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9th July 2024
Professor Mona Bafadhel tells Katherine Price about developing a new tool that has identified less obvious yet crucial cardiovascular disease risk indicators such as chronic obstructive pulmonary disease. She hopes the tool will impact health inequalities by better predicting at-risk individuals and ensuring previously under-detected populations can access preventative therapies.
Professor Mona Bafadhel is the chair of respiratory medicine at King’s College London and director of the King’s Centre for Lung Health. Her work on chronic obstructive pulmonary disease (COPD) has recently led to her working with colleagues across King’s College London and the Universities of Oxford, Nottingham, Bristol and Edinburgh to support the development of a new cardiovascular disease(CVD) predictive calculator.
COPD is the third leading cause of death worldwide, causing more than three million deaths in 2019. Nearly 90% of deaths in patients under the age of 70 occur in low- and middle-income countries, and it’s estimated that in the UK, at least 4.9% of people over the age of 40 have COPD. By 2050, it’s predicted that global COPD prevalence will approach 600 million cases and become the leading cause of death globally. ‘[This] is an important group of patients,’ stresses Professor Bafadhel.
Among COPD patients, cause of death is often CVD, Professor Bafadhel explains. She and colleague Dr Richard Russell, head of department of the Peter Gorer Department of Immunobiology, were aware of the association between COPD and CVD based on their clinical experience and an increasing body of evidence. However, they wanted to understand more about the link between the two.
CVD is also a leading cause of death globally, responsible for an estimated 17.9 million deaths in 2019. Research into risk factors is abundant, but the tools available in clinical practice to score cardiovascular risk were unable to offer much insight into the CVD risk in a patient with COPD.
‘Indeed, it appears that current risk tools were underestimating the actual cardiovascular risk associated with patients with COPD,’ adds Professor Bafadhel.
The duo liaised with Professor Julia Hippisley-Cox from the University of Oxford and Carol Coupland from the University of Nottingham and others, who designed three iterations of QRISK – the CVD risk score that has been used across the NHS since 2009. It involves measuring patients’ blood pressure, age and medical history to identify those at high risk of developing CVD.
However, even QRISK3 does not capture several conditions that have recently been associated with increased CVD risk, including COPD, meaning it will potentially underestimate risk in these groups, who may subsequently not be offered beneficial interventions.
The new research, utilising several UK primary care databases to assess a cohort of more than 16.5 million UK citizens for derivation and validation of the algorithm, led to the development of QRISK4 or QR4, which showed that COPD was indeed a risk factor. In fact, QR4 outperformed three widely used international CVD scoring models, including QR3, due to the size and validity of the data, accurately identifying more high-risk patients.
‘The accuracy required has to be very vigorous with regard to validation tools and replication models,’ explains Professor Bafadhel. ‘It took a rigorous amount of work as standard because my collaborators Julia and Carol have experience of getting this into patient practice with QRISKs 1, 2 and 3, so we were guided and as sure as we can be that we were doing it even more rigorously for QR4.’
Like QR3, QR4 – if approved – would be a free-to-access web platform into which clinicians can enter details about patient health to generate a percentage risk of them developing CVD in 10 years’ time. Thresholds are also offered to inform clinicians as to when preventative treatment should be offered.
The difference is the inclusion of seven new risk factors. In addition to COPD, this includes learning disabilities, Down syndrome, four cancer types (blood, lung, oral and brain), pre-eclampsia and postnatal depression. While risk factors such as smoking and high cholesterol are well-recognised, this latest research identifies less obvious yet crucial risk indicators and highlights how other significant conditions impact on heart health.
Not only was an increased risk of severe cardiovascular events in patients with COPD identified, but the greatest effect was seen in females – a surprise for Professor Bafadhel.
Evidence previously suggested that COPD most commonly affected men, but more women appear to have COPD than first thought. What’s more, ‘it’s clear actually that women [with COPD] have more susceptibility to cardiovascular risk,’ Professor Bafadhel says, stressing that clinicians need to consider COPD as a diagnosis and confirm it with spirometry, especially in women, to mitigate these cardiovascular risks.
The risk was also highest in younger patients with COPD, which, for Professor Bafadhel, was another sign that conditions such as COPD need to be diagnosed earlier.
