Research paper summary – Amazing-Grace Lawal

Effect of endurance exercise on respiratory muscle function in patients with cystic fibrosis

Charles C. Reilly, Katie Ward, Caroline J. Jolley, Lucy Anne Frank, Caroline Elston, John Moxham, Gerrard F. Rafferty

Published in the journal Respiratory Physiology & Neurobiology, January 2012

Cystic Fibrosis (CF) is a genetic disorder in which the genes that control the movement of salt and water in and out of cells are affected, this leads to a build up of mucus mostly in the lungs but also in the liver, pancreas and intestine. The aim of the study was to determine whether high intensity exercise tasks lead to fatigue (where the muscles become briefly less able to generate force) in the abdominal muscles or the diaphragm in patients with CF.

Two groups of people were tested, one group with 10 patients with CF and the other group with 10 healthy subjects. On two different occasions the test subjects went to the lab to carry out tests. On the first occasion the subjects performed an exercise test to characterise the subjects in terms of their exercise performance and to also calculate a work rate, which was used in the second test. The second occasion involved a cycling endurance test, lung function and respiratory muscle strength testing taken on all subjects. Before and after the exercise tests, subjects underwent magnetic stimulation of their diaphragm and abdominal muscles to assess how much force the muscles could generate.

Average exercise time was similar in the healthy subjects and those with cystic fibrosis, as was the intensity of exercise they performed during the test. The measurements taken show that there were not any significant changes in the responses to magnetic stimulation after exercise in both the healthy subjects and those with CF. A decrease the response to magnetic stimulation of greater than 15% is thought to be indicative of fatigue in respiratory muscles, however, none of the subjects saw a decrease larger than 15%, thus leading to the conclusion that fatigue did not occur in any of the subjects.

The fact that that fatigue did not occur in the diaphragm or abdominal muscles after exercise in the patients with CF suggests that feelings of breathlessness and weakness in leg muscles may be more important in limiting exercise performance in those with CF. Further studies are needed in order to exactly understand the factors that hinder exercise performance of those with CF such as muscle function in non-respiratory muscles.

This summary was produced by Amazing-Grace Lawal, Year 13 student from Harris Academy South Norwood, London as part of our departmental educational outreach programme.

Research paper summary – Casril Liebert

Observational study of the effect of obesity on lung volumes

Joerg Steier, Alan Lunt, Nicholas Hart, Michael I Polkey, John Moxham

Published in the journal Thorax, April 2014

With a rise in obesity, a bigger effort must be made to understand all the factors and effects of obesity on the human body. It is already known that obesity is associated with an increase in work of breathing and neural respiratory drive (the muscular effort required to breathe), as well as changes in lung capacities. It can also cause hypercapnic respiratory failure which is when there’s too much carbon dioxide in the blood. However, the effects on the mechanics of breathing are unclear. This study attempts to measure the effect of obesity on lung volume and various pressures in the chest and better understand the physiological differences between different weight people.

9 obese people and 9 normal weight people volunteered to be measured whilst seated and whilst lying on their back. During the study, the subjects breathed into the mouthpiece of a machine called a spirometer which monitors the speed and volume of air movement into and out of the lungs. Pressures in the chest and abdomen were also measured, along with the amount of air remaining in the lungs after a breath out (functional residual capacity, or FRC).

After evaluating results, it was noted that high pressures in the chest are have an important role in the mechanisms of the respiratory system. The chest and abdomen pressures were found to be much higher in the obese group, and the FRC lower. The strength of the breathing muscles were measured and the result showed that the obese group had weaker muscles. There was a direct relationship seen between subjects’ waist circumference and the chest and abdominal pressures, as well as with the drop in FRC.

One of the main conclusions is that gastric and oesophageal pressures correlated with waist size, since the obese group had significantly higher pressures. One can deduce from this result that these high pressures are inhibiting efficient function of the lungs, and contributing to the reduced volume of air in the lungs. To bring this research into practical everyday healthcare, more could be done to attempt to reduce abdominal pressures in obese patients. By doing so with appropriate treatment in the future, obese people may be able to reach normal lung function, thereby reducing the number of patients suffering from breathlessness and sleeping disorders from respiratory problems.

This summary was produced by Casril Liebert, Year 13 student from JFS School, Harrow, as part of our departmental educational outreach programme.

