLOSH data), education, cohabitation, physically strenuous work and chronic diseases. About 37% of the association was attributed to interaction between job demands and LBP in SLOSH. No interaction was found in WEHD. LBP partly mediated the relationship, by 14% in SLOSH and 2%, while statistically insignificant in WEHD. LIMITATIONS Possible limitations include lack of comparable data on disabling low back pain, different scales for depressive symptoms, misclassification and residual confounding. CONCLUSIONS This suggests mainly a direct effect of job demands on major depression, or through other pathways than LBP.
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Romo ML, George G, Mantell JE, Mwai E, Nyaga E, Strauss M, Odhiambo JO, Govender K, Kelvin EA. Depression and sexual risk behavior among long-distance truck drivers at roadside wellness clinics in Kenya. PeerJ 2019; 7:e7253. [PMID: 31355055 PMCID: PMC6642802 DOI: 10.7717/peerj.7253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/05/2019] [Indexed: 11/20/2022] Open
Abstract
Background Truck drivers in sub-Saharan Africa are at high risk for both mental health disorders and sexually transmitted infections. We sought to determine the prevalence of depression among a sample of long-distance truck drivers seeking services at roadside wellness clinics in Kenya and explore the relationship between depression and sexual risk behavior. Methods We used data from an interviewer-administered questionnaire from 284 truck drivers in Kenya who participated in a randomized controlled trial evaluating whether offering oral HIV self-testing could increase HIV test uptake. Depression was categorized based on the Patient Health Questionnaire-9 score, with a score ≥10 indicative of probable major depressive disorder (MDD). Sexual risk behavior was operationalized as the number of condomless sex partners in the past 6 months. Results The mean participant age was 36.9 years, 83.0% were married, and 37.0% had a secondary school education or higher. Overall, 24% of participants had probable MDD, and 58.2% reported having one condomless sex partner in the past 6 months, whereas 27.3% reported having had two or more. In a multivariable Poisson regression model adjusted for demographic and other relevant variables, including number of sex partners, MDD was significantly associated with a greater number of condomless sex partners (adjusted prevalence ratio 1.63, 95% confidence interval [1.25–2.12], p < 0.001). General self-efficacy significantly mediated the association between MDD and number of condomless sex partners. Conclusions The high prevalence of depression highlights the need to test the feasibility and acceptability of mental healthcare interventions for this population, possibly integrated with HIV prevention services. Future research is needed to better understand the association between depression and sexual risk behavior, as well as the role of self-efficacy.
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Affiliation(s)
- Matthew L Romo
- Department of Epidemiology and Biostatistics & Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA.,School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Joanne E Mantell
- HIV Center for Clinical and Behavioral Studies, Department of Psychiatry, Division of Gender, Sexuality, and Health, New York State Psychiatric Institute & Columbia University Medical Center, New York, NY, USA
| | - Eva Mwai
- North Star Alliance, Nairobi, Kenya
| | | | - Michael Strauss
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | | | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Elizabeth A Kelvin
- Department of Epidemiology and Biostatistics & Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
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Abstract
BACKGROUND Pain comorbid with depression is frequently encountered in clinical settings and often leads to significant impaired functioning. Given the complexity of comorbidities, it is important to address both pain and depressive symptoms when evaluating treatment options. AIM To review studies addressing pain comorbid with depression, and to report the impact of current treatments. METHOD A systematic search of the literature databases was conducted according to predefined criteria. Two authors independently conducted a focused analysis of the full-text articles and reached a consensus on 28 articles to be included in this review. RESULTS Overall, studies suggested that pain and depression are highly intertwined and may co-exacerbate physical and psychological symptoms. These symptoms could lead to poor physical functional outcomes and longer duration of symptoms. An important biochemical basis for pain and depression focuses on serotonergic and norepinephrine systems, which is evident in the pain-ameliorating properties of serotonergic and norepinephrine antidepressants. Alternative pharmacotherapies such as ketamine and cannabinoids appear to be safe and effective options for improving depressive symptoms and ameliorating pain. In addition, cognitive-behavioral therapy may be a promising tool in the management of chronic pain and depression. CONCLUSION The majority of the literature indicates that patients with pain and depression experience reduced physical, mental, and social functioning as opposed to patients with only depression or only pain. In addition, ketamine, psychotropic, and cognitive-behavioral therapies present promising options for treating both pain and depression.