Ultimately, the research underlines the importance of prescribing therapies that reduce CVD risk, including optimising inhaled therapies, to reduce mortality.
By integrating these seven risk factors into the QR4 model, the researchers were able to develop a more nuanced and comprehensive tool for predicting CVD, ensuring preventative strategies are more personalised, inclusive and cater to the needs of a broader and more diverse population. It also provides clinicians with the clearest picture yet of individuals’ risk of developing heart and circulatory diseases.
Although the QR4 is based on UK population data, Professor Bafadhel hopes that other countries can use the research and their own population data to assess their own algorithms and tools. For countries with fewer resources, she says available tools can be used, mindful that the data may not be population relevant.
The hope is that, by providing a more accurate CVD risk estimation, QR4 should lead to significant improvements in health outcomes, particularly among populations whose risk may have previously been under-detected. If implemented, it is estimated that optimising the care of COPD patients would save more than 2,500 lives a year in the UK and promote earlier recognition of both COPD and the associated cardiovascular risk.
Professor Bafadhel argues the most important impact of this research would be driving awareness of the interlinked risks of CVD and COPD across the multidisciplinary field, and of how that risk can be modified.
‘We just haven’t had enough investment and funding in [COPD]. People may not know what it is until it’s too late. We really do need to improve the global awareness of it,’ she says.
‘We need to diagnose COPD earlier and be familiar with what COPD is. We need to optimise COPD treatments, including all the available tools we have. And then we need to try and understand what causes that very close association to cardiovascular disease, and of course exacerbations.’
She also highlights the importance of preventing CVD, catastrophic events and deaths by optimising COPD pharmacological treatment as well as primary prevention.
The researchers anticipate that QR4 will supersede QR3, although there is currently no timeline for this. Nevertheless, the next five years are expected to be an exciting time in the COPD field that will further shape understanding of this debilitating condition, according to Professor Bafadhel.
While she and her colleagues are looking at platelets in patients with COPD, other multidisciplinary groups are investigating pulmonary lung-heart events in this group – research Professor Bafadhel hopes will reduce inequalities, raise standards and empower patients to ensure they get the best treatment they need, when they need it.
‘Gone are the days where we think we can’t do anything for a person with COPD,’ she says. ‘We now have multiple tools, from physiotherapy to inhaled treatments, to non-invasive and invasive surgery, and in the next few months, hopefully also biologics in COPD.’
3rd June 2024
While breast cancer mortality has reduced by as much as 40% over the past three decades, and five-year breast cancer survival rates exceed 90% in some countries, these figures mask global inequalities. Dr Carlos Barrios, director of the Latin American Clinical Oncology Research Group in Porto Alegre, Brazil, tells Katherine Price how The Lancet Breast Cancer Commission’s latest report provides a roadmap for change and how clinicians around the world can support it.
Breast cancer cases are increasing globally, and by 2040, it is predicted that there will be three million new diagnoses per year, with people living in low- and middle-income countries (LMICs) disproportionately affected.
‘We need to recognise that there has been unequal progress, and if we keep on doing what we have done so far, that’s not going to change,’ says Dr Carlos Barrios, director of the Latin American Clinical Oncology Research Group in Porto Alegre, Brazil.
To help to achieve this aim, Dr Barrios was invited to participate in The Lancet Breast Cancer Commission, an interdisciplinary group of commissioners and patient advocates from high-, middle- and low-income countries across the world seeking to address inequalities in healthcare access and education and counter the perception that this predicted upward trajectory in breast cancer cases is inevitable.
The Commission published a report in April 2024, which Dr Barrios co-authored while also coordinating the working group looking at metastatic breast cancer (MBC). He says the report offers a roadmap for achieving more equal progress on breast cancer care worldwide.
‘The task that was given to us was to try to identify the discrepancies and be transformative – what do we need to do to change this situation?’ he says.
As well as improving representation of participants and research leads from LMICs in trials, many of The Lancet Breast Cancer Commission’s recommendations are for policy change, and Dr Barrios was keen that those responsible for making such changes were explicitly named.
‘Most of the recommendations require a very active and proactive position of policymakers and administrators,’ he explains.