Research paper summary – Djenné Oseitwum-Parris

Measurement of neural respiratory drive via parasternal intercostal electromyography in healthy adult subjects

Victoria MacBean, Cara Hughes, Gavin Nicol, Charles C. Reilly, Gerrard F. Rafferty

Published in the journal Physiological Measurement, October 2016

Parasternal intercostal electromyography (EMGpara) is a method used to measure breathing function by monitoring signals sent from the brain, to the parasternal intercostal muscles (muscles between the ribs). These muscles, together with the diaphragm (a thin muscle under the lungs) and some others, move together to control your breathing. EMGpara can be used to measure a person’s neural respiratory drive (NRD), which is an indication of the strength of the respiratory (breathing) muscles under a certain amount of strain (how hard the muscles may have to work when they are coping with different diseases or environments). This method is an alternative to other more traditional practices that, for example, may involve the use of needles. Therefore, EMGpara is less invasive and ideal for monitoring the breathing muscles in many groups of people.

In the case of this study EMGpara was measured in healthy adults in order to discover what factors determine normal EMGpara readings. The participants were over the age of 18, and were of different body types and sexes.

In preparation for the EMGpara tests, each participant’s body size, shape and composition was measured – this included taking note of their height, weight, hip and waist size, body fat percentage and body mass index – as well as tests to confirm that each person had normally functioning lungs.

Electrode stickers were placed on the chest to measure the EMGpara signals as the subjects breathed normally and effortfully. The tests were repeated at a later date to make sure the results could be reproduced, thereby checking that the EMGpara technique is consistent.

The study suggests that sex is the most important factor in determining EMGpara; a higher value for EMGpara was observed in the women who took part. This may be because in general, woman have smaller lungs and narrower airways compared to men and their respiratory muscles are usually not as strong.

Age did not seem to have a significant effect on the readings; however this could have been because the average age of those involved was only 31, and those who were older were quite athletic, meaning their respiratory health was very good.

The results of this study can be used as a reference for what a normal EMGpara reading is, and therefore they can be used when assessing patients in the future. The study included many people from different backgrounds, so it is quite representative of the population. The study was also important in working out which methods and techniques are best for measuring EMGpara, as well as for highlighting possible areas of further research for future studies.

This summary was produced by Djenné Oseitwum-Parris, Year 12 student from Burntwood School, Wandsworth, as part of our departmental educational outreach programme.

A third Student Panel member writes about her practical experiences

On 5th July, we explored how researchers use an EMG to measure the effort the intercostal muscles exert during breathing. We did four tests on an employee, Galia. The first test was when DSC_2259she was breathing normally with no resistance and her results were recorded on an EMG trace which we extrapolated from and recorded on a table. We carried out the other three tests using different tube lengths (representing different stages of resistance) which were attached to a mask. While collecting the results we found that one of the results did not fit the pattern. To resolve this issue we should have repeated the experiment at  least three times. We tried out the equipment on ourselves and found how different factors affected the EMG trace e.g. your posture and slight movements can cause your intercostal muscles to work harder therefore the peaks on tDSC_2258he EMG trace are taller. We learnt that testing on children is hard work as they cannot stay still for a long period of time so you need to use certain tactics like putting on Peppa Pig to keep them entertained. We thoroughly enjoyed our experience and learnt valuable knowledge.
Trinecia Compton, Year 12, Burntwood Academy

Another Student Panel member explains her practical session

On 5th July was our second Student Panel meeting where we were fortunate enough to receive hands-on practical experience in the labs of the Chest Unit at King’s College Hospital! Our main point of interest today was to investigate measurements of inspiratory and expiratory muscle strength. The session started with all the members reintroducing ourselves to one another and speaking about what we study and what we would like to do in the future. It was great to catch up again and meet new members who I didn’t see at our last meeting! I made a load of new friends who gave me valuable tips regarding university and a career in medicine and science. These activities made us all feel very welcome again and very excited for the afternoon!

