Warwick and Swansea Medical Schools: Research and Collaboration in Healthcare, Study notes of Medicine

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GRADUATE-ENTRY RESEARCH IN

MEDICINE CONFERENCE

GUIDE AND ABSTRACT BOOKLET

WELCOME

We are delighted to welcome you to our fourth annual Graduate Entry Research in Medicine Conference. You

will be joined by colleagues from across the UK to celebrate the exceptional standard of work that has been

achieved by students studying fast-track accelerated programmes.

Warwick Medical School (WMS) is home to the UK’s largest exclusively graduate-entry programme, with

around 200 students in each cohort. This event has been heavily subsidised by the Academy of Medical

Sciences and the INSPIRE initiative, which is designed with the intention to supporting students to develop

their interest and skills within academic medicine. In order to build on the successive years of strength this

conference represents, we have teamed up with Swansea Medical School for a collaborative bid to attempt

to run this event in the future, hosted between these two schools.

At WMS, we believe that Academic Medicine is very much a continuum and not a dichotomy; a crucial role in

the future of what it is to be a doctor. However, we know that in accelerated degrees students have

significantly less time not only to conduct research, medical education or leadership, but moreover are at a

detriment in the time it takes to be able to disseminate this work. As such, we believe that events like today

are crucial in providing students with a platform to be able to engage in this side of their role, which will

become ever crucial in your career in the years to come.

This year, our event will be hosted at Scarman Conference centre, where the welcoming hospitality team will be

able to cater to your every need, including complimentary refreshments throughout the day. The day will be

filled by an exciting programme of INSPIREing keynotes and oral and poser presentations by colleagues from

throughout the UK.

We have made a conscious effort to make the day as ECO-FRIENDLY as we can. We are not mass printing

this guide, and we are reducing waste from single-use plastic, through not supplying lanyards or plastic

consumables. We hope you will support us in this aim.

There will be intermittent breaks throughout the morning, and facilities can be located via looking at the map

located within the guide. You will be able to help yourself to refreshments on offer throughout the day, so

please feel free and make yourselves feel at home in the lounge areas.

We hope you have a wonderful day!

Best Wishes, The Warwick INSPIRE GERMCON Committee

KEYNOTE BIOGRAPHIES

Dr Steven Laird

How do we get to where we are? A story from a research focussed clinician

Dr Steven Laird strives to combine front line clinical microbiologists and infectious disease specialists to enhance infection management and diagnostic effectiveness by appropriately engaging with colleagues and patients at the bedside. His specialist interests are tropical medicine, infectious disease, microbiology, public health medicine and outbreak management. Dr Steven Laird is a Consultant Physician in Infectious Diseases and Medical Microbiology based at the University Hospital of Coventry and Warwickshire, England and a medical examiner and clinical personnel tutor. At Warwick University At Warwick University, he is an OSLER examiner, medical student selection centre interview, a SSC 2 Project Supervisor and a SSC 1 ID and Tropical Medicine Co-module Lead. He is currently working ongoing research as chief investigator research on a randomized, DOUBLE-BLIND, placebo-controlled study to evaluate the efficacy, safety and pharmacokinetics of a single intranasal dose of STI-2099 (COVI- DROPSTM) in Outpatient Adults with COVID-19 as well as a clinical trial looking at whether Eicosapentaenoic acid (EPAFFA)gastro-resistant capsules can reduce the inflammation in the lungs of people with COVID-19 infection with COASPIRE.

Professor Prithwish Banerjee

The academic apple: How to grow it from seed

Prof Banerjee trained in cardiology in the Yorkshire (Leeds) Deanery and obtained his accreditation in Cardiology and General Internal Medicine in 2004. He was appointed as consultant cardiologist at the University Hospitals Coventry & Warwickshire in November 2004 to establish and lead the heart failure service in this hospital. At this time he also worked as an interventional cardiologist (doing primary and elective angioplasties) and lead for cardiac imaging for 8 years. He was the network lead for heart failure for the Coventry & Warwickshire Cardiovascular Network before it was dissolved in 2013. In 2007 he became an Honorary Associate Professor at the University of Warwick, Research Lead in cardiology in his hospital in 2011, Cardiovascular Lead for the West Midlands within the NIHR Clinical Research Network (CRN) in 2012, Chair for the Midlands Heart Failure Group and continues to hold all these positions. He was appointed Honorary Professor of Cardiology by Coventry University in May 2016 and by Warwick Medical School in 2019. He is a fellow of the Royal College of Physicians and the European Society of Cardiology. His research interests include Heart Failure with preserved ejection fraction (HFpEF), myocardial fatigue, vascular resistance in heart failure, cardiogenic shock, cardiorenal disease and electrical muscle stimulation of the legs for cardiac rehabilitation.