For example, researchers estimate that up to a quarter of breast cancer cases in high-income countries (HICs) could be prevented by modifying risk factors such as alcohol, physical activity and obesity. In addition, identifying those at increased risk is essential for equitable access to personalised prevention strategies, including cheap and effective medications, and early detection programmes. The authors call for stage-shifting as a sustained decline in breast cancer mortality rates can be achieved by diagnosing at least 60% of invasive cancers at less than 2cm in size.
‘More than 50% of that improvement that we see in the mortality is actually driven by early diagnosis and adjuvant therapy,’ says Dr Barrios.
The findings highlight a lack of information in some areas, particularly MBC rates. Relapse is not typically recorded by most national cancer registries, even though 20-30% of patients with early breast cancer relapse.
‘If you don’t have a specific number, it’s very difficult to know the size of the problem and how to devote strategies to these patients,’ says Dr Barrios.
‘We need registry data that tells us actually how many patients we have with metastatic breast cancer, what treatment these patients received, and what the outcomes are of these patients in different places in the world.’
Within the past five years, median survival has reached five years for two of the three main MBC subtypes, which account for approximately 85% of patients with breast cancer, and some subgroups are starting to be considered as having a chronic disease. Dr Barrios and the report authors argue for eradicating social stigma around MBC as a rapidly fatal disease, and for patients to not be excluded from potentially life-extending treatments.
They make the case for at least 70% of registries worldwide to record MBC rates, and for initiatives to promote societal inclusion of people living with MBC, such as, changes to labour laws that empower more flexible working arrangements.
There is also a lack of information around the associated and hidden consequences of breast cancer – the physical, psychological, social and financial costs that are not routinely captured by global health metrics.
The Commission’s UK-based CASCARA pilot study found that a fifth of participants with early breast cancer and a quarter of those with MBC reported difficulty in covering the costs of travel for treatment, for example, and tools are needed to measure these costs and the benefits of addressing them to guide policymakers on interventions.
The report also argues that at least half of patients with MBC should be discussed at multidisciplinary meetings, as well as 80% of patients with a new breast cancer diagnosis. However, while a multidisciplinary approach from diagnosis onwards is essential, as is applying approaches that have worked well in HICs to settings with fewer resources. And this must be tailored to local contexts.
‘Most patients with breast cancer in the world are not going to be treated in institutions where you have the ability for multidisciplinary discussion,’ says Dr Barrios. ‘Most will be managed by physicians [who] work alone, that are outside the capitals, that are not in the tertiary centres.’
As such, telementoring and virtual multidisciplinary meetings are suggested by the Commission to help enable resource sharing between cancer centres and local community hospitals, even between HICs and LMICs, with a vision for technology-enabled data exchange between all stakeholders of the oncology healthcare system and always with a focus centred in the patients’ best interests.
Although many of the recommendations are actions and targets for policymakers, Dr Barrios stresses that clinicians can make a difference by identifying discrepancies around them. ‘See what you can do as a clinician in your everyday clinic to identify patients that may have problems with information or access to healthcare procedures or medications,’ he says.
Better patient communication, for example, is key in improving quality of life, decision-making, body image, and even adherence to therapy – with subsequent positive impacts on survival. The Commission’s report calls for all healthcare professionals to receive communication training and for patient involvement in all stages of breast cancer clinical research, and even provides a framework for patient-centred consultations.
It stresses that healthcare professionals are there to help patients make the decisions that are best for them, which requires the patient to understand the goals, logistics and side effects of treatment, and the clinician to understand the patient’s preferences, values and life goals.
While action from clinicians is crucial, enduring change sits firmly within the power of policymakers. It is hoped that widely sharing the The Lancet Breast Cancer Commission’s report, its findings and recommendations, for example at global oncology conferences, will pave the way to global government and policymaker attention and engagement.
‘The idea here is that we need to have a more significant impact on the national cancer care plans, because that’s where the action will reach the patients,’ says Dr Barrios.
He is optimistic about further improvements in breast cancer care on the horizon, particularly the development of new drugs in the treatment of hormone-receptor-positive disease and antibody-drug conjugates. He says these are ‘revolutionising’ MBC management and will eventually improve cure rates and help patients with early disease as well. He is also keeping a keen eye on research being led by fellow Commission participant Felicia Knaul at the University of Miami into measuring hidden costs and suffering, which he says would be ‘extremely significant’ and transformative for patients and for clinical practice.
