As you would expect our Academic Clinical Fellows and Clinical Lecturers have been busy during the COVID-19 pandemic. There have been some unexpected opportunities thrown up by the emergency and our exceptional junior academics have been quick to respond.
Unsurprisingly our GP ACFs have been busy; here is what three of them have been doing:
Dr Luke Allen, ACF
I wrote a fairly early article on “The coronavirus outbreak: the central role of primary care in emergency preparedness and response” that has been used by the global organisation of family doctors: https://bjgpopen.org/content/bjgpoa/4/1/bjgpopen20X101041.full.pdf
I am also guest editor at British Journal of General Practice Open where we have issued a call for research on the impact of covid-19 on international primary care systems: https://bjgpopen.org/page/call-covid-19-research
Dr Laura Heath, ACF
During the COVID-19 pandemic, I was working as a palliative care doctor as part of my GP training. The role of palliative care in the pandemic was often overlooked, but the specialty has a vital role to play in care of the dying COVID-19 patient, as well as continuing to provide essential end of life care for patients suffering from other conditions such as cancer or heart disease.
As I have an interest in clinical research, I was offered the opportunity to collect data about the patients we were seeing who died from COVID-19. This included symptoms experienced, medications received, as well as holistic measures, such as visitation at the end of life from loved ones.
This small survey has been accepted for publication (https://pubmed.ncbi.nlm.nih.gov/32705889/). We found that there was unusually low visitation at the end of life (with implications for future bereavement support) and that most patients had symptoms well controlled with modest doses of medications. Both of these findings are important when planning resources for a potential second wave of infection in secondary care, primary care and the care home sector.
Dr Emma Ladds, ACF
During COVID-19 I have been closely involved in setting up two clinical trials for serine protease inhibitors that may be helpful against the virus - Camostat and Nafamostat. These drugs have been used for over 30 years in Japan and there is good preliminary evidence to suggest they may be helpful in inhibiting coronavirus intracellular uptake and therefore infection. Working with a small number of Oxford researchers, we secured a grant from LifeArc, sponsorship from CRUK, collaborators from Edinburgh University and approval from the MHRA and HRA. Recruitment has commenced for DEFINE (intravenous nafamostat in an inpatient setting) and will start for SPIKE-1 (oral camostat in a primary care setting) over the next few weeks. We are developing this work into a global ‘camostat’ collaboration to allow integration of results from multiple sites where similar trials are being set up.
In addition, I have been working on an education initiative with 33 medical student volunteers. I set up a programme for these students to call all the high risk and vulnerable patients within my GP practice. The students confirmed understanding of public health messages, checked patients could collect medications, were aware of local community group details, asked about how digitally connected patients were, and prompted them to think about end-of-life issues. Every evening for about 6 weeks I hosted an evening zoom debrief where we discussed issues arising from the day’s calls and conducted some communication skills training. Subsequently I designed a mixed-methods evaluation of the project, which the students carried out - thus learning primary care research skills - and we have written up the results into a paper for publication (in submission).
I am developing a longer-term, sustainable project based on this whereby medical student volunteers can continue to be involved in ‘routine’ primary care processes, with ongoing communication skills training.
The very nature of a global pandemic ensures that infectious diseases clinical academics are at the heart of both the clinical and research response. Two of our CLs give a flavour of what they have been doing:
Dr Susanne Hodgson, CL
As an NIHR Academic Clinical Lecturer in Infection my work is on malaria controlled human infection studies and early phase clinical assessment of blood-stage malaria vaccines. I am part of Professor Simon Draper’s group at the Jenner Institute. When COVID pandemic hit the UK, all vaccine and challenge trials at the University of Oxford were suspended, and access to our laboratories was limited to COVID research.
An ambitious accelerated programme was launched to clinically assess a novel COVID vaccine developed by Professor Sarah Gilbert at the University of Oxford (ChAdOx1 nCoV). This was made possible through an unprecedented collaboration between the Jenner Institute and the Oxford Vaccine Group. Aiming to condense 4 years work into 4 months, this programme involved vaccination of more than 11,000 participants at 19 UK sites. Together with more than 20 other clinician trialists working on existing vaccine programmes I joined a multidisciplinary team to execute this ambitious work.
