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 Best 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!
Once 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 muscle 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
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.
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
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 as 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!
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 munched 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
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 been 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 holding 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 an 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
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!
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).
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.
It’s time for a well overdue thank you to all of our student volunteers for their contributions to the lab over the summer. This year, instead of offering standard work experience to two or three students, as we have done in the past, we decided to ask our Student Panel members for help with a number of tasks that would be beneficial to both them and us. An experimental approach but it worked even better than we had hoped! So, many thanks to:
Lottricia Millett, Lily Groom, Morgan Walker, Reef Ronel, David Launer, Casril Liebert and Ashleigh Francis for writing summaries of published research papers from the lab. All of these summaries (which were of a very high quality!) are published here on the blog as well as being displayed in the patient waiting area of the department. A number of them have also been sent out to the patients and healthy volunteers who took part in those studies to inform them of the findings of the research to which they contributed. Feeding back results of studies to participants is really important, and it’s great to be able to send these summaries out to people. We also hope that the students will be able to use these summaries to demonstrate their skills when attending for university interviews and suchlike.
Kiki Riad-Forbes and Banke Faboyede for revamping the display board in our patient waiting area. The display has photos of the researchers in the department and information about the different types of research everyone does, plus links to this blog and our Facebook & Twitter accounts. We see a lot of people reading the information while they’re waiting so the eye-catching display is definitely doing its job!
Miki Friend, Asha Omar, Kiki Riad-Forbes, Banke Faboyede and Muska Yarzi for putting together a database of all of Alan and Vicky’s previous research participants and sending a huge mailshot to them all with the summaries of the studies for which they volunteered. This wasn’t the most interesting of jobs, involving lots of typing, printing, sorting piles of paper, and stuffing envelopes but was a task that probably just wouldn’t have happened otherwise. After some delays with a new postal system at King’s we’ve just sent out 216 A4 envelopes, with a few more to go out in due course.
Neta Fibeesh, Abi Mincer and Ma’ayan Dee, for writing a summary of Arietta Spinou’s PhD thesis studies, which again will be sent out to her patient participants to inform them of the outcome of the research. The nature of Arietta’s research is a bit different to the types of studies that most people are familiar with, so Neta, Abi and Ma’ayan did very well to summarise these studies in a way that’s accessible to people with no scientific background.
Ibtissam Adem and Deeqa Mohamed, for producing a great video of the SkinSuit study being undertaken at the KCL London Bridge campus with PhD student Phil Carvil and MSc student Alex Sehgal under Ged’s supervision. Not only did they film it in great detail, they took a lot of time to ensure they understood all of the complex science of both the suit (designed to mimic the some of the effects of gravity when astronauts are in space) and the measurements being made. The video will be a great resource for a lot of people.
So we think that’s a pretty decent summer of work! It has been wonderful to partner with our Student Panel members and we have been very impressed with the quality of the work they’ve all produced. We’re already looking forward to what achievements next summer will bring!
Airways Obstruction and Pulmonary Capillary Blood Volume in Children With Sickle Cell Disease
Catherine Wedderburn, David Rees, Susan Height, Moira Dick, Gerrard F. Rafferty, Alan Lunt, Anne Greenough
Published in the journal Pediatric Pulmonology, published online July 10th 2013
Children with Sickle Cell Disease (SCD) often face many obstacles due to the changes the condition causes in the body’s red blood cells. SCD results in anaemia, which is when there is less haemoglobin in the blood to help carry oxygen around the body. As a result, the heart has to pump much harder in order to ensure that the tissues of the body receive enough oxygen. This increased work by the heart also raises the amount of blood in the lungs, in order to allow sufficient oxygen is absorbed from the air. Children with SCD also frequently experience ‘airway obstruction’, which is the narrowing of the airways that makes it then harder to breathe. Airway narrowing can be caused by asthma, where muscles in the airways constrict, or by other causes.
This research was used to investigate whether the increased blood volume in lungs is associated with the ‘obstruction’ of the airways. The researchers tested this through testing the difference in the airways before and 30 minutes after using a medication called a bronchodilator (the blue asthma ‘reliever’ inhaler) which relaxes the airway muscles, widening the airways. The study used measurements called spirometry, which tests the amount and speed of air that can be moved in and out of the lungs, and Impulse Oscillometry (IOS), which uses sound waves in order to assess the resistance of the airways (airway narrowing).
If the bronchodilator had a substantial effect, the researchers would be able to say that the airway obstruction was due to an asthma-type condition, as the inhaler would have relaxed the muscles and allowed air to move more easily through the airways. What the results showed, however, was that there was little change in the measurements of lung function after the inhaler was given. The researchers can therefore use this evidence to support the hypothesis that the airway obstruction in SCD may be due to increased blood volume in the lungs.
Therefore, this study suggests that treatment of non-asthma related airway obstruction in SCD patients could perhaps move away from bronchodilators and towards more effective treatments for the anaemia aspect of SCD such as blood transfusions. A great deal of further work is needed but this is a valuable insight into the a potential process underlying breathing problems in SCD.
This summary was produced by Morgan Walker, Year 13 student from Harris City Academy Crystal Palace, as part of our departmental educational outreach programme.
Neuromuscular electrical stimulation to improve exercise capacity in patients with severe COPD: a randomised double-blind, placebo-controlled trial
Matthew Maddocks, Claire M. Nolan, William D-C. Man, Michael I. Polkey, Nicholas Hart, Wei Gao, Gerrard F. Rafferty, John Moxham, Irene J. Higginson
Published in the journal Lancet Respiratory Medicine, published online December 14th 2015
Patients with severe COPD often have weak legs as breathlessness can limit their ability to be active. Normally, to combat this and other symptoms of COPD, exercise classes called Pulmonary Rehabilitation (PR) are carried out. However, more severely affected patients may struggle to do PR.
An alternative therapy was introduced, neuromuscular electrical stimulation (NMES), to COPD patients with more severe symptoms. NMES is when electricity is used to create muscle contractions, in this case in the thigh muscles. While NMES has been used to strengthen muscles in previous research, this trial is the first to explore the impact on daily activities and the first to investigate the longer-term impact of the treatment.
52 participants with very severe COPD took part in this trial over two years. Participants received 30 minutes of NMES to both sets of thigh muscles daily for 6 weeks; 27 were placebo (‘sham’ stimulation) and 25 received active NMES. The aim: to assess the effectiveness of NMES, as a therapy to be conducted unsupervised at home, and at aiding daily activities. The main measure of effectiveness in this trial was a test of how far participants could walk in 6 minutes.
The results of the walk tests strongly support the use of NMES for severe COPD patients, with the patients who received the active NMES being able to walk substantially further. During interviews active NMES participants expressed a greater ease in everyday tasks (such as climbing the stairs) and stated that they could carry out physical activities for longer. No participants reported any negative views. Unfortunately, the improvement provided by NMES quickly waned after the treatment had stopped. Therefore, all existing evidence suggests that NMES should not be considered a replacement for PR. NMES can be used as an extension to PR, and could be used when patients are unable to take part in PR programmes. In addition, the short duration of effect suggests that longer programmes need to be investigated. Nonetheless, this trial has shown that NMES is a practical home-based therapy, suited to patients with more severe symptoms and has gives suggestions for future research.
This summary was produced by Reef Ronel, Year 12 student from JFS School, as part of our departmental educational outreach programme.