Dr Barrios and his co-authors hope that application of the recommendations set out in The Lancet Breast Cancer Commission’s report will not only lead to improvements in breast cancer rates, treatment and outcomes in a more equal way, but have a positive impact across the cancer field, healthcare and society as a whole.
‘[These] solutions and strategies could be applicable to other diseases, and also empowering women in general,’ says Dr Barrios. ‘If we make women more participatory in the process, this will have much broader implications for women in society overall.’
1st May 2024
Cholesterol-lowering drugs are less frequently prescribed to women compared to men, despite European Society of Cardiology (ESC) guidelines recommending statins for all patients with chronic coronary syndrome, new research has revealed.
Recommendations for target levels of low-density lipoprotein (LDL) cholesterol are the same for women and men, but previous studies have shown that women are less likely to meet these target levels.
This new retrospective observational study, presented at the recent ESC Preventive Cardiology 2024 congress, considered whether women and men actually receive the same treatments, as is outlined in ESC guidelines.
Electronic health records were used to obtain data on cholesterol levels of 1,037 men and 415 women with a chronic coronary syndrome diagnosed between 2012 and 2020, and who had never had a heart attack. The median age was 68 years in men and 70 years in women.
Information on dispensed medications was obtained from the Swedish National Prescribed Drug Registry and participants were followed up for three years following their diagnosis.
At the end of the third year of follow-up, just 54% of women were treated with cholesterol-lowering drugs compared with 74% of men. Additionally, 5% of women were treated with statin plus ezetimibe compared with 8% of men.
Dr Nina Johnston, study author and cardiologist at Uppsala University in Sweden, said: ‘Cholesterol-lowering drugs save lives and prevent heart attacks, and should be prescribed to all patients with coronary artery disease. Unfortunately, our study shows that women are missing out on these essential medications.
During the study, the researchers also examined treatments and cholesterol levels of women and men diagnosed with a chronic coronary syndrome at different ages: less than 60, 60-69.9, 70-79.9 and 80 years or older.
In all age groups, prescription of cholesterol-lowering treatment was found to be highest at diagnosis and declined over the following three years. This decline was steeper in women compared with men.
For example, in patients under 60 years of age, 65% of women and 79% of men were treated with cholesterol-lowering treatment the week after diagnosis, compared with 52% of women and 78% of men three years later. Achievement of LDL cholesterol targets was also lower in women than men.
Dr Johnston added: ‘Our findings should be a wake-up call about the undertreatment of women with heart disease. Equal prescribing practices are needed so that women receive all recommended therapies and are protected from adverse outcomes.’
The researchers are currently investigating factors which may explain the observed sex differences.
23rd April 2024
Many people with breast cancer are not receiving the treatment they should, with inequalities in care leading to many groups being ‘systematically left behind, ignored and forgotten’, according to a new report.
This comes despite considerable advances in breast cancer research and treatment over the last three decades, which has led to a more than 40% reduction in breast cancer mortality in some high-income countries.
People living with metastatic breast cancer are particularly disadvantaged since rates of this type of cancer are unrecorded, and the needs of this population are unmet. The findings of The Lancet Breast Cancer Commission suggested that systematic recording of cancer rates must be established and call for increased prevention strategies and personalised treatment.
Current predictions suggest there will be three million new cases a year of breast cancer worldwide by 2040 and a million deaths, with people living in low- and middle-income countries disproportionately affected.
Tackling breast cancer gaps and inequities should be achieved through ‘global collaboration, and communication and empowerment’, the researchers said, stating that The Lancet Breast Cancer Commission is a ‘forward-looking and optimistic road map’ to address urgent challenges in breast cancer care and reduce breast cancer rates.
The findings highlighted a lack of information around rates of metastatic breast cancer, despite statistics showing that 20-30% of early breast cancers experience relapse.
Often, the physical, psychological, social and financial costs of breast cancer were found to be ‘immense but under-recognised’ since current global health metrics do not capture them.
Professor Charlotte Coles, professor of breast cancer clinical oncology and deputy head of department of oncology at the University of Cambridge, said: ‘Recent improvements in breast cancer survival represent a great success of modern medicine. However, we can’t ignore how many patients are being systematically left behind.’
She added: ‘We hope that, by highlighting these inequities and hidden costs and suffering in breast cancer, they can be better recognised and addressed by healthcare professionals and policymakers in partnership with patients and the public around the world.’
