Healthcare Science Week 2018 – #1

It’s been a little while since I’ve posted to the blog, but Healthcare Science week seems like as good a time as any to do pick it up again. I’ll try my best to upload here or to Twitter, each day, be it information on what might be happening up and down the country, or things going on within my own Trust. I’ve also roped some colleagues into answering a couple of questions, too.

HCS week is an annual event celebrating all 85 specialisms within the discipline. As the oft-overlooked scientists within the NHS, it falls to us to put ourselves out there, and this week is the time to do it! Biomedical Scientists, Physiologists (there are a few different types of this particular scientist), Audiologists, Vascular Scientists, and many, many more are showcasing what they do for patients they treat in the NHS, and using the hashtags #HCSWeek18, and #HCSWeek2018, they’re getting it to the masses. We need to inspire the next generation of scientists to join our ranks, so HCSWeek gives us the perfect opportunity to show students and potential scientists exactly how far-reaching their options are.

Today, I spoke to my colleague Oli, who like me, is a newly-qualified Physiologist, about why he opted to undertake a career as a Physiological Scientist, and what he plans on doing, moving forward.

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Clinical Physiologist, Oli. Here, he is setting up an exercise tolerance test in an attempt to induce ECG changes associated with angina, and ischemia

What attracted you to this particular scientific career in the first place?

It’s as simple as being able to help people, really. Clinical Physiology allows for patient-facing tests to be performed, so I felt like it would let me make an immediate difference.

Now that you’re qualified, and are well-versed in the basics of the job, are there aspects that you appreciate more from a post-graduate perspective?

Definitely. Every day presents a different challenge, because every patient is different. In the RUH, we have a wide array of clinical skills we have to learn, and as a result, I find that I’m adding to my knowledge every day.

Where do you see your career heading, moving forward?

I’m hoping to specialise in Cardiac Imaging, and have applied to the STP programme to help with that speciality. There are a wealth of options, even after that, so whilst I’m not entirely sure at this stage, I may look at the Higher Specialist Training after that!

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Cardiologist’s Kitchen Workshop #1

When Cardiologist’s Kitchen put forward its Health Foundation application, it stated that it would run patient workshops at Neston Park Farm & Kitchen to engage patients with professionals and good, healthy food. 

Neston head chef Steve Mercer cooked a fabulous 2-course meal for guests, and after a brief interlude by Ali Khavandi and Mary Fifield, there were some indroductions for myself, nurses in Cardiac Rehabilitation and the CardioFITr team (more on these guys in the future), as well as local food producers Fussels, and Fresh Range, whose ingredients made up some of the food.

The workshop wasn’t about us, however; it was a patient-centred event, so the real stars of the evening came in the form of the service users themselves. A select few were gracious enough to share their stories regarding the improvements that Cardiologist’s Kitchen had made to their lives. One had lost a considerable amount of weight and thus, could do normal, everyday things that she had previously found difficult as a result of her (now greatly improved) angina, another was part of the CardioFITr programme, which, run by healthcare professionals and in conjunction with Cardiologist’s Kitchen, uses evidence-based science and medicine to improve physical fitness and promote a continued change in lifestyle. He too, had seen a considerable and positive reduction in weight and blood pressure, and was almost ready to cease his medication for the latter. This is a particularly palpable achievement for the scheme, and proves it actually supports patients to persevere.

A 2010 paper by Curtis Triplitt of The University of Texas titled Improving Treatment Success Rates for Type 2 Diabetes cites clinical inertia as the biggest barrier to treating the condition, so by beginning to see positive results in this manner, initiatives like this really do matter with regards to health and wellbeing. It’s long been known that diet and exercise have a massive impact on health, but anyone who’s struggled with dieting, knows that support is one of the most important factors in sticking to whatever regime one is using to better their health.

As I chatted to patients and heard their stories, I became aware of just how thankful they were for Cardiologist’s Kitchen, and the positive impact it was having on their lives. Many of them had been rushed to the Catheterization Laboratory with a suspected infarct, and regardless of the findings had assumed their lives were irrevocably altered. The advice and specific support given by CardioKit meant they were now turning a corner and seeing measurable changes in their own health. The best part was knowing that they had essentially been encouraged to do it themselves with their own willpower. 

Cardiologist’s Kitchen can be found on TwitterFacebookInstagram and the web.