We were split into three groups depending on what we’d prefer to investigate and I chose to do respiratory muscle testing. My team’s practical was led by Brittany BestIMG_20170718_161321 who is a current MSc student. Britt was extremely supportive and reassuring which made us find the practical easy and exciting to carry out. She started by teaching us the names and functions of the equipment which we were going to use; these included nose bungs, mouth pieces and a 3-chamber metal valve which we all used at some point of our practical. We also got to pop in to the other group’s rooms and see the cool stuff they were using such as an ECG! In my team, we performed measurements of inspiratory and expiratory muscle strength using the PImax, PEmax and SNIP technique. The PImax was much harder to carry out because we were not used to the equipment but also because it was so unusual to us! This made us think about how difficult a healthcare professional may find it to get accurate data from a patient’s results as patients can often be giggly or even find the unusual technique very awkward and hence will alter their breathing pattern, either purposefully or subconsciously. To obtain results, patients must suck air into their lungs through a mouth-piece. This may sound simple at first, however it quickly challenged our lung muscle ability when my partner was told to close one of the valves. It felt as though my lungs were about to burst because I couldn’t breathe in any air after a certain point due to the valve, but was generating a lot of pressure in my lungs! The SNIP test was much easier to do as it just involved sticking a nose-bung up your nose and breathing regularly with a little twist: give a powerful sniff after every third breath out. Although it isn’t the most fashionable way to gather results, it sure was easier!

IMG_20170718_161324Once we all had a chance to take on the roles of both a patient and the scientist, we each analysed our data to see if our values fell into the predicted range values. After a couple of attempts with Brittany reassuring us that it is tough when you’re new to it, we finally got the hang of it! Our values started looking normal as we got more used to the test.

Once we finished our practical, we then all discussed how these tests might be adapted to different patient populations including younger children or those on intensive care. We discussed about how someone on intensive care may not be able to breathe as they usually would and hence more invasive measures would be taken into consideration such as a technique which runs a tube through your nose and down the back of your throat which allows successful results to be collected. We also thought of the difficulties an individual may face due to weakened IMG_20170718_161256muscle strength such as those who suffer from motor neurone disease. The team spoke about how hard it must be for somebody’s biceps to always feel very painful and heavy as if a heavy bag was attached on to them! This made us reflect and contemplate about how difficult their home life could be, especially if they lived alone as simple everyday activities such as walking up the stairs could be a challenge to them.

The day was just as expected: very fun and factual! I always enjoy our student panel meetings as each meeting is different from the rest and always involves activities which I have never done before or even knew existed!

Huge thank you again to Dr Vicky MacBean and everybody else who works hard to make all our meetings amazing!

Sarah Ezzeddine, Year 12, Harris Academy Peckham

A Student Panel member writes about her experience of learning lung function techniques

On the 7th of July, as part of the King’s College Muscle Lab Student Panel session, we looked at measuring lung function in two ways, Impulse Oscillometry and Spirometry.

Impulse Oscillometry involved measuring the patient’s tidal breathing over 90 seconds at a 5Hz resistance. We felt the procedure was simple, and once you get used to the noise of the machine, easy to get good readings from. We repeated the examination 3 times, layering the graphs to ensure our results were concordant. We saw a regular trace graph over a 90 second period.19756366_1973918919558822_5565308448661342079_n

Spirometry was a little more difficult to carry out; we recorded some tidal breathing first to ensure the patient was comfortable and ready, then the patient was asked to inhale as much air as possible into the lungs, then exhale as quickly as possible, all air from their lungs (we encouraged this through shouting as we found the first time round both patients didn’t expel as much air as they could!). This gave us a forced expiratory volume in 1 second value. We also repeated this examination to ensure out results agreed.

Both these tests are good in determining aspects of airway function, with Spirometry also giving FEV1 values and vital capacity, and Impulse Oscillometry giving tidal breathing patterns, however for patients with breathlessness which is a common symptom seen in the chest clinic, these tests could be difficult to carry out and gain accurate results, especially from Spirometry. Also young children may find this difficult to carry out, as it can take a while to get used to breathing with your mouth round the mouthpiece and with a nose clip. Overall it was a good experience to get some practical skills in the clinic and gain some valid result and values to analyse.

Estelle Thomas, Year 12, Harris Academy Crystal Palace

A second Panel member reflects on last week’s meeting

Students interested in the Science and Medicine field were recently granted the special opportunity to be a part of the King’s Muscle Lab advisory student panel which took place down the road from King’s College Hospital. Many of those were Year 12 and 13 students who like myself were from the ‘Harris Experience Advanced’ scheme along with some other students from JFS, Burntwood and Graveney schools who were lucky enough to be invited with us! This was the first gathering of the upcoming few for many of the students.

