Lalit Kalra

King's College Hospital NHS Foundation Trust, Londinium, England, United Kingdom

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Publications (175)1242.59 Total impact

  • Lalit Kalra

    No preview · Article · Feb 2016 · The Lancet
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    ABSTRACT: There is little available evidence to demonstrate how cough strength mediates the risk of aspiration-related pneumonia in acute stroke. Our secondary analysis of trial data indicates that risk of pneumonia reduces with increasing peak cough flow (PCF) of voluntary cough (OR 0.994 for each 1 L/min increase in PCF, 95% CI 0.988 to 1.0, p=0.035); and to a lesser degree with increasing PCF of reflex cough (OR 0.998 for each 1 L/min increase in PCF, 95% CI 0.992 to 1.004, p=0.475). These data serve hypothesis generation. Further studies are needed to confirm these findings and validate their clinical utility. Clinical trial registration number ISRCTN40298220 (post-results).
    Full-text · Article · Feb 2016 · Thorax
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    ABSTRACT: http://thorax.bmj.com/content/70/Suppl_3/A196.1.abstract?sid=980b842d-76f7-4911-aac6-c016db70e4c9
    Full-text · Conference Paper · Dec 2015

  • No preview · Article · Dec 2015 · International Journal of Stroke
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    ABSTRACT: Background Post-stroke pneumonia is associated with increased mortality and poor functional outcomes. This study assessed the eff ectiveness of antibiotic prophylaxis for reducing pneumonia in patients with dysphagia after acute stroke.
    Full-text · Article · Sep 2015 · The Lancet
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    Full-text · Dataset · Jul 2015
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    ABSTRACT: Lower respiratory tract infections frequently complicate stroke and adversely affect outcome. There is currently no agreed terminology or gold-standard diagnostic criteria for the spectrum of lower respiratory tract infections complicating stroke, which has implications for clinical practice and research. The aim of this consensus was to propose standardized terminology and operational diagnostic criteria for lower respiratory tract infections complicating acute stroke. Systematic literature searches of multiple electronic databases were undertaken. An evidence review and 2 rounds of consensus consultation were completed before a final consensus meeting in September 2014, held in Manchester, United Kingdom. Consensus was defined a priori as ≥75% agreement between the consensus group members. Consensus was reached for the following: (1) stroke-associated pneumonia (SAP) is the recommended terminology for the spectrum of lower respiratory tract infections within the first 7 days after stroke onset; (2) modified Centers for Disease Control and Prevention (CDC) criteria are proposed for SAP as follows-probable SAP: CDC criteria met, but typical chest x-ray changes absent even after repeat or serial chest x-ray; definite SAP: CDC criteria met, including typical chest x-ray changes; (3) there is limited evidence for a diagnostic role of white blood cell count or C-reactive protein in SAP; and (4) there is insufficient evidence for the use of other biomarkers (eg, procalcitonin). Consensus operational criteria for the terminology and diagnosis of SAP are proposed based on the CDC criteria. These require prospective evaluation in patients with stroke to determine their reliability, validity, impact on clinician behaviors (including antibiotic prescribing), and clinical outcomes. © 2015 American Heart Association, Inc.
    Full-text · Article · Jun 2015 · Stroke
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    ABSTRACT: Diagnosis of pneumonia complicating stroke is challenging, and there are currently no consensus diagnostic criteria. As a first step in developing such consensus-based diagnostic criteria, we undertook a systematic review to identify the existing diagnostic approaches to pneumonia in recent clinical stroke research to establish the variation in diagnosis and terminology. Studies of ischemic stroke, intracerebral hemorrhage, or both, which reported occurrence of pneumonia from January 2009 to March 2014, were considered and independently screened for inclusion by 2 reviewers after multiple searches using electronic databases. The primary analysis was to identify existing diagnostic approaches for pneumonia. Secondary analyses explored potential reasons for any heterogeneity where standard criteria for pneumonia had been applied. Sixty-four studies (56% ischemic stroke, 6% intracerebral hemorrhage, 38% both) of 639 953 patients were included. Six studies (9%) reported no information on the diagnostic approach, whereas 12 (19%) used unspecified clinician-reported diagnosis or initiation of antibiotics. The majority used objective diagnostic criteria: 20 studies (31%) used respiratory or other published standard criteria; 26 studies (41%) used previously unpublished ad hoc criteria. The overall occurrence of pneumonia was 14.3% (95% confidence interval 13.2%-15.4%; I(2)=98.9%). Occurrence was highest in studies applying standard criteria (19.1%; 95% confidence interval 15.1%-23.4%; I(2)=98.5%). The substantial heterogeneity observed was not explained by stratifying for other potential confounders. We found considerable variation in terminology and the diagnostic approach to pneumonia. Our review supports the need for consensus development of operational diagnostic criteria for pneumonia complicating stroke. © 2015 American Heart Association, Inc.