Is Screening all Young People for Cardiac Disease Cost Effective?

In Western medicine, especially the U.K. and U.S.A., mandatory screening for cardiac disease in young people doesn’t exist.

The NHS currently offers screening for the following:

  • Newborns (blood, cardiac, hearing tests, and physical examination)
  • Pregnancy (foetal abnormalities, blood tests, and infectious disease)
  • Diabetic eye testing (annual follow-ups for cases confirmed in >12 year olds)
  • Cervical (every 3 years for 26-49 year olds, and every 5 years for 50-64 year olds)
  • Breast cancer (50-70 year olds, 70+ individuals can self-refer)
  • Bowel cancer (55-74 year olds)
  • Abdominal Aortic Aneurism (65 year old men. Over 65s can self-refer)

These tests are designed to aid in patient healthcare and to alleviate the long-term financial burden on the heath service, but as you can see, they’re fairly narrow in their scope. Aside from newborns, the vast majority of the screening programmes cater to individuals in later life, or after index presentation/diagnosis. If one suspects an abnormality, then of course, there are many private options available, and in fact, cardiac screening for precursors to sudden cardiac death (such as hypertrophic cardiomyopathy) is in place for young athletes. Given that the estimated number of young people with the abnormality currently stands at 1 in 500, it has been theorised with this and other cardiac diseases in mind, that mandatory screening for young people could ease the cost on the NHS, enhance patient treatment/safety and the emotional fallout that comes as a result of the morbidity associated with serious cardiac conditions.

The results of a nationwide U.K. screening programme known as Cardiac Risk in the Young imply that mass-screening that also encompasses ECG in addition to the standard physical exam and history increases the likelihood of early diagnosis and actually saves money.

The results are the endpoint of a 4-year process, involving roughly 30,000 young persons who were screened using the above methods, all of which were performed and interpreted using the relevant professionals and governing body guidelines.

8.1% of the 30,000 were deemed to produce an abnormal 12-lead ECG, 3.5% had an abnormal physical exam and/or history, and 0.5% showed abnormality in all three areas. 11.7% underwent echocardiography to confirm or deny the presence of dysfunction, 0.9% were referred for cardiac MRI, 1.7% were moved on to longer-term ECG monitoring, and 1.7% had exercise stress testing.

87 abnormalities associated with SCD syndrome were positively diagnosed at the 2-year follow up mark, accounting to 0.3% of the cohort, and 83% of this number was done so using the ECG alone. Interestingly this 83% was found in individuals who presented as asymptomatic, and would likely go undiagnosed otherwise.

The cost of this screening and subsequent treatment of a positive identification is estimated to be 20% lower than the cost of treatment and screening using current requirements, due to its lowering of false positives from 21.8% to 4.3%. This, in turn, lowers the amount of unnecessary follow ups, so this study may have great implications for young athletes, and non-athletes alike in helping to spot these potentially fatal conditions, many of which can be managed.

More on this story and more at: Cardiac Risk in the Young

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Detecting CAD with Vocal Biomarkers

Beyond Verbal, an Israeli company leading the market in voice/emotion analysis software are making headlines thanks to their study with the Mayo Clinic, that shows that voice analysis can indicate the presence of coronary artery disease (CAD).

CAD is responsible for one of the highest cardiovascular mortality rates in developed countries globally, and whilst lower in developing countries, this figure is quickly rising. With this in mind, inexpensive, low-risk  and non-invasive screening methods are a very desirable prospect. Currently, ECG, Exercise Tolerance Testing (ETT), Radionuclide testing and Pharmaceutical Stress Testing are the most common procedures used to screen for CAD, but, aside from ECG, each has contraindications, and/or is fairly invasive. Again, aside really from a simple ECG, each has a middling to significant associated cost attached to it. Technology that could reduce these costs and the potential for unnecessary testing presents a possible alternative to patients being referred to chest pain clinics and such, without a sure fire reason to do so.

Beyond Verbal have already used their vocal analysis software to find audio characteristics associated with Parkinson’s disease and autism, and have now turned their technology to CAD.

The Beyond Verbal/ Mayo Clinic study hypothesised, due to the association coronary atherosclerosis has with other systemic pathologies, that vocal processes and the structures responsible may also be affected.

