Asthma: personalised clinical care improves treatment and management 

Asthma is a common medical condition affecting the breathing of both children and adults, which can have a life-long negative impact on quality of life. The research led by Professor Somnath Mukhopadhyay (view his profile here) is helping to transform the management of asthma and allergy, change treatment practice and improve patient outcomes. 

By developing personalised medicine clinics, which explore specific genetics, allergic traits and other individual characteristics to provide tailored care, the work of Professor Mukhopadhyay and colleagues has enabled the provision of holistic care to children. These clinics are now a standard practice at the Royal Alexandra Children’s Hospital, Brighton. 

This work has changed patients’, parents’ and clinicians’ perceptions of asthma treatment plans, while also generating new understanding of the role of genetic variation in delivering tailored care, thus improving children’s overall quality of life and experience. In addition, using this individualised approach has helped clinicians gain parents’ trust as they feel understood and heard, making the work more meaningful. 

Reviewing childhood asthma deaths in New South Wales, the Medical Journal of Australia commented that Mukhopadhyay’s work might explain the reduced response to asthma medicines and consequent deterioration and death in some children, possibly as a result of their underlying adverse gene status. Thus, a distinct highlight of Mukhopadhyay’s work is that it has informed healthcare practitioners in Australia and the findings of his research influenced subsequent prescribing advice in the Asthma Australia Handbook (2015). Hence, the impact of this research has extended globally, beyond clinical applications within the NHS. 

Through participation in the Brighton Fringe Festival (2016), British Science Festival (2017) and New Scientist Science Forum (2018), the work has raised public awareness of and encouraged discussion on personalised medicine for asthma. The findings were received with great interest when presented to pupils and staff in schools in Portugal and West Bengal (India) and resulted in greater awareness and understanding of how asthma and allergy may affect each child in a different manner and how personalised management approaches may thus result in more holistic care for children with asthma.  

This work has attracted funding from Action Medical Research and the Henry Smith Charity, both known for bringing a positive change to personalised health care research.

Read more about our paediatric research here >

Transforming the management of hypertension in the over 80s age group 

High blood pressure (hypertension) is a prevalent condition in the elderly, which can lead to serious health risks such as heart attack and stroke. While several research studies had been conducted on the treatment and management of hypertension, very few have focused on the very elderly, people aged 80 years and over. Indeed, this group had been largely overlooked and under-studied in public health. 

Research led by Professor Rajkumar Chakravarthi (view his profile here) and colleagues over the last two decades has addressed this gap, through the international HYVET Trial (Hypertension in the very elderly trial). This trial was the first large trial of blood pressure-lowering treatment in the very elderly. The trial recruited 3845 participants across 195 centres in 13 countries in Europe, China, Australasia and North Africa. The trial set a target blood pressure threshold of under 150/90 mm/Hg to manage hypertension. Participants were prescribed the diuretic drug indapamide and the ACE inhibitor perindopril to achieve blood pressure below the target threshold. 

Working collaboratively with the British Heart Foundation and the Institut de Recherches Internationales Servier, the trial achieved some important outcomes. Two years into the treatment, 80% of patients successfully met the blood pressure target, which was associated with a 30% reduction in the rate of fatal or non-fatal stroke; a 21% reduction in the rate of death from any cause; a 23% reduction in the rate of death from heart and circulatory events; and a 64% reduction in the rate of heart failure. The success of this ground-breaking trial led to its incorporation into NICE clinical guidelines in the UK and wider adoption of its findings internationally. 

The team also carried out a parallel study on the findings that  older patients frequently exhibi high blood pressure when in a clinical setting; a phenomenon termed White Coat Hypertension (WCH). Traditionally, WCH was considered a benign condition not requiring antihypertensive treatment. However, it was estimated that between 40% and 60% of HYVET participants may have had WCH. Given the remarkable health benefits associated with the main HYVET study, it seems likely that this was also true for patients with WCH. 

This research represents a significant advancement in the quality of care of the population aged over 80 with hypertension. It has changed clinical practice and significantly improved health outcomes among those aged 80 and over with hypertension. What is more, the research confirms the importance of delivering appropriate healthcare for the very elderly.

Patients’ preferences for different methods of delivering trastuzumab in the treatment of HER2-positive breast cancer

Almost one in five breast cancers are HER2-positive. It can be treated successfully with a drug called trastuzumab which was usually given intravenously (an infusion into a vein). This treatment poses several challenges; patients who have completed their surgery and chemotherapy are required to continue attending hospital for trastuzumab infusions once every three weeks for 12 months. Setting up IV infusions and delivering the drug could sometimes take several hours and patients had to travel to cancer centres. This can be enormously burdensome for patients who just wish to resume everyday life as it involves such a significant amount their time. It is also costly and time-consuming for chemotherapy departments. A new method of administering the drug through a subcutaneous injection (under the skin) taking just five minutes was developed and research studies showed that it was safe to administer the drug in this way. An international study was then launched to find out which method of delivery patients preferred and why. 