    Full-text · Article · Apr 2015 · Stroke
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    ABSTRACT: Background Extracranial carotid and vertebral artery dissection is an important cause of stroke, especially in young people. In some observational studies it has been associated with a high risk of recurrent stroke. Both antiplatelet drugs and anticoagulant drugs are used to reduce risk of stroke but whether one treatment strategy is more effective than the other is unknown. We compared their efficacy in the Cervical Artery Dissection in Stroke Study (CADISS), with the additional aim of establishing the true risk of recurrent stroke. Methods We did this randomised trial at hospitals with specialised stroke or neurology services (39 in the UK and seven in Australia). We included patients with extracranial carotid and vertebral dissection with onset of symptoms within the past 7 days. Patients were randomly assigned (1:1) by an automated telephone randomisation service to receive antiplatelet drugs or anticoagulant drugs (specific treatment decided by the local clinician) for 3 months. Patients and clinicians were not masked to allocation, but investigators assessing endpoints were. The primary endpoint was ipsilateral stroke or death in the intention-to-treat population. The trial was registered with EUDract (2006-002827-18) and ISRN (CTN44555237). Findings We enrolled 250 participants (118 carotid, 132 vertebral). Mean time to randomisation was 3.65 days (SD 1.91). The major presenting symptoms were stroke or transient ischaemic attack (n=224) and local symptoms (headache, neck pain, or Homer's syndrome; n=26). 126 participants were assigned to antiplatelet treatment versus 124 to anticoagulant treatment. Overall, four (2%) of 250 patients had stroke recurrence (all ipsilateral). Stroke or death occurred in three (2%) of 126 patients versus one (1%) of 124 (odds ratio [OR] 0.335, 95% CI 0.006-4.233; p=0.63). There were no deaths, but one major bleeding (subarachnoid haemorrhage) in the anticoagulant group. Central review of imaging failed to confirm dissection in 52 patients. Preplanned per-protocol analysis exduding these patients showed stroke or death in three (3%) of 101 patients in the antiplatelet group versus one (1%) of 96 patients in the anticoagulant group (OR 0.346,95% CI 0-006-4.390; p=0-66). Interpretation We found no difference in efficacy of antiplatelet and anticoagulant drugs at preventing stroke and death in patients with symptomatic carotid and vertebral artery dissection but stroke was rare in both groups, and much rarer than reported in some observational studies. Diagnosis of dissection was not confirmed after review in many cases, suggesting that radiographic criteria are not always correctly applied in routine clinical practice. Funding Stroke Association. Copyright (C)Markus et al. Open Access article distributed under the terms of CC BY.
    No preview · Article · Apr 2015 · The Lancet Neurology
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    ABSTRACT: Erratum in Lancet. 2015 Feb 14;385(9968):606. Abstract BACKGROUND: High blood pressure is associated with poor outcome after stroke. Whether blood pressure should be lowered early after stroke, and whether to continue or temporarily withdraw existing antihypertensive drugs, is not known. We assessed outcomes after stroke in patients given drugs to lower their blood pressure. METHODS: In our multicentre, partial-factorial trial, we randomly assigned patients admitted to hospital with an acute ischaemic or haemorrhagic stroke and raised systolic blood pressure (systolic 140-220 mm Hg) to 7 days of transdermal glyceryl trinitrate (5 mg per day), started within 48 h of stroke onset, or to no glyceryl trinitrate (control group). A subset of patients who were taking antihypertensive drugs before their stroke were also randomly assigned to continue or stop taking these drugs. The primary outcome was function, assessed with the modified Rankin Scale at 90 days by observers masked to treatment assignment. This study is registered, number ISRCTN99414122. FINDINGS: Between July 20, 2001, and Oct 14, 2013, we enrolled 4011 patients. Mean blood pressure was 167 (SD 19) mm Hg/90 (13) mm Hg at baseline (median 26 h [16-37] after stroke onset), and was significantly reduced on day 1 in 2000 patients allocated to glyceryl trinitrate compared with 2011 controls (difference -7·0 [95% CI -8·5 to -5·6] mm Hg/-3·5 [-4·4 to -2·6] mm Hg; both p<0·0001), and on day 7 in 1053 patients allocated to continue antihypertensive drugs compared with 1044 patients randomised to stop them (difference -9·5 [95% CI -11·8 to -7·2] mm Hg/-5·0 [-6·4 to -3·7] mm Hg; both p<0·0001). Functional outcome at day 90 did not differ in either treatment comparison-the adjusted common odds ratio (OR) for worse outcome with glyceryl trinitrate versus no glyceryl trinitrate was 1·01 (95% CI 0·91-1·13; p=0·83), and with continue versus stop antihypertensive drugs OR was 1·05 (0·90-1·22; p=0·55). INTERPRETATION: In patients with acute stroke and high blood pressure, transdermal glyceryl trinitrate lowered blood pressure and had acceptable safety but did not improve functional outcome. We show no evidence to support continuing prestroke antihypertensive drugs in patients in the first few days after acute stroke. FUNDING: UK Medical Research Council. Copyright © 2015 Bath et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd. All rights reserved.
