Lung Volume Reduction: A personalised medicine approach
Lung volume reduction is an effective therapy for symptoms in patients with hyperinflation due to emphysema and COPD. Despite its clinical effectiveness its role has been limited in the UK. This has changed more recently with the development of new techniques (e.g. endobronchial valves). However, it is not clear which treatment is right option for individual patients.
Leicester has the largest historical cohort of LVR procedures in the UK, performing the most surgical procedures in the UK. This offers a rich source of data for research and development of fellowships.
- It is possible to identify patients more likely to clinically respond to different LVR techniques (LVRS, endobronchial valves and coils)
- Newer imaging techniques (e.g. V/PSPECT, quantitative CT) are better able to identify target areas for LVR than traditional techniques
- Using existing cohort data (and prospectively collect further data) to investigate the clinical response to LVR, for surgery, valves and coils.
- Assess the accuracy of V/PSPECT and quantitative CT compared with Q scan and non-quantitative CT in the identification of target areas for LVR
- Develop a decision pathway for patients potentially undergoing lung volume reduction
The use of high-fidelity simulators to improve endovascular outcomes in the elderly (attach to Clinical Radiology)
The purpose of this study is to determine the effects of simulation-based medical education on the skills required to perform endovascular procedures in elderly patient with multiple co-morbidities.
Elderly patients with multiple co-morbidities cannot tolerate prolonged procedures either with general anaesthetic or local procedures in the Angiosuite. There has been some research in Cardiology (Schimmel et al, CCI journal 2016) that has demonstrated trainees in virtual reality simulators have improved performance with reduced procedural and screening times. Studies have also shown that operators with minimal endovascular experience can improve their time taken and contrast usage during short-phase training on a simulator (Aggarwal R et al, Eur J Vasc Endovasc Surg. 2006).
We have purchased a highly advanced high-fidelity endovascular simulator which has the ability to load real patient CT imaging to form realistic endovascular scenarios. Procedures such iliac and calf vessel angioplasty, endovascular abdominal aortic aneurysm repair (EVAR), endovascular thoracic aortic aneurysm repair (TEVAR) can be replicated on these simulators.
To our knowledge there are no known studies that have shown in daily practice if simulators can be used to replicate real cases prior to intervention, therefore reducing procedural time, fluoroscopic radiation exposure, contrast volume and complication rates in this elderly vulnerable population.
Understanding the clinical phenotype of aortic dissection
Aortic dissection is a condition involving catastrophic separation of the aortic wall which causes loss of circulation to vital end-organs. Its mortality rate is >1%/hour in the first 24 hours alone. Approximately 6,000 patients die from this condition each year in England and in Wales. To better understand clinical presentation, diagnostic approaches, treatment/management and outcomes of the condition, the International Registry of Acute Aortic Dissection (IRAD) was begun by the PI and others as an observational registry to understand the disease in 24 international centres. After 20 years and 70 publications (including the New England Journal of Medicine, JAMA and other top-tier journals), IRAD is presently recognized as the authoritative study group on this condition. British institutions have not been represented in this study, however. As an original investigator of the IRAD study, the PI will employ his experience and knowledge and the ACF will undertake investigative approaches to understand the clinical phenotype of aortic dissection in the institution by audit and further possibly to local/national levels including further comparison with global IRAD results. Using this clinical database, there is potential to further undertake phenotyping studies (e.g. metabolomics, imaging) to develop new blood- and imaging-based biomarkers of the condition.
The Impact of Pulmonary Tuberculosis on Muscle and Fat Wasting
Tuberculosis (TB) remains a global epidemic that is associated with considerable morbidity attributable to the systemic effects of infection. The classical symptoms of weight loss, fatigue and muscle wasting are clinically well recognised and the long term burden of systemic inflammation is thought to contribute to declining lung function. However, there is little published work profiling these clinical observations and the effects this may have on the host immune response to TB infection.
This project is a prospective clinical cohort study investigating whole body composition (using DEXA scans and multi-frequency bioelectrical impedence), lung function decline (corrected for cigarette and cannabis smoking), lung damage (quantified by cross-sectional analysis of radiological (CT) imaging) and the host immune response (T-cell function and genome (transcriptomic) analysis) in patients with active Pulmonary TB. Additionally, the longitudinal changes that occur during TB treatment and recovery will be examined.
The main objective of this project is to identify systemic biomarkers that link the inflammatory response and the muscle wasting seen in active TB and compare these with established and novel biomarkers in a cohort of COPD patients. A secondary aim is to describe the effects of cannabis smoking on the immune response, muscle wasting and lung function decline.
The ACF will be involved in the collection of whole body mass and appendicular measures of muscle and fat using techniques such as DEXA and bioelectrical impedance.
Determining the clinically relevant anatomy to teach UG medical students
Human anatomy has been a core component of undergraduate medical education for many years, and while it continues to be a key theme, the depth of anatomy taught has seen a steady decline. The need for a solid foundation of anatomical knowledge, while more readily appreciated as essential for those pursuing surgical careers, is important for any practicing clinician. Clearly, which areas of anatomy are most relevant will vary depending on the postgraduate speciality. With ever increasing pressures on space within the UG curriculum, there is obvious priority to ensuring what is taught best enables students to meet the demands of the breadth of future clinical practice.
While the GMC do not currently stipulate specific outcomes for the level of anatomy within the UG medical curriculum, the future introduction of the UK Medical Licensing Assessment will likely lead to efforts to better establish ILOs for the basic sciences, as a whole. In 2016, in response to the lack of consensus and guidance on the appropriate level of anatomy, the Anatomical Society defined a core regional anatomy syllabus of 156 ILOs, which were to help curriculum planners determine the clinically relevant anatomy to teach UG medical students. The proposed ILOs were determined by a Delphi panel of experts, which included surgeons, radiologists and anatomists.
The first step of the project will involve a series of focus groups and surveys with a variety of early clinical trainees from medicine, surgery and primary care. The purpose of this will be to identify whether there are elements of the 156 identified ILOs that represent a base of anatomical knowledge common across a breadth of specialities (surgical and non-surgical). The second step will be to explore how well they perceive (by self-report) to have retained knowledge of those areas of anatomy (identified in the first step of the project).
The findings from this project will help to better define areas of anatomy that are seen as most important, relevant and common to a breadth of clinical specialities. Further work/projects could explore how this anatomy could be prioritised or given greater attention within the UG medical curriculum, or early postgraduate period and whether there are any interventions that can be applied to improve retention of knowledge in those areas.