The North West Emergency Medicine Regional Research Symposium 2015

On Thursday 23rd July we held our annual North West Emergency Medicine Regional Research Symposium. This is an opportunity to celebrate some of the fantastic Emergency Medicine research going on around Greater Manchester. And this year, as we usually do, we had a terrific line up. Here’s a quick run down on some of the fantastic work that’s going on.

1

The double act from Novartis: Serrelaxin

First, we were honoured to have a double act from Novartis talking about their new drug for acute decompensated heart failure – serrelaxin. Phil Liptrot presented the results of two early phase trials of serrelaxin: PRE-RELAX and RELAX-AHF.  Serrelaxin is a recombinant form of a hormone that’s naturally released in pregnancy – relaxin.  It’s a vasodilator with favourable effects on renal blood flow and a whole host of other mechanisms that could be beneficial for patients with acute decompensated heart failure.

PRE-RELAX was a phase 2 trial to find the optimum dose of serrelaxin.  With 234 patients, it was a reasonable size.  In that trial, the patients who received 30μg/kg serrelaxin had significantly lower cardiovascular mortality at 180 days than patients who received placebo (0.0% vs. 14.3%, p=0.046).  Of course, that was an exploratory analysis (and one of many – there was no difference in some of the other outcomes)  so we can’t rely on it – but it’s a promising early sign.

RELAX-AHF was another phase 2 trial but this time including 1,161 patients.  Being a phase 2 trial, it wasn’t powered to detect changes in mortality and the primary outcome was the area under the curve of dyspnoea experienced by patients.  Serrelaxin significantly reduced dyspnoea measured by a visual analogue scale but not using a Likert scale.  However, once again there was a significant reduction in all cause mortality at 180 days with an absolute difference of 4% (NNT 25).  This was a secondary analysis so – again- we can’t hang our hats on it just yet.  We need the definitive phase 3 trial, which is what Dani Fairclough told us all about (RELAX-2).  This trial is ongoing in Central Manchester as well as numerous sites around the world.  Dani – a Clinical Research Associate who monitors everything we do – talked about the extremely high standards that we need to meet when conducting the research.  Afterwards, we discussed peoples’ perceptions of commercial research.  Of course, we recognise that there’s potential for bias because the sponsor will make money if the findings are positive.  Then again, even academics are biased – we all want positive findings!  The key is to conduct the research in a robust, scientific, dispassionate way – regardless of how it’s funded.

EMERGING research

Following that, we had a double act from Central Manchester.  Rachel Pearson (research nurse) told us about all the research that’s going on at Central Manchester ED.

Active trials at Central Manchester ED

Active trials at Central Manchester ED

Niall Morris told us about his PhD project – to derive a new prediction model that could help to improve the way we diagnose NSTEMI using the ECG.  Niall compared the ECG to Bruce Forsyth.  Brucey was born only 20 years after we started using the ECG in practice.  Niall reminded us that, “Just like the ECG, he may be getting on a bit but he’s still relevant”.  But while the ECG is a great test, the rate of misinterpretation is really substantial – and the criteria we use right now miss a big proportion of acute coronary occlusions.  Could we do better?  And could this turn Niall into the next Steve Smith?  We’ll see but it’s looking promising!…

Brucey: According to Niall he may be getting on a bit but he's still relevant - just like the ECG

Brucey: According to Niall he may be getting on a bit but he’s still relevant – just like the ECG

2

After the break, we heard from an inspiring research nurse – Lisa Murthen – who (together with Richard Parris, ED consultant, and a great team) has set up a research team in Bolton – a District General (community) hospital.  It was inspirational to hear how this CAN be done – and done well.

Lisa Murthen has successfully set up an active research team at a community hospital

Lisa Murthen has successfully set up an active research team at a community hospital

Following that, Richard Carden and I presented some unpublished data on gender distribution at conferences and some research that could be a game changer for high sensitivity troponin (more on those another time).

Rich Carden: more of a machine than a man, he presented on gender distribution at conferences between working night shifts

Rich Carden: more of a machine than a man, he presented on gender distribution at conferences between working night shifts

Naomi Reeves presented a terrific review of the evidence around the use of age-adjusted D-dimer cut-offs for venous thromboembolism as well as a great two-centre retrospective study of the same.  The sensitivity of the age-adjusted cut-off was approximately 93% (you’ll have to wait until the findings are published to find out more) and the big question is whether the small sacrifice in sensitivity justifies the reduction in imaging rates.

UK TARN

Manchester is also home to UK-TARN (Trauma Audit & Research Network), which all of our major trauma centres must report data to.  Antoinette Edwards, Director of Operations, also presented some preliminary (as yet unpublished) findings about the development of patient related outcome measures (PROMS).  We don’t want to give the game away but the image below will tell you something about what Antoinette and her team are trying to achieve and what a PROM actually is.

Patient related outcome measures - defined by Antoinette Edwards

Patient related outcome measures – defined by Antoinette Edwards

Post-resuscitation care

Finally, Dan Horner brought the afternoon to a climax by telling us about his ongoing work to optimise post-resuscitation care for patients who have achieved spontaneous return of circulation after atraumatic cardiac arrest.  Dan told a story about such a patient who arrived at a community hospital with the ECG below.  What would you do?  Admit the patient to your ED? Or tell the paramedics to drive on to the Heart Attack Centre for primary PCI?  I can tell you that a straw poll of the audience showed clear equipoise.  Is it time for a trial?  Maybe…

This patient arrives in the Emergency Department after cardiac arrest.  You don't have a Cath Lab.   Should the paramedics bypass your ED or should you admit the patient to stabilise their condition first?

This patient arrives in the Emergency Department after cardiac arrest. You don’t have a Cath Lab. Should the paramedics bypass your ED or should you admit the patient to stabilise their condition first?

Dan Horner gives a dynamic presentation

Dan Horner gives a dynamic presentation

Dan's bottom line

Dan’s bottom line

All in all, the afternoon was a huge success.  It was terrific to hear about so much work going on – and there’s so much more that we couldn’t cover as well – including our work in triage, suffering, point of care testing, major trauma care, humanitarian & disaster medicine and so much more.

We hope it might have inspired some more people to get involved.  There are plenty of ways to do so.  Why not start by writing a Best BET?  Or by obtaining your Good Clinical Practice certificate so you contribute to our ongoing clinical research?

There’s no better way to be at the cutting edge.  After all, who else is already giving serrelaxin to patients with acute decompensated heart failure?  Who knows – we might be among the first to give a landmark new treatment.  The only way to find out is to get the evidence – and that’s just what we’re doing!

All the best,

Rick

Posted by Rick Body

Professor Richard Body MB ChB, FRCEM, PhD is Professor of emergency medicine in Manchester. He is honorary Consultant in Emergency Medicine at Manchester Foundation trust. He is also the director of the Manchester Diagnostics and Technology Accelerator (DiTA) and Research Director of the Emergency Medicine and Intensive Care Research Group (EMERGING). His research interests include diagnostics, cardiac disease and the philosophy of emergency medicine. He is an acclaimed international speaker on cardiac diagnostics . He can be found on twitter as @richardbody

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