    Full-text · Thesis · Feb 2015
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    ABSTRACT: Peak cough flow (PCF) measurements can be used as indicators of cough effectiveness. Portable peak flow meters and spirometers have been used to measure PCF, but little is known about their accuracy compared to pneumotachograph systems. The aim of this study was to compare the accuracy of four portable devices (Mini–Wright and Assess peak flow meters, SpiroUSB and Microlab spirometers) in measuring PCF with a calibrated laboratory based pneumotachograph system. Twenty healthy volunteers (mean (SD) age 45 (16) years) coughed through a pneumotachograph connected in series with each portable device in turn, and the differences in PCF readings were analysed. In addition, mechanically generated flow waves of constant peak flow were delivered through each device both independently and when connected in series with the pneumotachograph. Agreement between PCF readings obtained with the pneumotachograph and the portable devices was poor. Peak flow readings were on average lower by approximately 50 L min −1 when measured using the portable devices; 95% limits of agreement spanned approximately 150 L min −1 . The findings highlight the potential for inaccuracy when using portable devices for the measurement of PCF. Depending on the measurement instrument used, absolute values of PCF reported in the literature may not be directly comparable.
    No preview · Article · Feb 2015 · Physiological Measurement
  • Lalit Kalra
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    ABSTRACT: The past decade has witnessed major advances in stroke care, but stroke continues to remain a major cause of death and the most common cause of adult physical disability. This chapter presents an overview of selected future developments which will have an impact on reducing stroke-related complications. Foremost amongst these is the prevention of post-stroke pneumonia, and the chapter discusses the difficulties in diagnosing post-stroke pneumonia and various interventions to reduce its incidence. Brain injury is a major consequence of stroke; imaging methods that may provide insight into repair mechanisms and their modulation using physical therapy, pharmacological interventions, and stem cells are discussed. Motor impairment is a major complication after stroke, and a commentary on the role of bi-hemispheric interactions and interventions for modulating this interaction to reduce impairments is given. Monitoring of stroke-related complications and their consequences is also important for reducing their incidence and quality assurance, and this chapter highlights ongoing initiatives and the use of health information technology to meet some of the challenges in improving stroke care.
    No preview · Article · Jan 2015
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    ABSTRACT: Background and Purpose—Cough protects the lungs from aspiration. We investigated whether respiratory muscle training may improve respiratory muscle and cough function, and potentially reduce pneumonia risk in acute stroke. Methods—We conducted a single-blind randomized placebo-controlled trial in 82 patients with stroke (mean age, 64±14 years; 49 men) within 2 weeks of stroke onset. Participants were masked to treatment allocation and randomized to 4 weeks of daily expiratory (n=27), inspiratory (n=26), or sham training (n=25), using threshold resistance devices. Primary outcome was the change in peak expiratory cough flow of maximal voluntary cough. Intention-to-treat analyses were conducted using ANCOVA, adjusting for baseline prognostic covariates. Results—There were significant improvements in the mean maximal inspiratory (14 cmH2O; P<0.0001) and expiratory (15 cmH2O; P<0.0001) mouth pressure and peak expiratory cough flow of voluntary cough (74 L/min; P=0.0002) between baseline and 28 days in all groups. Peak expiratory cough flow of capsaicin-induced reflex cough was unchanged. There were no between-group differences that could be attributed to respiratory muscle training. There were also no differences in the 90-day incidence of pneumonia between the groups (P=0.65). Conclusions—Respiratory muscle function and cough flow improve with time after acute stroke. Additional inspiratory or expiratory respiratory muscle training does not augment or expedite this improvement. Clinical Trial Registration—URL: http://www.controlled-trials.com. Unique identifier: ISRCTN40298220.
    No preview · Article · Dec 2014 · Stroke
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    S. Kulnik · G. Rafferty · S. Birring · J. Moxham · L. Kalra