ORAL PRESENTATIONS

Breakout Room 1 Morning Interventions addressing loneliness among university students: a systematic review Olivia Betty Ellard, Christina Dennison, Helena Tuomaine, Ph.D. Warwick Medical School, University of Warwick Background Loneliness is detrimental to mental health, with university students at higher risk of feeling lonely than other population groups. However, little research has explored interventions to reduce loneliness among students. This systematic review identifies the characteristics and effectiveness of interventions targeting students at university or college. Methods PsycINFO, PubMed, ASSIA and Web of Knowledge were searched from inception using keywords linked to ‘loneliness’, ‘intervention’ and ‘students’. Relevant peer and non-peer reviewed English-language articles on studies implementing an intervention with loneliness as an outcome and investigating undergraduate or postgraduate students at a higher education institute were included for quality analysis and narrative synthesis. Risk of bias was assessed at both study level and at outcome level using the revised Cochrane risk of bias tool for randomized trials (ROB2) and the risk of bias in non-randomized studies of interventions (ROBINS-I). Results 20 articles were included, comprising 17 studies assessing loneliness quantitatively and three qualitatively, covering 27 interventions, most implemented in the United States. Interventions were based on psychoeducation, social support groups, increasing social interaction, or reflective exercises. Evidence from the RCTs suggests that most interventions had an effect on loneliness outcomes but the magnitude of the benefit is unclear. Across all quantitative studies, 86% (12/14) of interventions based on either social support groups, increasing social interaction or reflective exercises, and 40% (4/10) of interventions based on psychoeducation were deemed effective in reducing loneliness. 20 out of 24 interventions measured quantitatively were delivered in a group setting, of which 65% (13 out of 20) were considered effective in reducing loneliness scores, regardless of intervention. Conclusions Universities have a choice of interventions to help reduce loneliness among students either on campus or virtually. Ones promoting social connectedness appear to be more successful. More high-quality studies in a larger number of countries are needed, taking vulnerable student groups into consideration. Key words: students, university, college, mental health, loneliness, social connectedness, interventions, prevention Using the 100,000 Genomes Project to explore SARS-CoV-2 infection susceptibility in the UK rare disease population Background Since its emergence in December 2019, SARS-CoV-2 has had enormous impact as a global health threat. Age, gender, and the presence of co- morbidities are well established risk factors for both mortality and severe

Anna Scott Department of Medical Genetics, University of Cambridge disease. Several host genetic factors have been linked to disease severity, including variants in ACE2 , TMPRSS2 and the OAS gene cluster. The role of genetic factors in relation to infection susceptibility, rather than outcome, has been less of a focus. Determining risk factors for infection susceptibility is crucial for identifying individuals at risk and allows tailoring of public health measures, such as shielding, to those who would most benefit. This project sought to explore the role of host genetic background in determining SARS-CoV-2 infection susceptibility in the patients with a diagnosed rare disease. Methods SARS-CoV-2 PCR test results of 2738 participants of the 100,000 Genome Project rare disease cohort were associated with genotype at 25 pre- selected loci. Associations were determined using Fisher’s test using samples of participants subset by disease, as well as across the cohort as a whole. Association testing was also performed between positive tests and disease classification to identify any disease groups with significantly higher rates of infection. Results Four variants (rs10735079, rs1156361, rs143334143 and rs10774671) were significantly associated with SARS-CoV-2 infection among 100K rare disease cohort. Three of these are co-located within the OAS gene cluster and is particularly associated with infection among participants with neurodevelopmental disorders. It was also found that participants with disorders of sex development were significantly more likely to receive a positive SARS-CoV-2 test result than other participants. Conclusion These findings suggest that variation in OAS genes may influence individual susceptibility to SARS-CoV-2. As this locus has previously been associated with severe COVID-19, this suggests that molecular mechanisms determining infection susceptibility and disease severity may be shared. Further investigation of the observed increased susceptibility to SARS-CoV-2 in patients with disorders of sex development may provide clues to mechanisms underlying susceptibility in general, as well as previously observed sex bias in disease outcome. HTK versus multidose cardioplegias for myocardial protection in adult cardiac surgery: A meta-analysis. Alexander C. Reynolds1BSc, Sanjay Asopa MD2, PhD, Amit Modi MD3, Nicola King PhD

_1. Swansea University Medical School, Wales, UK.