In particular I co-led a team developing and executing a pathway to identify and test vaccinees for symptomatic and asymptomatic COVID infection in order to inform efficacy assessment of the vaccine.
Twenty clinical medical students from the University of Oxford joined the Oxford COVID-19 clinical trials team. With a colleague, I was responsible for training them in clinical trials procedure and supporting them within the team. We set up projects for the students with mentors within the wide trial team working on laboratory assays, data analysis and qualitative research.
I continued to work clinically as an Infectious Diseases registrar on the departmental on call rota throughout the lockdown period.
Dr Alexander Mentzer, CL
I am a Registrar in Infectious Disease and an Academic Lecturer with an interest in recruiting patients with acute infectious diagnoses presenting to hospital. My major objectives are to understand how to triage and prognosticate these patients more effectively using modern bioinformatics techniques with the hope that we can use this information to personalise treatments and improve outcomes for patients with sepsis. I realised early in February, whilst I was on a clinical rotation, that we were very likely to see a spike in cases of the novel coronavirus spreading from China and so I worked with a number of collaborators to restructure our study protocols and prepare for recruitment and sampling of patients with coronavirus.
We experienced the fastest ethical and health and safety considerations and approvals we had ever experienced so we were able to recruit patients and move blood samples around the campus by early March. I became nominated as the University lead for sampling of patients with COVID-19 and as a Work Package lead for the UKRI-funded ISARIC-4C Diagnostics evaluation platform I became involved in a huge range of projects spanning serology and T-cell response evaluations, and human genomics as well as continuing my deep involvement in the complex multi-OMIC interrogation of this devastating disease. Now as part of the COvid-19 Multi-OMICs Blood ATlas (COMBAT) consortium, I am co-leading the bulk RNA transcriptomics analysis group. We are trying to understand how we can use gene markers to improve our understanding of how and why this disease progresses and how we can use this information for patient benefit. I am incredibly grateful to all of the patients who have agreed to participate in our research and to the University and collaborators who have supported our work and I hope our results do provide insights into how we can stratify and protect patients at risk of severe disease.
Obstetrics and Gynaecology
Pandemics do not slow down the arrival of babies. It does make delivering care during pregnancy more challenging though, especially with the many unknowns about how the virus might affect both mother and baby.
Dr William Cooke, ACF
The COVID pandemic hit the UK just as I returned to the delivery suite in Reading from an ACF academic block. As our junior colleagues were redeployed to general medicine and ICU, we faced a rota filled with extra on-calls. Anxiety levels were high: we heard in the news of two women in the UK with COVID-pneumonia who had died shortly after delivery of their babies. Experience and evidence in the management of pregnant women with COVID was minimal. In our unit we had two women admitted with significant respiratory compromise early in the third trimester of pregnancy. Both became sufficiently unwell that multi-disciplinary decisions were made to deliver their babies very prematurely to facilitate maternal ventilation; both women made rapid recoveries after delivery. I spoke with the women involved, as well as colleagues in obstetrics, intensive care and anaesthetics who had cared for them, and we agreed to share our experiences and reflections with colleagues in other units. Our case report was published open-access in EJOG in early May (https://doi.org/10.1016/j.ejogrb.2020.05.025). Enquiries have since come from across the world. It has been fascinating to be involved in describing how a new disease affects pregnant women. As evidence builds, we are beginning to see that things are not as bad as we first feared.
Dr Sofia Cerdeira, CL
As an NIHR Academic Clinical Lecturer at the Nuffield Department of Women’s Health and Reproductive Research and a Specialty Registrar in Obstetrics and Gynaecology at the John Radcliffe Hospital, Sofia’s research interest is preeclampsia. Preeclampsia is a pregnancy disorder responsible for substantial maternal and fetal morbidity and in very severe cases death. It is difficult to diagnose and unpredictable. Sofia performed the first clinical trial looking at the use of the first biomarkers (sFlt/PlGF ratio) to help manage patients with suspected disease (P.I. Dr. Manu Vatish). This led to the development of a clinical guideline and implementation of the test in Oxford (first unit in the country to do so) which is being followed by other units. The test is used between 20-34+6 weeks of gestation. During the COVID pandemic Sofia joined the clinical workforce full time and has reanalysed the data from her clinical trial showing that the test was effective at later gestations too. Based on this analysis and other existing data, Sofia re-wrote the clinical guideline in order reduce admissions and keep patients with suspected preeclampsia safe outside the hospital.