    Full-text · Conference Paper · Oct 2014
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    S. Kulnik · G. Rafferty · S. Birring · J. Moxham · L. Kalra

    Full-text · Conference Paper · Oct 2014
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    Dulka Manawadu · Jithesh Choyi · Lalit Kalra
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    ABSTRACT: Delays in treatment of in-hospital stroke (IHS) adversely affect patient outcomes. We hypothesised that early referral and specialist management of IHS patients will improve outcomes at 90 days. Baseline characteristics, assessment delays, thrombolysis eligibility, 90-day functional outcomes and all-cause mortality were compared between IHS patients referred for specialist stroke management within 3 hours of symptom onset (early referrals) and later referrals. Patients were identified from a prospective stroke registry between January 2009 and December 2010. Inclusion criteria were primary admission with a non-stroke diagnosis, onset of new neurological deficits after admission and early ischaemic changes on CT or MR imaging. Eighty four (4.6%) of 1836 stroke patients had IHS (mean age 74 year; 51% male, median NIHSS score 10). There were no significant differences in baseline characteristics between 53 (63%) early and 31 (37%) late referrals. Thrombolysis was performed in 29 (76%) of the 37/78 (47%) potentially eligible patients; 7 patients were excluded because specialist referral was delayed beyond 4.5 hours despite symptom recognition within 3 hours of onset. Early referral improved functional outcomes (modified Rankin Scale 0-2 at 90 days 40% v 7%, p = 0.001) and was an independent predictor of mRS 0-2 at 90 days after adjusting for age, pre-morbid function, primary cause for hospital admission and stroke severity [OR 1.13 (95% C.I. = 1.10-1.27), p = 0.002]. Early referral and specialist management of IHS patients that includes thrombolysis is associated with better functional outcomes at 90 days.
    Preview · Article · Aug 2014 · PLoS ONE
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    ABSTRACT: Objective: To describe the content and delivery of the adapted London Stroke Carers Training Course intervention evaluated in the Training Caregivers after Stroke (TRACS) trial. Setting: The London Stroke Carers Training Course is a structured training programme for caregivers of inpatients who are likely to return home after their stroke. The course was delivered by members of the multidisciplinary team while the patient was in the stroke unit with one recommended follow through session after discharge home. Intervention: The intervention consists of 14 training components (six mandatory) that were identified as important knowledge/skills that caregivers would need to be able to care for the stroke patient after ischarge home. Following national training days, the London Stroke Carers Training Course was disseminated to intervention sites by the cascade method of implementation. Results: The intervention was adapted for implementation across a range of stroke units. Training days were well attended (median 2.5 and 2.0 attendees per centre for the first and second days, respectively) and the feedback positive, demonstrating face validity for the intervention. However cascading of this training to other members of the multidisciplinary team was not consistent, with 7/18 centres recording no cascade training. Conclusion: The adapted London Stroke Carers Training Course provided a training programme that could be delivered in a standardised, structured way in a variety of stroke unit settings throughout the UK. The intervention was well received by stroke unit staff, however, the cascade method of implementation was not as effective as we would have wished.
    No preview · Article · Jul 2014 · Clinical Rehabilitation