150 patients, 120 of which presented for angiography of the coronary arteries and 50 healthy, or non-cardiac control patients had their voice recorded prior to the test. Beyond Verbal then used a variety of their analytical software to record three 30 second voice clips from each patient; the first (R1) was a predetermined script, R2 was a description of a positive experience, and R3 was personal like R2, only a negative experience.

The analysed results show a 19-fold increase in the likelihood of CAD in R3, the negative voice clip, irrespective of traditional cardiac risk factors such as age, suggesting there is indeed a link between CAD and voice.

BV hope that future development of this technology can be used to screen patients telephonically.

 

The poster outlining the study can be found here

Beyond Verbal on the web.

The TSP resources relating to CAD can be found here and here.Heart

Fitbit’s Familiarity with Class Action Lawsuits

Fitbit, the wearable fitness tracker, has gone from strength to strength since its launch. The company recorded a record $1.858 billion (!) in revenue at the close of the 2015 financial year, and, due to its affordable price tag, everyone from we regular folk, to soon-to-be ex-P.O.T.U.S. Barak Obama can be seen wearing one. That said, Fitbit are known to court controversy; in 2015, it was suggested that the advertised “sleep-tracker” in the company’s Flex model was inaccurate, and over-logged sleep. This case is still ongoing, but it is important to note that it is not suggesting negligence with regards to health; rather that the product itself was falsely advertised. It remains to be seen how this case will play out, but as if that wasn’t enough, at the beginning of the year, a multiple-plaintiff class action lawsuit was filed, with a study showing evidence that Fitbit’s PurePulse technology was woefully inaccurate during exertion.

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The study, performed by a team at California State Polytechnic, compared exertional heart rates acquired via the wearable device and from an ECG. After exercising 43 individuals for 65 minutes, it was noted that the various Fitbit models displayed a heart rate that differed by up to 22bpm compared to that on the ECG, and that some didn’t display a heart rate at all.

According to the study’s team, there exists a distinct lack of rigorous, scientific testing in the wearables market (this is further suggested by lawsuits filed against other, similar product developers), but Fitbit have dismissed both this statement and the study itself, citing bias and, perhaps humorously for reasons I shall soon disclose, a lack of scientific methodology. Fitbit have stated that they perform extensive testing during development, and have pointed towards another study which purports to have found PurePulse products to be highly accurate, although it is important to note that this particular study tested a sample size of two (yes… two).

Wearable devices aren’t anything new, but with technological advances, they are no longer being seen as simply fitness trackers and companies are exploring their application in healthcare. As this gains further traction, accuracy will be incredibly important. In fact, one of the plaintiffs in this case, an 82 year old woman, has alleged that her device underestimated her heart rate by such a margin, that were she to have tried to reach her supposed target heart rate, she would have likely done serious damage to her health, so it is already having a potential impact.

The company’s financial growth since the launch of this generation of devices is thought to be largely due to PurePulse, what with it being the most heavily marketed new feature, so Fitbit’s request that the case be dismissed has last week been denied. Judge Susan Illston has decided that the plaintiffs case has sufficient merit, with regard to fraudulent claims about Fitbit’s accuracy, so it will be considered in court. This does not necessarily give an indication as to the outcome, however.

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SCST Diploma Day: A Reflection

Myself and OliGS recently sat the SCST Electrocardiography Diploma and Practical Examination, so I thought I’d jot down some of my experiences in the run up, and my retrospective thoughts on the day itself.

If you’re thinking of doing it, or have your PTP finals looming, then read on, as this will give you an idea of what to expect.

I’ll start by saying this: Oli and I have NEVER been so stressed in our entire lives.

This exam was a nightmare for which to prepare; I have extensive experience in taking exams, and it is my view that they’re 50% what you know, and 50% what the examiners want you to tell them. Without having met these examiners or seen a previous paper, it was very difficult to know what to really nail, in the revision stage. The syllabus was long, detailed, and contained what seemed like an entire career’s-worth of things to learn, so we already knew it was going to be a slog, but nothing prepared us for the written paper…

Read these. Lots.

We studied, sometimes sleeplessly, for weeks. Tested each other on rare arrhythmias, read textbooks cover-to-cover (repeatedly), and watched each other’s once sunny outlooks and youthful (ahem) features rapidly wither as the examination date draw closer. It consisted of 20 multiple choice questions, 10 arrhythmia analysis and knowledge questions, and 4 full ECG analysis recordings. Some of these were almost instantly recognisable, but others were brutally difficult to analyse. The MCQs (often the most looked-forward to section of any exam) were equally tough. Those 3 hours lasted a lifetime…

We left the exam battered and bruised, but glad it was over.