Upon arrival, we met 6 professionals in various fields including Doctors, Physiologists, Physiotherapists and Researchers. Each one gave a helpful presentation about their journeys into their professions and the various routes they took. Some were not panel presentation 010317as successful as others in their initial attempt. However, this broadened my insight into the very many similar pathways I could take other than Medicine including biomedical research. Our day was based around the broad topic of ‘Physiology’, the study of the functioning of the body, and specifically ‘Paediatrics’.

Soon after, we were assorted into groups with people we’d never met and each group was assigned a speaker to work with for 15 minutes. Here, we had the beneficial opportunity of asking questions that we were curious about. We discussed the differences between adults and children and their lung capacities. We then answered the question “Are children mini adults?” To my surprise, the answer was no. We also got the chance to share our future aspirations with them and gain useful tips and advice including upcoming work experience offers with the team which I am thrilled by! panel notes sheet 010317

As an aspiring neurologist, my favorite thing which we spoke about was the topic of brain diseases such as epilepsy, a neurological disorder which causes recurrent seizures in an individual. Also, learning about what causes the irregular brain wave signals which a sufferer experiences was fun. We deduced how factors such as other health conditions, race and age make developing epileptic seizures much more likely. Dr Harris also informed us about children he previously worked with in Uganda where the rate of death caused by open-fires is exceptionally high. Along with this, we brain-stormed the many difficulties a modern family with an epileptic child could face and the future issues which could arise.

Altogether, the experience was fascinating and a great success. Dr MacBean and her team organized it very well for us to feel welcomed and comfortable with one and other despite it being the first time seeing each other. (Side note: the snacks we panel meeting 010317munched on whilst being fascinated by the works of the respiratory system were lovely and a great aid for helping us absorb the new scientific content we learned.) It was not at all as difficult and fact-heavy as I initially expected it to be and turned out to be one of my favorite experiences so far this year. I will definitely be including this experience on my personal statement in future when I apply for Medicine, which I feel more content in doing after the Muscle Lab!

Special thanks to everybody who worked hard to provide us students with such an amazing experience!

Written by Sarah Ezzeddine, Year 12 Harris Academy Peckham

A new Student Panel member writes about our Panel meeting on March 1st

For those, like me, who love science it is natural to consider becoming a doctor. However, many students have very little idea what this involves and there are limited opportunities to find out more. So I was very grateful to be invited onto the King’s Muscle Lab panel. I went for the first time today and loved it. I have done the usual volunteering and work experience but this gave me a genuine insight into real life inside the NHS – how the moving parts all work together to produce better outcomes. Our panel were able to properly talk to the doctors and other healthcare professionals about their work which was a particularly valuable experience.

I’d never 20170303161836been on a student panel and had no idea what it involved but when I was sent the itinerary with a list of guest speakers I started to get excited! I arrived at King’s College London Institute of Psychiatry, Psychology & Neuroscience (is there anything they don’t do?!) with a few other keen scientists from my school. We were welcomed by Dr Vicky MacBean who introduced us to the ‘Muscle Lab’ and the visiting professionals and then we were off!

Each professional, a mixture of doctors, physiologists and physiotherapists, had fifteen minutes with their group of five to discuss a topic that incorporated everything from child physiology to ethics to care plans to early intervention. I was fascinated to see that so many professionals with such varied backgrounds were all working in the field of respiratory studies whether it was research or clinical. To see how all the healthcare professionals’ work fit together was particularly interesting and very reassuring for those on the panel who are trying to narrow down what they might want to do in the future. Whether you’re the person 20170303161741holding the spirometer measuring vital capacity or the person in the lab examining lung tissue you are part of a wider system that works with the primary focus of caring for patients. All the professionals that we met were at different stages of their career and yet all of them were genuinely enthused to be sharing their experiences with us.

The focus of the session was paediatrics and specifically how this differs to adult healthcare. It was emphasised that children are not just ‘mini adults’. Although all the students attending learnt a great deal it wasn’t like being in a class at school. The small group environment created an easy atmosphere for discussion where every idea was valued and we felt able suggest something that we weren’t necessarily sure was correct. We were guided by our experts but given the ability to be free thinkers.