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Milot M, Borkenhagen E. Job stress in users of an Employee Assistance Program and association with presenting status. JOURNAL OF WORKPLACE BEHAVIORAL HEALTH 2018. [DOI: 10.1080/15555240.2018.1502044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Marc Milot
- WorkReach Solutions, APAS Laboratory Inc., Montreal, Canada
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Lotfizadeh M, Rahimzadeh S, Zareiy S. Predictors of the work-related depressive symptoms among blue-collar male employees of an industrial unit in Iran. Ind Psychiatry J 2016; 25:160-165. [PMID: 28659694 PMCID: PMC5479088 DOI: 10.4103/ipj.ipj_74_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND AIM Possible associations between depressive symptoms and work-related parameters have frequently been discussed in the literature. The present study was aimed to evaluate the work-related depressive symptoms and their possible-related parameters among male employees of Esfahan Steel Company (ESCO) as one of the most important industrial sites in Iran. MATERIALS AND METHODS With a cross-sectional design and a stratified random sampling method in 2010, a total of 400 male employees were enrolled from the operational parts of the ESCO. RESULTS Among 400 participated employees, 245 (61.3%) were rotational duty employees and 358 (89.5%) were reported making <$500. After applying the linear regression model, some variables including: economic difficulties (P = 0.022, odds ratio [OR] = 0.558, 95% confidence interval [CI] =0.339-0.919), family-related problems (P = 0.003, OR = 0.303, 95% CI = 0.138-0.669), and work environment (P < 0.001, OR = 0.244, 95% CI = 0.140-0.426) were found to be significantly associated with higher depressive symptoms among the participants. CONCLUSION The present study brought to light the predictors of occupational depressive symptoms among blue-collar employees of ESCO. More research is needed to find the causal relations between mental health and work-related parameters among Iranian employees.
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Affiliation(s)
- Masoud Lotfizadeh
- Department of Community Health, Shahrekord University of Medical Sciences, Shahrekord, Iran.,Social Determinants of Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Shadi Rahimzadeh
- Noncommunicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Epidemiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeid Zareiy
- NAHAJA Health Research Center, AJA University of Medical Sciences, Tehran, Iran
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Investigating anhedonia in a non-conventional species: Do some riding horses Equus caballus display symptoms of depression? Appl Anim Behav Sci 2015. [DOI: 10.1016/j.applanim.2014.11.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Pjanic I, Messerli-Bürgy N, Bachmann MS, Siegenthaler F, Hoffmann-Richter U, Znoj H. Predictors of depressed mood 12 months after injury. Contribution of self-efficacy and social support. Disabil Rehabil 2013; 36:1258-63. [DOI: 10.3109/09638288.2013.837971] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stephan U, Roesler U. Health of entrepreneurs versus employees in a national representative sample. JOURNAL OF OCCUPATIONAL AND ORGANIZATIONAL PSYCHOLOGY 2010. [DOI: 10.1348/096317909x472067] [Citation(s) in RCA: 163] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wåhlin-Norgren C, Ekberg K, Oberg B. Is an expert diagnosis enough for assessment of sick leave for employees with musculoskeletal and mental disorders? Disabil Rehabil 2010; 33:1147-56. [PMID: 20942619 DOI: 10.3109/09638288.2010.523509] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE The aim of this study is to determine differences in self-reported work ability, work conditions, health and function between ICD-10 groups with musculoskeletal disorders (MSD), mental disorders (MDs) and MSD + MD and to determine which variables are associated with sick leave. METHOD A cross-sectional study of 210 employees was conducted at an occupational health service unit. Physiotherapists and physicians classified the employees' health problems according to ICD-10 and the employees answered a questionnaire with questions on demographic variables, health, functioning, work ability and work conditions. RESULTS Forty-four per cent of the employees had MSD, 22% had MD and 34% had a MSD + MD. The group on sick leave had worse results for all health and work measures. Belonging to the MD group, belonging to the MSD + MD group, having poor work ability and functioning were associated with being on sick leave. The value for the model explaining being on sick leave was 0.63 (Nagelkerke R²). CONCLUSIONS Having a diagnosis of MD based on a professional opinion and having poor work ability and functioning based on self-reports are associated with being on sick leave. The results suggest that self-reported data could be used to complement the expert-based diagnosis.