But it wasn’t over. It was far from over. As well as the written paper that had almost ruined us, we had the practical exam to do as well.

We had made sure that during our post-ECG placements we still got ourselves in the clinic so as to keep everything fresh, as performing a perfect ECG is not like riding a bicycle.

 

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The last attempt before test day

It turns out that this was the correct call, as was practicing on one another in the hotel the evening before the exam; the margin for error in the exam is 2mm(!) Anyone who’s had an informal assessment, or had their Direct Observed Practice scrutinised whilst training knows that it’s very easy to second-guess when it comes to electrode placement, and despite having 20 minutes to complete the whole thing, this timeframe becomes devastatingly short once you’re in there. It’s a clinical assessment, so one needs to complete the necessary ID checks, explain the procedure to the patient AND to the examiners (i.e. in two different ways), perform it whist answering questions, and then complete a verbal examination.

Three hours after we had finished the written paper, we were called to attempt our practical exam. There were ashen faces all around. Some were on those still waiting for their number to be called as ours had just been, others had been told that their 2 attempts had been unsuccessful. Neither of us were looking forward to this. Now, given that I’ve already stated that each electrode is allowed to deviate only 2mm from the precise, gold standard location, the internet-purchased electrodes pictured in the above image would be somewhat unfair, right? It seems that the examination board concur, as they provide some rather cool, transparent electrodes complete with crosshairs. They doesn’t make it easier, per se, but they certainly go some way eliminate that lingering trepidation when it comes to deciding you’re happy with your placement and ready for judgement.

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Crosshair emblazoned electrodes(!)

I opted for the “all at once” technique: I explained everything to the patient before I started, gained consent, then explained everything I was doing as I went along. Once was put simply to the patient, then once to the examiners, using correct terminology. I paid extra special attention to V1, V2 and V4, as my patient had a particularly wide sternum, so I wanted to be totally sure that I had the sternal border, especially given the electrodes were rather far apart when placed and looked slightly odd to me. After I took a step back and looked at my work, I was incredibly tempted to move the aforementioned electrodes, but either due to fear, fatigue, or a combination of the two, I decided to leave them as they were, opting to go with my initial judgement. After that, I waited.

I’m not entirely sure how the placements are measured, as candidates are asked to leave the room whilst they are checked by two examiners. I heard someone mentioning special rulers, but I didn’t get a look at them (it’s all very cloak and dagger), in any event, you’re called back into the room and, in my case at least, informed of your passing or failing grade. I’m pleased to report that I passed on the first attempt, which as I’m sure you can imagine, was a tremendous relief; I lost my cool somewhat, and expressed my joy rather loudly, as I was informed I wouldn’t have to do it again. Oli soon found me in the waiting area and, grinning wildly, slapped me on the back and hissed “YESSSSS!” before promptly throwing himself into a chair. It was over, and we were victorious.

We didn’t speak too much about it, on the way home, but in the couple of days that have passed since the exam, we both feel a tremendous sense of pride that we actually did it, and did it successfully. If I were to give you all some advice, it would be the following:

  1. Be prepared for anything and everything, including waiting around for a long while
  2. Practice analysing ECGs until you hate them
  3. Practice performing ECGs until you hate them
  4. Go with your gut as much as you can during the practical exam
  5. Bring lunch
  6. Don’t under ANY circumstances, stay at the Ibis Hotel in Birmingham’s Chinatown district (I can’t stress this enough because it backs onto a nightclub that doesn’t stop playing the most bass-heavy music until the wee hours of the morning)

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The Power of Social Media Influence

Like it or loathe it, social media is pretty much inescapable. It’s used by your family, friends, and increasingly by institutions and corporate entities to connect and share ideas, market and promote. Statista puts worldwide social media usage at 2.22 billion people, so it’s no surprise that it has been utilised, and continues to be, to the extent to which we are now accustomed.

It’s been proved that it’s possible to connect with all kinds of people using social platforms, so why should the resource fall solely into the hands of multi-million dollar companies like Coca-Cola and McDonalds, for whom advertising is merely a formality, as oppose to a make-or-break necessity?

Perhaps it needn’t.