2. Southwest Cardiothoracic Centre, England, UK. 3.Sussex Cardiac Centre, England, UK. 4.Faculty of Health, University of Plymouth, England, UK._ Background Histidine–tryptophan–ketoglutarate (HTK) cardioplegia for myocardial protection obviates the need for maintenance cardioplegia doses, and thus allows for greater focus on procedure accuracy. The aim of this meta- analysis is to evaluate the safety and efficacy of HTK versus multidose cardioplegias during cardiac surgery in an adult population. Methods Electronic searches were performed using PubMed, Science Direct, and Google Scholar databases. The key search terms included HTK cardioplegia AND cardiac surgery AND adult. This was followed by a meta- analysis investigating cardiopulmonary bypass (CPB) duration, cross-clamp duration, spontaneous defibrillation, inotropic support, mortality, atrial fibrillation, creatine kinase muscle brain band (CK-MB) and troponin I (TnI). Results

Initial results have shown promising results from NEL technique for PPH treatment. 5 papers were gathered from a MedLine search. A total of 189 patients were involved in the 5 studies and shunt rates were between 56%-60.8%. A positive trend is seen in post procedure complications with fewer CSF infections and no recurrent haemorrhages. In regard to NeuroCognitive assessment one study reported “good cognitive results in 53.3% of patients” and another reported “78% were able to walk independently”. Frailty scores in the Older Person Assessment Service: To what extent do allocated scores vary between healthcare professionals? Claire McGregor Swansea University Medical School Aims There is an unmet need to minimise the variability of frailty scores allocated to patients in the Older Person Assessment Service (OPAS). The Clinical Frailty Scores (CFS) are widely used on the wards, in the community and in OPAS and can significantly alter the treatment and care pathway of the patient. Frailty scores are based on clinical judgment of cognition and physical health, ranging from 1, ‘very fit’ to 9 ‘terminally ill’, however, between these values there is a great deal of subjectivity which can be detrimental to patient care. This audit aims to determine the extent of the variability between the frailty scores allocated by doctors, nurses, physiotherapists and occupational therapists in OPAS, explores the consequences of this and considers methods for minimising this discrepancy. Methods An audit was conducted in Morriston Hospital, Swansea’s OPAS department over a period of 14 days in June 2021. The variability of frailty scores given by 4 types of healthcare processional to 26 patients was analysed. Results Of all the patient scores audited in OPAS, the frailty scores allocated varied by at least 1 point in 46% of patients, with a 2 point difference being found in only 3% of patients. Most commonly, variability tended to occur between frailty scores of 4-6. The average difference between the highest and lowest score given to each patient was 0.5. Conclusions Frailty scores are allocated based on clinical judgment and are useful in determining the risk and benefits of critical care support. The pathway of care that patients in OPAS receive can significantly vary depending on the perceived level of frailty, and where significant variability is found this must be addressed. With higher scores determining whether palliative care is given, or lower scores encouraging clinicians to provide treatments of higher risk or discharge patients, it is clear that misjudged frailty scores can be detrimental to patients where, as a consequence, the incorrect level of treatment is given. This audit reveals that the frailty scores allocated in OPAS are not completely harmonious throughout the different healthcare practitioners, however no significant fluctuations were found. Where larger disparities are evident, methods of reducing this variability would help to ensure patients are more accurately scored and receive the most optimal treatment pathway. However, given the average variation of 0.5 per patient in this small sample, it is possible that larger disparities would be discovered in a larger sample set and so further research may be required.