I had an20170303161810 encouraging and inspiring experience at the ‘Muscle Lab’. It opened my eyes to the complexity of our comprehensive healthcare system which is particularly topical. Instead of leaving fearful for the future of the NHS I left energised by the passion and enthusiasm of those who are working to keep it going. Their desire to include the next generation in their work is admirable and I’m extremely lucky to have met such wonderful people with such passion for the respiratory system!

 

 

Post written by Tilly Roberts, Year 12 student at Graveney School, London

How does scientific publishing work?

So we talk a lot about the studies we do, and we’ve had a lot of summaries on here of the published papers detailing the results of the research studies.  What might be a bit of a mystery though is how the process between those two points works…  So here’s an overview.

Once we’ve gone through all the hard slog of acquiring research data and analysing the results, we write up a report, that we generally call a manuscript.  This is normally something around 3,000 words long, and contains:

– An introduction to the area of study, why we decided to do the research, and what we expected to find (our hypothesis).

– The ‘methods’ section, which is a detailed description of what we did and how (what equipment we used, how long we measured things for, where we identified participants from, in what order our measurements were made, etc.).

– Results:  this is where we put all the numbers, in the form of tables and graphs and some explanatory text.

– The discussion, which is where we talk about what we think the results mean.  It might be that we found what we expected (i.e. supported our hypothesis), or that we got completely different results to what we hypothesised.  Either way, we discuss aspects of the study that we think were particularly strong, highlight any weaknesses, and then refer to our results within the context of other research in the same (and related) fields.  This section often contains suggestions of what future studies could do to build on the results we’re presenting.

So once we’ve written the manuscript and all authors are happy with it (everyone who has contributed significantly to the research is listed as an author, with the first person in the list being the person who did the majority of the work, and the last person being the senior academic responsible for overseeing the project), we decide on a journal to send it to.  This decision is based on the type of research study we’ve done (there are some journals more suited to studies with a pure physiology focus, and some better for more clinically-orientated work) and how significant we think the work is.  A larger study, or one with more exciting findings (perhaps that would really change the way people think about that area of study), would be sent to a more prestigious journal.

Once the journal receives the manuscript via their online submission system, it is evaluated by a member of the journal’s editorial team.  They judge whether the manuscript is the sort of thing they’re looking for, and at that point either reject it straight away (disappointing) or decide to send it out to review.  If the latter, the manuscript will be sent to usually two or three expert researchers who work in the same field to ask them to give their opinion.  These reviewers will write a report of the manuscript and suggest how suitable they think the manuscript is for publication in the journal.  The editors of the journal will take into account the opinions of all the reviewers (and these opinions won’t always agree…) and make their decision.   They will send us an email informing us of the outcome, which will be one of three things:  that the manuscript has been rejected, that it will be reconsidered after some changes are made, or that it is accepted as it stands (a relatively unusual outcome, but one that we would celebrate with some vigour!).

If the manuscript is rejected, we will look carefully at the reviewers’ comments and make any appropriate changes to the manuscript before choosing a new journal to send it to (and the process starts again).

If changes are requested, these could be relatively simple (such as adding in some more details about the participants, including some different graphs to represent the data more clearly, or referring to some other research within the discussion section), or could be complex (for example requiring some major data reanalysis or lengthy explanations of why a certain approach was chosen).  We would work on these changes and send back a revised manuscript with a detailed letter describing what changes we have (or sometimes haven’t) made and why.  These documents then are sent back to the reviewers and they write another report.  Based on this, the editors decide whether we’ve done a good enough job for the manuscript to be accepted.  Sometimes the changes and corrections process is repeated once (or more), but generally the manuscript will be accepted in response to the first or second set of changes.

Once the manuscript has been accepted by a journal (whether that’s the first, second or fifth journal to which it was sent), the journal’s editorial assistants prepare the written document in their own specific format and send ‘proofs’ to the authors to approve (making sure that everything looks correct, there are no spelling errors, and that the layout for the journal hasn’t led any data to be presented in a misleading manner).  The paper (no longer just a manuscript) is then first published online, and a few months later appears in print (though actually very few people read journals in paper form any longer).  And importantly, we add it to our CVs!