Due to the fairly self-regulating nature of some of healthcare’s more specialised areas, the burden falls predominantly on us to showcase innovations and engage with patients, prospective students and fellow professionals. Networking tools like LinkedIn are already being used to connect professionals, even from physiology backgrounds. This platform is relatively self-serving, being a predominantly business to business niche, but according to current statistics it has seen a rise in use to over 60 million views per month in 2016, so is undeniably a great tool to use for quick networking with other like-minded individuals.

Of course, social media can be used to network with everyone, not just our own, so, in the same way that we utilise more than one test to make a diagnosis, we should be using the whole spectrum of tools in this instance, shouldn’t we? Facebook (1.6 billion users worldwide) and Twitter (325 million)  usage polls would suggest that users are logging on for a surprisingly narrow selection of reasons. 68% (Twitter) and 65% (Facebook) of users state that they log on to keep abreast of the latest news relevant to themselves, and 63% and 48% of Twitter and Facebook users respectively, use the platforms to receive information relevant to their personal interests. These present huge, potentially untapped resources for healthcare professionals, that can be used to promote transparency and trust, gain feedback and keep colleagues and patients informed.

I’ve mentioned before, the relatively unknown nature of physiology as a profession, so I think that taking hold of the opportunities available on Twitter, and other forms of social media could be something that could benefit physiological science. One of my favourite online healthcare personalities is Mr Olivier Branford, a plastic surgeon in London. He advocates education as a resource that should be available to all, and public engagement as a high priority. Olivier has over 62.1k followers and uses Twitter to provide news relevant to his specialism, and to wider healthcare in general. I conversed with him about the use of social media as a free platform to provide evidence, studies, inspiration and information to students, prospective students and patients everywhere, and we both agreed that it was the perfect resource to utilise. We aren’t alone, however; Olivier ran a telling informal poll, the results of which I have displayed below, enquiring as to what other users believed was the best way for plastic surgeons to use social media, and I feel that the words “plastic surgeon” can be substituted for any within the health service with a similar outcome. As you can no doubt see; despite the unscientific nature of the evidence, the percentages speak for themselves.

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Whilst it would be incorrect to state that healthcare organisations have no presence on social media, they don’t dominate in the same way that more commercial entities do, at least not in the UK. That doesn’t necessarily mean that it is a lost cause, however. Mr Branford has provided a personal touch that corporate entities cannot emulate; his approach of “evidence not opinion” when dealing with healthcare information, is complimented by his willingness to offer an opinion when it’s relevant, on top of the facts. This transparency is refreshing, and, in conjunction with his professional accolades, is surely something that has aided him in gaining  over 62.1k people who want to listen to what he has to say. The cardiac physiology profession is notoriously under-staffed, and whilst the numbers of applicants is on the increase, a quick visit to various college forums shows that the ins and outs of the career are still lost on many students (if you can find a discussion at all). The general career pathways and the salaries seem to be known to these confused individuals, but the actual job is what nobody has much of an idea about. How are we to persuade these potential cardiac scientists to sign up if they don’t know what they’ll be doing for the rest of their professional lives? Asking someone to commit their future to a career and saddle themselves with increasing debt when they don’t really have a great deal of information readily available to them is a far cry from the informed consent we strive to gain from our patients. Taking responsibility, and putting some research into one’s own future is obviously something everyone has to get used to, but I’m sure most people remember how overwhelming that was, so the shortage of new staff members must be more complicated than students simply not looking hard enough. Besides which, it SHOULDN’T be so difficult to find this career..! I’ve got a year to go until I qualify, and I’ve met some truly inspiring people whom, if I wasn’t already on my way, I know could easily convince me to start. We find what we do fascinating, so surely some of these young minds will be just as invested if they have the chance to see it for themselves.

SocMed by age

The Pew Research Centre provides data that places 16-24 year olds as the most avid users of social media (above), and displays a steady growth of users across all age groups year-on-year since 2005, so with a collective effort, it surely wouldn’t be too difficult to a) entice some of these users who are in the middle of their A-Levels, and unsure of which healthcare profession is for them, and b) come together as a profession in a more open and approachable manner to showcase our science and how much of an impact we have on medical diagnostics.

Olivier Branford is a plastic surgeon and associate editor of PRS Global Open journal, and can be found on Twitter under his eponymous handle @OlivierBranford.

Social media statistics obtained from The Pew Research Centre, Statista & Visually

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