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Recent advances in MRI brain scanning developed at the UCL Institute of Neurology have underpinned major improvements in the surgical treatment of epilepsy. Information about the location of critical brain structures, such as the optic radiation that carries visual signals, and language areas of the brain, are used to identify the risks of neurosurgery in specific individuals. This helps to inform patient choice and to reduce the risk of loss of any part of the visual field or language when performing the surgery. UCL's pioneering use of these imaging techniques during surgery, with correction of the movement of the brain that occurs during surgery, showed that this approach reduced the occurrence of serious loss of vision to zero. This information is now used in epilepsy surgery every week at the National Hospital for Neurology and Neurosurgery and is being rolled out to other centres.
The epilepsy research group at the University of Liverpool (UoL) has undertaken a programme of work assessing treatment outcomes associated with antiepileptic drug treatment in patients with epilepsy. This includes two large pragmatic trials in patients with first seizures and newly diagnosed epilepsy, and cohort studies assessing malformations and cognitive development in children exposed to antiepileptic drugs in utero, and the work of the Cochrane Epilepsy Group.
This work has influenced prescribing in the UK and worldwide through the following impacts:
As a direct result of work led by Professor Rod Scott and colleagues at the UCL Institute of Child Health (ICH) midazolam, administered by the buccal cavity, has become first-line therapy in the NICE pathway for treating children, young people and adults with prolonged or repeated generalised, convulsive seizures in the community. It also forms part of the APLS guidelines. Buccal midazolam has demonstrated clinical superiority over the previous paediatric standard of care (rectal diazepam) with an equivalent safety profile and greater patient/social acceptability. Its use is now widespread in Europe and the USA and a licensed preparation is now available.
A research programme of randomised controlled trials undertaken at the University of Southampton demonstrating the efficacy of the New Forest Parenting Programme (NFPP) played a crucial role in: (i) influencing the developers of clinical guidelines to recommend parent training in general as a core part of the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) and (ii) establishing the NFPP, in particular, as a widely employed evidence-based treatment for ADHD, a condition estimated to affect up to 400,000 children in the UK alone. As a direct result of the trials, the programme, a novel therapeutic intervention that teaches parents of preschool children with ADHD how to modify their children's behaviour and improve their self-regulation, has been included in the National Institute for Health and Clinical Excellence (NICE) and other clinical guidelines and recommended internationally as an effective alternative to medication, which often brings only short-term benefits and is associated with a range of potentially debilitating side-effects.
Glaucoma is the commonest cause of irreversible blindness world-wide and, in many parts of the world, surgery to create a new drainage channel is the only practical treatment. The commonest cause of surgical failure is scarring, and the use of injections of cytotoxic agents prevents scarring but has many complications. Our research identified how convenient single 5-minute treatments with cytotoxic drugs work and led us to carry out pilot and randomised trials, which showed they reduced post-operative scarring. Combined with other refinements of surgical technique (named the Moorfields Safer Surgery System) this has improved outcomes of glaucoma surgery world-wide.
Infantile nystagmus (IN), previously known as congenital nystagmus, is a condition that impairs vision by causing continual and involuntary oscillatory movements of the eyes. IN begins in infancy and is a lifelong disorder, affecting over 88,000 people in the UK. Leicester is the leading UK centre for research into the underlying mechanisms and treatment of IN: discovering the genetic mutations behind some of the common forms of nystagmus; pioneering early diagnosis of IN; and conducting randomised clinical trials into drug treatments and other therapies. The centre provides advanced scientific and medical knowledge, and support and advice to sufferers of this physically and psychologically debilitating condition. The work has resulted in new methods of diagnosis which are more comfortable and convenient for patients and enable cost-savings for healthcare providers; and has led to the testing and subsequent prescription of pharmacological treatments which offer patients improvements in quality of life.
Epilepsy, a condition that affects ca. 1% of the world's population, has severe clinical consequences; people with epilepsy (PWE) and poorly controlled seizures exhibit nearly an order of magnitude increase in premature death relative to the general population. About one-third of PWE do not benefit from treatment with currently approved medicines. Although historical evidence has suggested that cannabis might be useful in the control of epilepsy, work initiated by Drs Ben Whalley and Gary Stephens at University of Reading revealed that non-psychoactive components of cannabis can control epileptic seizures in animal models. This finding has led to a funded collaboration of ca £1.4M with GW Pharmaceuticals (UK) and Otsuka Pharmaceuticals (Japan) to establish a case for translation of two such components, cannabidiol (CBD) and cannabidavarin (CBDV), to human clinical drug trials. In particular, Reading research has resulted in GW trialling CBD (Phase 2, 50 participants, design stage) for a new indication of epilepsy treatment. A Phase 1 trial for CBDV (20 participants) began in July 2013, with a Phase 2 trial to begin immediately after successful completion of Phase 1. Results from the use of CBD on an open-label basis have shown major quality-of-life improvements for the patients concerned.
The University of Oxford's International Subarachnoid Aneurysm Trial (ISAT) changed clinical practice worldwide by showing that endovascular coiling is a more effective and safer treatment than neurosurgery following subarachnoid haemorrhage, with fewer complications and improved quality of life. Subarachnoid haemorrhages account for 1 in 14 strokes and are caused by bleeding in and around the brain; approximately 85% occur when cerebral aneurysms rupture. ISAT was the first trial to compare neurosurgery, or neuroradiological endovascular coiling in patients with ruptured cerebral aneurysms causing acute subarachnoid haemorrhage.
The MRC Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer trial (CLASICC) is the largest and most successful UK trial of a technology applied to general surgery. It addressed an area of huge clinical uncertainty, providing a rigorous evaluation of a new technology and enabling its safe and widespread implementation. The impact of CLASICC has been global, confirming the advantages for patients (quicker recovery) and healthcare providers (cost-effectiveness) and so influencing national and international policy in favour of the laparoscopic technique. It informed NICE guidance and led to a major DH initiative that has seen the UK become one of the largest providers in the world of laparoscopic colorectal cancer surgery. CLASICC is regarded as a benchmark surgical trial, combining high quality trial design with rigorous quality assurance, which has informed the design of many subsequent colorectal cancer studies.
Research at UCL into the use of tocilizumab has led to a new treatment and improved care for patients with juvenile idiopathic arthritis (JIA) and rheumatoid arthritis (RA) in adults. The drug is now approved around the world and recommended by NICE guidelines and is the standard of care in children with systemic onset JIA. It has been prescribed in every rheumatology centre in the UK for patients with severe RA. The impact of the drug on patients is to prevent disability, halt joint damage, improve function and increase quality of life.