In 2011, Professor Dame Lesley Fallowfield (view her profile here) and colleagues at the Sussex Health Outcomes Research and Education in Cancer Centre (SHORE-C) led the research finding out which system of delivery, intravenous or subcutaneous, patients preferred and reasons why. This was a large, randomised study, called PrefHER, conducted in 10 European countries, Turkey and Canada. A computer randomly sorted HER2- positive patients into 2 groups – Group 1) received SC treatment every three weeks for four months then crossed over to IV delivery Group 2) received IV treatment every three weeks for four months then crossed over to SC delivery.  Before starting treatment, patients were interviewed in their own languages by specially trained interviewers about issues such as their attitudes to needle and injections. At the end of study treatment patients completed further interviews regarding their experiences and preferences.

A challenging aspect of this study was the need for a multilingual approach. SHORE-C had to produce educational DVDs in 10 different languages explaining the study and a comprehensive manual for the use of all interviewers. which aided their ability to develop trust and rapport with the patients. Training DVDs were also produced for the healthcare professionals who were delivering trastuzumab subcutaneously.

The PrefHer study showed that patients had a strong and compelling preference for SC delivery as it saved so much time, caused less pain and discomfort and was more convenient then IV administration.

This research, led by Professor Dame Lesley Fallowfield contributed to the approval by NICE in the UK and health authorities in other countries of SC delivery of trastuzumab. The approach also offers the potential for treatment closer to patient’s home – a central tenet of the NHS Five Year Forward plan for improvement in health outcomes for cancer patients. 

Read more about SHORE-C here >

Palliative Care in Advanced Chronic Liver Disease: Time for Action

Advanced chronic liver disease (ACLD) has high morbidity and mortality. Despite this, palliative interventions remain woefully inadequate. Development of fluid in the abdomen (ascites) is the most common complication of ACLD and once refractory to medical treatment the average life expectancy is 6-12 months. Such patients need hospital admission every 10-14 days for drainage. Only a small minority receive a curative treatment such as a liver transplant or a shunt in the liver (TIPS). Professor Sumita Verma and her team are researching a novel intervention (long-term abdominal drain -LTADs). These drains allow drainage of small amounts of fluid guided by patients so can improve symptom control and quality of life. They also allow patients to be managed in their own homes and for them to spend their remaining time outside of hospital.  Following on from a feasibility study (REDUCe), Prof Verma and collaborators have received funding for a national 35-site trial to further assesses these LTADs. Both REDUCe and REDUCe 2 studies are funded by the NIHR and run by the Brighton and Sussex Clinical Trials Units. Collaborators include colleagues from Sussex (SHORE-C), Kent, Surrey, Southampton, Exeter, London and a strong PPI group.

Controlling institutional scabies outbreaks in care homes for the elderly, refugee camps, and beyond

Scabies is something most of us don’t think about often, and don’t want to think about!  It’s caused by a mite that lives in the skin, and is transmitted mainly by close physical contact. In addition to severe distressing itching, it can lead to secondary infections with long-term health impacts. Scabies is most common in the global south, but institutional outbreaks remain a public health problem worldwide (including in the UK) in settings such as care homes for older people, prisons, hospitals, and refugee camps. 

At BSMS Jo Middleton and Jackie Cassell have led a unique research programme which has described the problem and generated solutions. This has included (1) providing doctors with new diagnostic criteria for scabies in the elderly, (2) giving recommendations to aid organisations on how to improve management in refugee camps, and (3) championing new treatments for outbreak control. In the first ever National Guidance for scabies outbreaks, most of the research cited is from BSMS.

Developing sustainable models of high-quality healthcare 

Climate change poses a major public health threat, and the healthcare sector contributes towards this, responsible for 5% of greenhouse gas emissions. There is growing awareness and momentum towards developing sustainable models of high-quality healthcare, and it is important that an evidence-based approach is taken. The Sustainable Healthcare Group at BSMS, led by Professor Mahmood Bhutta, alongside Dr Chantelle Rizan and Dr Anna Jones and a growing team, are undertaking leading research, education, and shaping policy focusing on mitigating impact of healthcare on the environment, and on related labour rights issues in manufacture of medical goods in low and middle income countries. 

The group seek to translate their research into influencing practice and policy; as report chair (Prof Bhutta) and academic chair (Dr Rizan) of a national Green Surgical Care Report in collaboration with the UK Health Alliance on Climate Change, and as senior advisors on an Intercollegiate Green Surgery Checklist. Their work on mitigating the carbon footprint of Personal Protective Equipment featured in a WHO report and informed NHS England policy. They collaborate closely with the Greener NHS, including through Dr Rizan’s Knowledge Exchange Policy Fellowship, and Prof Bhutta serves on a clinical advisory board. Sustainability is reflected in our BSMS20 (20th anniversary) theme, ‘a sustainable and inclusive medical school’, and is a core theme of the Brighton and Sussex Health Research Partnership.