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    ABSTRACT: Stroke-induced aphasia is associated with adverse effects on quality of life and the ability to return to work. For patients and clinicians the possibility of relying on valid predictors of recovery is an important asset in the clinical management of stroke-related impairment. Age, level of education, type and severity of initial symptoms are established predictors of recovery. However, ana-tomical predictors are still poorly understood. In this prospective longitudinal study, we intended to assess anatomical predictors of recovery derived from diffusion tractography of the perisylvian language networks. Our study focused on the arcuate fasciculus, a language pathway composed of three segments connecting Wernicke's to Broca's region (i.e. long segment), Wernicke's to Geschwind's region (i.e. posterior segment) and Broca's to Geschwind's region (i.e. anterior segment). In our study we were particularly interested in understanding how lateralization of the arcuate fasciculus impacts on severity of symptoms and their recovery. Sixteen patients (10 males; mean age 60 AE 17 years, range 28–87 years) underwent post stroke language assessment with the Revised Western Aphasia Battery and neuroimaging scanning within a fortnight from symptoms onset. Language assessment was repeated at 6 months. Backward elimination analysis identified a subset of predictor variables (age, sex, lesion size) to be introduced to further regression analyses. A hierarchical regression was conducted with the longitudinal aphasia severity as the dependent variable. The first model included the subset of variables as previously defined. The second model additionally intro-duced the left and right arcuate fasciculus (separate analysis for each segment). Lesion size was identified as the only independent predictor of longitudinal aphasia severity in the left hemisphere [beta = À 0.630, t(À 3.129), P = 0.011]. For the right hemisphere, age [beta = À 0.678, t(–3.087), P = 0.010] and volume of the long segment of the arcuate fasciculus [beta = 0.730, t(2.732), P = 0.020] were predictors of longitudinal aphasia severity. Adding the volume of the right long segment to the first-level model increased the overall predictive power of the model from 28% to 57% [F(1,11) = 7.46, P = 0.02]. These findings suggest that doi:10.1093/brain/awu113
    Full-text · Article · Jul 2014 · Brain
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    ABSTRACT: Assessment of fitness to drive (FTD) is important after stroke or transient ischaemic attack (TIA) to ensure that neither patients nor public are at risk. This is particularly important in patients with TIAs or minor stroke as many are discharged directly from emergency departments by a range of health professionals. We assessed stroke-related FTD knowledge among physicians' and allied health professionals' (AHPs) treating patients with stroke at a hyperacute stroke centre. Knowledge of FTD restrictions following a stroke or TIA for domestic and commercial use was assessed in 195 physicians and 45 AHPs using a multiple-choice questionnaire between January and December 2009. The effect of discipline, seniority, previous instruction in FTD restrictions and experience in stroke medicine on FTD was assessed. The correct driving restriction following stroke with domestic and commercial license was known to 29% and 73% of physicians, respectively. For AHPs, these figures were 36% and 20%. For TIA with domestic and commercial license, this was 37% and 43% for physicians, and 44% and 11% for AHPs. 25% of physicians and 11% of AHPs believed that no driving restrictions applied after a TIA. The correct office for reporting FTD was known to 180 (92%) doctors and 31 (69%) AHPs (p=0.0001); 160 (82%) physicians and 27 (60%) AHPs correctly identified that reporting was the patients' responsibility (p=0.001). FTD knowledge correlated with post in stroke (OR 3.2 (95% CI 1.6 to 6.2, p=0.001)) but not with seniority or previous FTD education. Health professionals providing stroke care showed limited knowledge of FTD regulations after minor stroke or TIA. Imparting accurate information on driving restrictions is an important but neglected part of stroke management.