In response to the findings, the researchers established a UK-based pilot study that provides a snapshot of the economic burden and care needs of people affected by breast cancer. Nearly all of the 606 people living with breast cancer and carers surveyed experienced physical or wellbeing issues related to breast cancer, such as losing a job whilst undergoing treatment or experiencing sexual dysfunction.
Many cancer patients were also found to experience financial difficulty as a result of their illness, with 27% of patients with early breast cancer and 35% with metastatic breast cancer reporting money problems. A fifth of participants with early breast cancer and a quarter of those with metastatic breast cancer reported difficulty in covering the costs of travel for treatment.
Estimates of serious health-related suffering indicated the need for palliative care. In 2020, approximately 120 million days were spent with serious health-related suffering per year for people who died of their cancer. A further 520 million days were estimated for patients living with the disease.
Dr Carlos Barrios director of the the Oncology Research Center at Hospital São Lucas, Brazil, said: ‘Even in countries with well-developed healthcare systems, patients with breast cancer experience inadequate support and care. In countries lacking affordable health care facilities, patients experience these costs more commonly and intensely, too often leading to catastrophic spending and impoverishment.’
The Lancet Breast Cancer Commission advocates the development of new tools to estimate the hidden costs of breast cancer and better communication between healthcare workers and patients to improve the quality of life for patients and guide policymakers to invest in breast cancer prevention and interventions that relieve suffering, such as early detection, cost-effective therapy, optimal management and financial protection.
The researchers estimate that up to a quarter of breast cancer in high-income countries could be prevented by modifying risk factors for breast cancer. This involves education and awareness-raising efforts, as well as ‘bold policy changes’ that reduce the number of people exposed to these risk factors, such as alcohol consumption and being overweight.
In addition, systematic approaches that identify those at increased risk of the disease are essential to enable equitable access to personalised prevention strategies, including cheap and effective medications that can avert breast cancer for many women and early detection programmes.
Professor Benjamin Anderson, professor of surgery and global health medicine at the University of Washington, concluded: ‘Access to evidence-based prevention and care that isn’t dependent on where an individual lives or their ability to pay would reap wide-ranging benefits for patients, families and healthcare systems striving to achieve universal health coverage.’
A version of this article was originally published by our sister publication Nursing in Practice.
9th October 2023
Women and older people are less likely to receive clinical guideline-recommended treatment than men and younger people if they experience myocardial infarction or are diagnosed with heart failure or atrial fibrillation, according to new research into heart care inequalities.
Led by a team from the University of Leeds and funded by the British Heart Foundation, the researchers analysed evidence from a range of studies from the last 20 years that explored how a person’s age, sex, ethnicity and geographical location are linked to the heart care they receive and their outcomes.
These studies were based on evidence from nationwide secondary care registries and primary care health records.
The resulting analysis, published in The Lancet Regional Health – Europe, showed that after an ST-segment elevation myocardial infarction (STEMI), women were around a third less likely than men to receive coronary angiography and percutaneous coronary intervention.
Following a non-STEMI, women were 28 per cent less likely than men to receive a coronary angiogram and less likely to be prescribed secondary prevention.
In addition, women and those aged 75 and over were found to be less likely to receive a diagnosis of heart failure in primary care, and less likely to be prescribed treatments to slow the progression of their heart failure.
Ethnic disparities were also apparent in heart care, although less extensive evidence prevented firm conclusions from being drawn.
Black patients with atrial fibrillation were less likely to receive blood thinning treatment to prevent stroke than white patients. However, south Asian patients did not appear to receive unequal treatment for myocardial infarction compared with white patients, and they had similar case fatality.
The research also highlighted an estimated 500 potentially avoidable deaths in the UK each year among patients waiting for transcatheter aortic valve implantation. This is despite prompt treatment being crucial to survival as 50% of patients will die within two years of symptom onset.
The researchers hope that in better understanding differences in heart care it may enable the implementation of appropriate strategies to mitigate differences in outcomes. As such, the BHF is calling on the UK Government and all political parties to prioritise efforts to tackle cardiovascular disease and health inequalities in the run up to the next general election.