EMRTS out of hospital cardiac arrest recording: how does it compare to Utstein and other International Registries? Jared Charlton-Webb, Swansea University Medical School Dr David Rawlinson, Consultant, Emergency Medical Retrieval and Transfer Service (EMRTS Wales) The Emergency Medical Retrieval and Transfer Service in Wales (EMRTS Wales) offers Consultant and Critical-Care Practitioner led care throughout Wales. Launched in 2015 the service has grown to include four aircraft and multiple rapid response cars to serve the Welsh population. As of 2021 they have started undertaking air operations at night. The main roles for EMRTS is in direct emergency response to critically unwell medical and trauma patients, and in inter-hospital transfers for unwell patients of all ages. The Utstein criteria are guidelines for reporting cardiac arrests, first proposed in 1991 with the name deriving from Utstein Abbey in Norway where a conference was held in 1990. The criteria were developed to allow for uniform comparison between different registries. The criteria were revised in 2015. EMRTS incident reporting database was reviewed to compare the data fields to the Utstein criteria, to see whether the service met international guidelines. Additionally, the EMRTS database was compared to 13 international cardiac arrest registries. Lastly, the EMRTS database was reviewed to see whether termination of resuscitation (ToR) decision reporting could be improved. On review of the EMRTS data fields, there is room for improvement to meet the Utstein criteria. It was noted that information about bystander CPR and AED use wasn’t recorded, information regarding the number of defibrillations wasn’t recorded, and post event outcome wasn’t recorded in detail (e.g. cause of death, patient reported outcome measures, quality of life measurements). Additionally, there is a need to have more specific data fields for ToR decisions. In comparison to the international registries, no registry fully met the criteria, with only one coming close. A lot of registries did not report outcome of the patient, nor the investigations undertaken during resuscitation, or information about the patient’s comorbidities. From here further discussion about the EMRTS database will be undertaken to see what can be altered or added to help meet the criteria, additionally sections on ToR decisions will be added. The database will be reviewed a year after change to see progress.

To assess the intra- and inter- individual variability of VOC levels within whole saliva. Methods Unstimulated whole saliva was collected from participants after a minimum of 6 hours fasting on 5 mornings over a 3 week period (week 1: 3 samples, week 2: 1 sample, week 3: 1 sample). Exclusion criteria included: smokers, active oral disease, immunosuppression, clinically significant systemic disease. Triplicates of 500uL of saliva in 20mL glass headspace vials were incubated for 30 minutes at 37°C. Direct headspace analysis with the SIFT-MS (VoiceUltra200, Syft Technologies) was used to quantify VOCs with a targeted approach for short chain fatty acids (SCFA). Osmolality and production (flow) rates for each saliva sample was determined. Results Ten healthy participants (7 female) were recruited with a median age of 30 (IQR:25-32). Acetic-, butyric and propanoic acid demonstrated a wider variation within individuals. A single individual produced acetic acid levels ranging from 6.0 to 16ppbv (CV% 54), and butyric acid between 3.0 and 10ppbv (CV% 53). Hexanoic- and pentanoic acid remained the most consistent with low variability; CV% 14 (0.6 - 0.9ppbv) and CV% 11 (2.9 – 4.0 ppbv) respectively. The mean salivary flow rate for the cohort was 0.7ml/min (IQR: 0.5-0.9) and osmolality 77mOsm (IQR: 57-89). The inter-individual variability over the 3 weeks was minimal for butyric-, hexanoic- and pentanoic acid (p>0.05). Acetic acid (p=0.03) and propanoic acid (p<0.001) were statistically different. Conclusion Select VOCs within saliva can vary significantly within an individual. However, there is minimal inter-individual longitudinal variation with an acceptable coefficient of variation. It is important to define a normal range of VOCs in a healthy population to determine clinically significant disease-specific VOCs. Subarachnoid Haemorrhage: Are we meeting the 48-hour time to treatment target? Gauri Ang Birmingham Medical School Background: Subarachnoid haemorrhage (SAH) is a life-threatening bleed into the subarachnoid space. The majority of these bleeds (85%) are caused by ruptured aneurysms of cerebral vessels (1). Treatment of SAH is time- critical, with the mortality rate of untreated SAH being 30% in 24 hours. The RCP Stroke guidelines (2016) recommend bleeding cerebral aneurysms are treated within 48 hours of diagnosis (2). However, a national audit from the Getting It Right First Time programme in 2018 revealed that 22%* of patients across UK centres were not treated within this time frame (3). Aims:

To determine whether all SAH admissions into Queen Elizabeth Hospital Birmingham (QEHB) are meeting the 48-hour target. To determine the impact of the COVID-19 pandemic on the care of patients with SAH. Methods: A retrospective audit was performed on patients presenting to QEHB with SAH from 01/03/2020 and 31/08/2020 (start of pandemic). 62 Patients with aneurysmal SAH were included in the study. Patient notes were used to gather their times of their journey, non-clinical reasons for treatment delay, rebleed incidence, survival, 6-month MRI outcome. Data was then analysed using Microsoft Excel to determine where delays occur and the reasons for these. Key findings

1. Out of 62 patients included, 14 presented to QEHB directly and 48 presented to local hospitals
2. The median time from diagnosis to treatment was <48 hours for all groups.
3. However, 23% of patients (n=14) had treatment >48 hours post diagnosis
4. Delays were noted in getting a CT-angiogram at local hospitals, referrals getting accepted, and time to treatment after admission to QEHB.
5. Common reasons for delays included issues with receiving/sending scan images and capacity issues.
6. 29% of patients are still awaiting a follow up scan >7 months post SAH. This scan usually occurs 6 months after discharge. Conclusions The audit revealed that 23% of patients admitted to QEHB with aneurysmal SAH were NOT given treated within the 48-hour target timeframe. Improvements in time delays can be made by: · Educating radiographers to automatically perform CT-angiogram alongside CT when SAH is present · Producing a concise document outlining exact referral criteria and scans needed · Improving image transfer systems and communication between hospitals Unfortunately, there was no comparison data from before COVID-19, making it difficult to determine the impact of COVID on meeting the 48 hour target. It is likely that the COVID-19 pandemic has significantly contributed to the delay in follow-up scans which may affect patient

Results There was no evidence of spiritual care being delivered to the T&O patients (n=24) on any documentation and by any staff. However basic spiritual care data was available for 100% of the patients on their demographic records online. This showed that 62% of the patients belonged to a religious group. 78% of patients (n=9) would feel comfortable being asked about aspects of spiritual care. However, only 35% of staff had referred a patient to spiritual care (for example chaplaincy services) and/or were aware of the referral process. Key Messages Patients on the T&O ward are welcoming of spiritual care Staff are underutilising this aspect of holistic care Staff education on the benefits and how to deliver spiritual care is needed Evaluating Alginate- Nanocellulose Bioinks for 3D Printing Human Ears Tasmin Nicholson Swansea Medical School 3D printing has received increasing interest over the last few years. Previously 3D printing was largely restricted to metals and plastics, but recent developments have enabled progression towards 3D printing biomaterials (Jessop, 2019). The ability to 3D print cartilaginous structures, such as the human ear, could offer a less invasive approach to reconstructive surgery (Jessop, 2019). This project aims to evaluate three alginate-nanocellulose bioinks: nanocellulose crystals (NCC), nanocellulose fibrils (NCF) and a blend of nanocellulose crystals and fibrils (NCB). These inks have previously been assessed for their rheological properties and show promise as candidates for 3D printing. Here, we aim to assess the printability of each ink, in terms of printing pressure, consistency of line and fidelity to the original design. Each design was constructed on TinkerCAD, before being loaded onto CellInk’s HeartWare programme for slicing. The printing pressure was identified as the point at which a continuous filament was achieved. All bioinks required pressures of ≤ 10 kPa which is low enough to allow cells to be integrated into the bioink in future. After printing, each structure was crosslinked with calcium chloride before being measured with digital callipers. Grid assay measurements demonstrated that NCF had the greatest consistency in border thickness, and NCC had the greatest consistency of gridlines and fidelity to the original design. A ring assay demonstrated NCF to have the greatest consistency of line. However, for the antihelix, NCB offered the greatest fidelity to the original design. The variable performance of each bioink could be attributable to the unique properties of the ink, or degradation of the ink over time. Further research is needed to confirm this. Nevertheless, these assays have demonstrated the viability of each candidate bioink for 3D printing cartilaginous structures. Further studies will be conducted to evaluate the use of multiple printheads to combine different bioinks into a single printed structure

POSTER PRESENTATION

and to assess the properties of each bioink in combination with cartilage cells.