    No preview · Article · May 2014 · Postgraduate medical journal
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    ABSTRACT: After stroke, pneumonia is a relevant medical complication that can be precipitated by aspiration of saliva, liquids, or solid food. Swallowing difficulty and aspiration occur in a significant proportion of stroke survivors. Cough, an important mechanism protecting the lungs from inhaled materials, can be impaired in stroke survivors, and the likely cause for this impairment is central weakness of the respiratory musculature. Thus, respiratory muscle training in acute stroke may be useful in the recovery of respiratory muscle and cough function, and may thereby reduce the risk of pneumonia. The present study is a pilot study, aimed at investigating the validity and feasibility of this approach by exploring effect size, safety, and patient acceptability of the intervention.Methods/design: Adults with moderate to severe stroke impairment (National Institutes of Health Stroke Scale (NIHSS) score 5 to 25 at the time of admission) are recruited within 2 weeks of stroke onset. Participants must be able to perform voluntary respiratory maneuvers. Excluded are patients with increased intracranial pressure, uncontrolled hypertension, neuromuscular conditions other than stroke, medical history of asthma or chronic obstructive pulmonary disease, and recent cardiac events. Participants are randomized to receive inspiratory, expiratory, or sham respiratory training over a 4-week period, by using commercially available threshold resistance devices. Participants and caregivers, but not study investigators, are blind to treatment allocation. All participants receive medical care and stroke rehabilitation according to the usual standard of care. The following assessments are conducted at baseline, 4 weeks, and 12 weeks: Voluntary and reflex cough flow measurements, forced spirometry, respiratory muscle strength tests, incidence of pneumonia, assessments of safety parameters, and self-reported activity of daily living. The primary outcome is peak expiratory cough flow of voluntary cough, a parameter indicating the effectiveness of cough. Secondary outcomes are incidence of pneumonia, peak expiratory cough flow of reflex cough, and maximum inspiratory and expiratory mouth pressures. Various novel pharmacologic and nonpharmacologic approaches for preventing stroke-associated pneumonia are currently being researched. This study investigates a novel strategy based on an exercise intervention for cough rehabilitation.Trial registration: Current Controlled Trials ISRCTN40298220.
    Full-text · Article · Apr 2014 · Trials

Publication Stats

5k Citations
1,242.59 Total Impact Points

Institutions

  • 2015
    • King's College Hospital NHS Foundation Trust
      Londinium, England, United Kingdom
  • 1993-2015
    • King's College London
      • • Department of Clinical Neuroscience
      • • Division of Asthma, Allergy and Lung Biology
      • • School of Medicine
      Londinium, England, United Kingdom
    • The Peninsula College of Medicine and Dentistry
      Plymouth, England, United Kingdom
  • 2004-2014
    • ICL
      Londinium, England, United Kingdom
  • 2009
    • University of London
      Londinium, England, United Kingdom
  • 2008
    • University of Oxford
      • Department of Public Health
      Oxford, England, United Kingdom
  • 2006
    • University of Wales
      Cardiff, Wales, United Kingdom
    • The University of Tokushima
      • Department of Radiologic Technology
      Tokusima, Tokushima, Japan
  • 2001-2005
    • The King's College
      Charlotte, North Carolina, United States
  • 1994
    • University College London
      Londinium, England, United Kingdom
    • Kent Hospital
      Warwick, Rhode Island, United States