Summary of Arietta’s thesis – Ma’ayan Dee, Neta Fibeesh & Abi Mincer

Systematic review and meta-analysis of health status questionnaires in bronchiectasis

A recent study regarding Bronchiectasis questionnaires was used to understand the quality of life of patients with a chronic lung disease called Bronchiectasis. These results were used to understand the connections between HRQOL (Health Related Quality of Life) and clinical measures, which are other tools we use to assess a disease. The aims of the study were to identify all the evidence and select the appropriate studies that can later be assessed in an unbiased and balanced way. The importance of collecting this data in this way is that it provides useful insights about the quality of life of patients from a personal point of view and helps the researchers understand the effectiveness of their clinical tools.

The searching and selection process using electronic databases were used to choose appropriate studies, for instance patients with cystic fibrosis (a genetic condition) were not chosen. The studies which were chosen were analysed to check for certain criteria that made sure their results were reliable. Then, a meta-analysis (a combination of various data assessments) was used to test how strong the connections between HRQOL and the clinical measures actually were. Out of the initial 1,918 studies first identified, 43 studies were used in the reviews and 38 ended up being chosen as suitable for the meta-analysis.

Results showed that there was a strong relationship between the HRQOL and subjective outcome measures such as fatigue (tiredness) in comparison to objective measures such as ability to exercise and how severe the Bronchiectasis was revealed to be on a CT scan.

 

Development and validation of the Bronchiectasis Health Questionnaire (BHQ): a new patient-reported outcome measure

There is an insufficient amount of questionnaires in relation to assessing the health status of someone with bronchiectasis. The questionnaires themselves are easy to understand and they give an idea of the patient’s perspective. A study was conducted to develop and confirm the value of the BHQ (Bronchiectasis Health Questionnaire). The BHQ is a new tool to measure the health status for patients with bronchiectasis. Questionnaires are needed for individual conditions due to the fact that every disease has its own causes and symptoms. This means that in order to help patients with different diseases questionnaires have to be adapted in order that the questions lead to suitable answers which can thus help those asking the questions to find answers that will lead to help for those taking part.

Patients who took part in the study were recruited from two outpatients clinics. The BHQ was developed by the introduction of item generation as well as item reduction. As well as this, the BHQ was developed by repeated testing and validation.

Two hundred and six patients took part in the study and completed a questionnaire with 65 questions. Fifty five of the questions were removed from the initial questionnaire to make the tool easy to use and more valid. The final version of the BHQ consisted of 10 items with a score between 0-100 with 100 being the best health status.

The BHQ generates a total score and general consensus. It can be used in clinical and research settings in order to assess the effect of bronchiectasis from the perspective of the patient who has the disease.

 

The objective assessment of cough frequency in bronchiectasis

Bronchiectasis is the abnormal widening of the bronchi or their branches, which causes a risk of infection. Cough is a common symptom of this condition and recent advances in technology in the monitoring of cough sound have enabled the assessment of cough frequency to be used to better understand various diseases. This study was aimed at quantifying cough frequency and by doing so investigating how the cough frequency affects the health status of individuals.

54 Bronchiectasis patients were assessed along with 35 healthy people (controls). The researchers measured their health status, cough severity, lung function and 24-hour cough. 24-hour cough was measured using a small portable audio recording device.

Data revealed that the cough frequency was high for patients suffering from Bronchiectasis meaning they coughed a significant amount more that healthy people. Additionally, patients with Bronchiectasis had impaired health status. Various factors associated with the objective cough frequency included sputum production (coughing up phlegm), the frequency of antibiotics for respiratory infections and older age. However, there was no good association between cough frequency and a common lung function test (spirometry).

 

Summary

Overall the studies revealed that questionnaires were a successful technique to provide results regarding the quality of life of those suffering from Bronchiectasis. This shows that a patient’s own perspective is very valuable in medical research and not only their physical condition!

This summarises the PhD research undertaken by Arietta Spinou, under the supervision of Surinder S Birring & Rachel Garrod. The summary was produced by Neta Fibeesh, Abi Mincer & Ma’ayan Dee, Year 12 student from JFS School, Harrow, as part of our departmental educational outreach programme.