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Affiliation(s)
- Charlotte Wåhlin-Norgren
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Sweden.
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Holden L, Scuffham PA, Hilton MF, Vecchio NN, Whiteford HA. Work Performance Decrements Are Associated With Australian Working Conditions, Particularly the Demand to Work Longer Hours. J Occup Environ Med 2010; 52:281-90. [DOI: 10.1097/jom.0b013e3181d1cdbb] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hochwarter WA, Byrne ZS. The Interactive Effects of Chronic Pain, Guilt, and Perfectionism on Work Outcomes. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY 2010. [DOI: 10.1111/j.1559-1816.2009.00564.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ferris GR, Rogers LM, Blass FR, Hochwarter WA. Interaction of job‐limiting pain and political skill on job satisfaction and organizational citizenship behavior. JOURNAL OF MANAGERIAL PSYCHOLOGY 2009. [DOI: 10.1108/02683940910989002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Woo JM, Postolache TT. The impact of work environment on mood disorders and suicide: Evidence and implications. INTERNATIONAL JOURNAL ON DISABILITY AND HUMAN DEVELOPMENT : IJDHD 2008; 7:185-200. [PMID: 18836547 PMCID: PMC2559945 DOI: 10.1515/ijdhd.2008.7.2.185] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
The purpose of this paper is to review the evidence estimating an impact of occupational factors on mood disorders and suicide, and the efficacy of interventions. This review is based on literature searches using Medline and Psych INFO from 1966 to 2007 (keywords: work stress, job insecurity, job strain, shift work, violence, occupational health, mood disorders, depression, and suicide). To establish the relationship between occupational variables and mood disorders, we focused on clinically significant disorders rather than depressive symptoms. During the last decade, prospective epidemiological studies have suggested a predictive association between the work environment and mood disorders. Recently, increasing numbers of clinical trials have shown favorable effect size of intervention and suggested preferable return-on-investment results. However, low awareness and social stigma still decrease workers access to treatment. Mental health professionals in conjunction with employers have to devise a creative system to make the quality care being offered more accessible to employees. In addition, further outcome data is needed to evaluate the benefit of managing mood disorders in the workplace, and to foster awareness of positive implications for employees, employers, their families, and the society at large. In addition, the work environment, with its chemical (e.g. chemosensory factors, pollutants), physical (e.g. lighting, noise, temperature, outdoor views and activities), biological (e.g., chronobiological factors, allergens, infectious agents), psychological (e.g. demand-control, effort-reward balance), social (e.g. cohesiveness, support), and organizational (e.g. leadership styles) component should meet minimal standards, and may improve with striving towards the optimum.
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Affiliation(s)
- Jong-Min Woo
- Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Teodor T Postolache
- Mood and Anxiety Program (MAP), Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, United States
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Stansfeld S. Chronic pain, depressive disorder, and the role of work. J Psychosom Res 2006; 61:661-2. [PMID: 17084144 DOI: 10.1016/j.jpsychores.2006.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2006] [Revised: 06/05/2006] [Accepted: 06/27/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Stephen Stansfeld
- Center for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and The London, Queen Mary's School of Medicine and Dentistry, London, UK.
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