Elizabeth Sylva Adeeko* 1, Abbie Tutt* 2, Aswin Chari 3,4, Kristian Aquilina 3, 1 University Hospital of Coventry and Warwickshire 2 Warwick Medical School 3 Department of Neurosurgery, Great Ormond Street Hospital 4 Institute of Child Health, University College London A scoping review of Neuroendoscopic Lavage as a treatment for Intraventricular Hemorrhage and Post-hemorrhagic hydrocephalus in the premature infant 15 Olivia Davies, Clare Blackburn (PhD (Social Science and Health) Warwick Medical School The use of group music therapy to reduce symptoms of agitation in people living with dementia living in group residential settings: a systematic review 16 Daniel Fox, Ewan A. Stephenson, Ben L. Roberts & Robert Dallmann Division of Biomedical Sciences, Warwick Medical School Time to Take Your Medicine: Towards Assessing the Functional Importance of Claudin-5 for Circadian Variation in Blood-brain Barrier Permeabilit 18 Claire McGregor Swansea University Medical School Frailty scores in the Older Person Assessment Service: To what extent do allocated scores vary between healthcare professionals? 20 Amy Haddock, ScotGEM An attempt to increase video consultation (VC) use in a General Practice in the Scottish Highlands during the COVID- 19 pandemic. 21 Melina Pelling, Bhamini Vadhwana, Piers R Boshier, George B Hanna Department of Surgery and Cancer, St Mary’s Hospital, Imperial College London Longitudinal Variation in Volatile Organic Compound Levels in Whole Saliva 22 Gauri Ang and Shumail Mahmood University of Birmingham Are we meeting the 48-hour diagnosis to treatment guidelines in the management of Subarachnoid Haemorrhage? 23 Imogen Rimmer (Swansea Medical school), with help from Dr. Julia Schaife & Dr. Manju Krishnanv (Morriston Hospital Stroke team) Delayed young stroke post minor COVID-19 infection A case report 24 Mr Alistair Wilson, Mr Emmanuel Shofoluwe, Mr Daniel Mercer, Dr Thomas Dale MacLaine Warwick Medical School Peer teaching vs self study - Can peer medical education improve the clinical understanding of second year medical students as they transition from pre-clinical to clinical teaching: a comparison between peer-led teaching and independent study 25 Daniel Zhou University of Warwick The effectiveness of the skin prick test in diagnosing paediatric food allergy: a systematic review 26 Tamsin Nicholson, Tom Jovic, Prof. Iain Whitaker Swansea University Evaluating alginate-nanocellulose Bio inks for 3D Printing human ears 27 Emma Cogswell, Estie Hughes, Alex Sergiou, Emma Andrews and Emily Roisin Reid Warwick Medical School University of Warwick - Factors affecting career destinations of widening participation doctors 28 Flora Chamberlain, Dr Jo Fleming, Professor Jeremy Dale Warwick Medical School The Role of Primary Care in Tackling the Climate Emergency – What is being done in Coventry and Warwickshire? 29 Hope Rowden 1,2, Renata Pavlič1, MajaPušić 1, Maša Sinreih1, Nick Progestins effects on an endometriotic cell line

Hopcroft 2, Tea LanišnikRižner 1 University of Ljubljana 1, University of Warwick 2, EUTOPIA 30 R Hall, M Young, MR Harvey Warwick Medical School Efficacy of propranolol in wound healing for adult burn patients: A systematic review 31 Laura Statham, Saran Shantikumar Warwick Medical School A Cross-Sectional Study Examining the Relationship Between Short-Acting Beta 2 Agonist Inhaler Prescriptions and Deprivation in England in 2019. 32 Dale Harding, Meera Unnikrishnan and Kate Watkin Warwick Medical School Intracellular Staphylococcus aureus Interactions with Antibiotics 33 Jennifer Hein Swansea University A project report on the Tudor Hart Welsh National Health Inequalities Conference 34 Joanne Igolia, Mrs Jennifer Dunnb, Mr James Beastallca University of St Andrews & Dundee (ScotGEM), bT & ONHS Tayside, cT&ONHS Highland Spiritual Care First Audit Cycle of a Full Audit on a Trauma and Orthopedic (T&O) Ward in the Scottish Highlands