Donal Skelly, ACF Neurology
I became involved in COVID research thanks to another OUCAGS academic trainee (Alex Mentzer). I offered my help as the scale of the problem became apparent and soon the places where I could contribute became similarly clear. With the help of many others, I have built up a cohort of approximately 250 Oxford- based healthcare workers who were PCR-positive for SAR-COV-2 and want to contribute to our understanding of COVID immunology. This cohort is being followed longitudinally and is contributing to university-wide efforts to advance our inchoate understanding of antibodies, T Cells, and the factors that determine the development and evolution of COVID. Data drawn from the cohort has already contributed to multiple submitted manuscripts and we have secured funding to support it going forward.
The pandemic era has fostered a supportive and vibrant academic environment here in Oxford. I have found that there is a willingness to integrate and mentor people, like me, who want to help. Oxford has been at the forefront of much COVID research and it has been exciting, somewhat exhausting and hugely beneficial to be a small part of this enormous collective effort. All research problems are important, but it has been remarkable to be involved in some small part in such an immediate, pressing, global problem.
As a Neurology Academic Clinical Fellow, albeit with an interest in immunology and inflammation, COVID research did not necessarily seem like the next logical step. In this sense, my deepening involvement reflects the openness of the current research world. For all those embarking on a research career, these experiences have taught me that there is always something you can get involved in and help with. Dive in and follow interesting opportunities, no matter how peripheral or inexperienced you feel.
Kinan Muhammed, CL Neurology
The impact of COVID-19 has been widespread. This includes the teaching available for students at Oxford Medical School. Students in their final years of training require exposure to patients in order to observe important clinical signs and learn how to communicate in a hospital environment. Due to new safety restrictions enforced by the university, students are no longer allowed to interact with patients face-to-face on hospital wards, preventing this important part of their clinical education.
To tackle this problem, we decided to construct an innovative method to give students as close to the same experience of real-life bedside teaching as possible, using remote virtual reality. In neurology, bedside teaching forms a key component of students learning experience during their clinical neuroscience rotation at the John Radcliffe Hospital. Therefore, we adapted 360-degree solutions for real estate and the manufacturing industry and tailored a solution for our own teaching requirements. Using relatively inexpensive 360-degree camera equipment linked to a smart phone, a remote yet highly immersive bedside teaching experience for students was achieved.
Catherine Lovegrove, ACF Urology
The COVID-19 pandemic has brought much of modern clinical practice into question; how do we assess patients; why do we manage them in the manner that we do; are there alternatives; why have these been dismissed; what can we change? As a profession, medics have changed many established treatment pathways to minimise risk of COVID-19 spread between patients and healthcare professionals. Within urology, ureteric colic is a common acute presentation with a range of treatment modalities from conservative to interventional management. There are guidelines concerning the optimal management in “normal” circumstances however in light of the COVID-19 pandemic clinical practice may have changed. In collaboration with urologists at Addenbrooke’s Hospital, Cambridge myself, Dr Sarah Howles (Academic Clinical Lecturer in Urology) and Mr Ben Turney (Associate Professor in Urology) are steering a nation-wide, collaborative audit to determine how management of ureteric stones has changed during and after the COVID-19 pandemic in the UK and whether this has affected patient outcomes.
Andrew Lewis, CL Cardiology
I gave up all my academic time and returned to the NHS front line to support the cardiology COVID response. We had anticipated that we would be running a joint HDU with the respiratory team but in fact this was not necessary. In addition to the clinical duties, we developed a new study looking at the interaction between obesity and critical respiratory illness upon the right ventricle. This included a new collaboration with colleagues in Birmingham and Cambridge and building on our existing work using MRI in this space – we have submitted the manuscript, and are hopeful that it will eventually be a useful piece of work to others in the field.