Dr Sonya Babu-Narayan, associate medical director at the British Heart Foundation and consultant cardiologist, said: ‘These findings should sound the alarm bell for the state of heart care in the UK. This concerning review is further evidence that people’s experience of heart care was far from equal even before the Covid-19 pandemic began. The pandemic underlined and amplified existing health inequalities, and we fear these are worse than ever now that we are firmly in the grip of a heart care crisis.
‘To stop this crisis in its tracks and address the unjust inequalities in heart care, we need bold action from Government. Protecting our hearts by tackling risk factors will help to prevent heart disease and strokes happening in the first place.
‘Prioritising NHS heart care will allow people to get the help they need more quickly, preventing avoidable death and disability. And powering up research will unlock the treatments and cures of tomorrow to give more people hope for a bright and healthy future.’
Professor Chris Gale, professor of cardiovascular medicine at the University of Leeds and honorary consultant cardiologist at Leeds Teaching Hospitals NHS Trust, who led the research, added: ‘We need urgent action to revive heart care. The NHS is full of fantastic people who make truly monumental efforts every day to do the very best for their patients. Despite this, the NHS is creaking at the seams, and we see this played out in cardiovascular care and outcomes.
‘Past efforts to transform heart care and drive down waiting lists were hugely successful, and we must build on the lessons from these to move forward.
‘It’s also clear that we’re not making the most of NHS data, and we’re missing vital opportunities for this to inform policy and help target investment.
‘We need a systematic approach to collect data and report on all aspects of treatment, care and outcomes. Only then will we be able to improve patient’s experiences and outcomes across the board.’
1st December 2021
A key theme of World AIDS Day 2021 is a call to end the division, disparity and disregard for human rights which has become associated with HIV infection. Acquired immunodeficiency syndrome (AIDS) was first recognised as a new disease in 1981 when a number of homosexual men succumbed to unusual opportunistic infections and rare malignancies.
It was later identified that these cases were due to infection with the human immunodeficiency virus type 1 (HIV-1) which is spread via sexual transmission through the lower genital and rectal mucosa, and it is these routes of infection that account for the vast majority of current and new infections. HIV targets the immune system, weakening an individual’s defence against many infections and as the virus both destroys and impairs the functionality of immune cells, those infected with the virus gradually become immunodeficient.
Although antiretroviral therapy (ART) has been available for many years and while the treatment is not curative, it does provide longer lives for patients and reduce HIV transmission. However, to date, there is still no effective vaccine but this might change as a trial is about to begin at Oxford University.
Despite the advances in treatment provided by ART, the HIV virus continues to represent a global major health challenge. According to the World Health Organization (WHO), the virus has already claimed 36.3 million [27.2–47.8 million] lives and WHO estimates that in 2020, there were 37.7 million [30.2–45.1 million] people living with HIV, of whom, over two thirds (25.4 million) reside in the African Region.
In order to access ART and associated counselling services for those with HIV, it is imperative to have equality of access to HIV testing, especially in areas of African, where the virus affects a huge number of people. Sadly however, a 2020 analysis from 16 countries in sub-Saharan Africa, revealed that while relative socioeconomic inequalities in uptake of HIV testing in the region have decreased to some extent, absolute inequalities have persisted or increased.
Other data have been equally pessimistic. The Start Free, Stay Free, AIDS Free initiative which began in 2015 and has a five-year framework which called for a super Fast-Track approach to ensure that every child has an HIV-free beginning, that they stay HIV-free through adolescence and that every child and adolescent living with HIV has access to antiretroviral therapy.
The approach focused on 23 countries, 21 of which were in Africa, that accounted for 83% of the global number of pregnant women living with HIV, 80% of children living with HIV and 78% of young women aged 15–24 years newly infected with HIV. The group’s most recent report from 2020 provides additional evidence of the current inequalities of access among those with HIV, revealing how nearly half (46%) of the world’s 1.7 million children living with HIV were not on treatment in 2020 and 150,000 children were newly infected with HIV, which is four times more than the 2020 target of 40,000.
Despite having being discovered over 30 years ago, and with treatments that enable infected individuals to live a virtually normal life, HIV is still very much a global health concern. Given the current enormous and global effort directed towards fighting COVID-19, it is hoped that the 2021 World AIDS Day call can gather an equal amount of energy in both reducing the inequality of access to testing and treatment as well as ending HIV.
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