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University of Bristol researchers at the Bristol Heart Institute (BHI) have pioneered the development and clinical take-up of the novel technique of off-pump coronary artery bypass (OPCAB) surgery. Over ten clinical trials and several large cohort analyses have assessed the impact of this technique on elective and high-risk patients. The results have shown that it is as safe as the conventional coronary artery bypass grafting (CABG) technique that uses a cardiopulmonary bypass pump and cardioplegic arrest. Most importantly, however, OPCAB significantly reduces the risk of post-operative complications, and reduces morbidity and mortality. It also uses less hospital resources, reducing time in intensive care and length of hospital stay. In 2011 (the last year for which data are available), 20% of CABG operations in the UK were carried out with the OPCAB technique and it has had significant take-up overseas (for example, 18% of CABG operations in the US and 21% in the EU in 2010). NICE has recommended the safety and efficacy of OPCAB surgery.
As a result of research undertaken by Professor Mervyn Singer and colleagues at UCL, the oesophageal Doppler haemodynamic monitoring device is now a standard of care in intensive care units and operating theatres. The research underpinned the development of the CardioQ Oesophageal Doppler Monitor that guides optimisation of the circulation in critically ill and perioperative patients. In multiple studies its use has led to significant reductions in postoperative complication rates and length of stay in patients undergoing high-risk surgery. Over 500,000 patients have now benefitted from this technology that, between 2008-13, generated over £33m in sales for its manufacturer, Deltex Medical. The device is recommended in NICE guidance and has been identified by the Department of Health as one of six high impact innovations to be implemented fully across the NHS.
The most frequent surgical procedure undertaken in the NHS is cataract surgery and it improves vision and quality of life (QoL). In the 1990's there were long waiting times for cataract surgery with rationing most frequently restricting surgery on the 2nd eye. A randomised controlled trial undertaken at the University of Bristol (UoB) demonstrated clear QoL benefits from 2nd eye cataract surgery, followed by a population study quantifying population requirements for 1st and 2nd eye surgery and the surgical backlog. Government policy, announced in `Action on Cataracts — Good Practice Guidance, 2000', advised that the volume cataract surgery, including on the 2nd eye, should be increased. This policy ensured timely access to surgery becoming routine practice in the NHS, thus improving the lives of thousands of people. Second-eye surgery rates rose from ~25% of operations to 35-40%, with overall increases in operations for patients needing surgery (e.g. in England up from 201,682 operations in 1998-1999 to 332,625 in 2009-2010) and reduced waiting times. These improvements were sustained through to the end of the 2000's. The research has become highly relevant again as the NHS enters another period of constrained expenditure.
The management of childhood pleural empyema has been standardised and improved as a direct result of research at the UCL Institute of Child Health (ICH). Pioneering trials demonstrated the clinical equivalence of chest drain insertion with fibrinolytic installation compared to video-assisted thoracoscopic surgery as a primary intervention. Chest X-ray and ultrasound scanning were shown to provide enough information and it was established that chest CT scanning had no role in the routine management of empyema. International guidelines have been modified to reflect this, reducing paediatric exposure to unnecessary general anaesthesia, invasive surgery and ionising radiation. Cost savings are estimated to be £1.5 million/year in the UK alone.
The Variable Life-Adjusted Display (VLAD) is a graphical tool for monitoring clinical outcomes. It has been widely adopted by UK cardiac surgery centres, and has helped a shift in culture towards more open outcome assessment in adult cardiac surgery, which has been credited with reduced mortality rates. VLAD is also being used for a broad range of other clinical outcomes by regulatory bodies worldwide. For example, Queensland Health uses VLAD as a major part of its Patient Safety and Quality Improvement Service to monitor 34 outcomes across 64 public hospitals, and NHS Blood and Transplant uses VLAD to monitor early outcomes of all UK transplants.
Heart failure affects more than 22 million people worldwide, including 6 million in Europe and 5 million in the United States, with approximately 500,000 new patients diagnosed each year.
The cardiac resynchronisation in heart failure trial (CARE-HF) demonstrated that, in patients with heart failure and cardiac dyssynchrony, use of an implantable pacemaker to improve heart contraction led to a 37% reduction in the risk of death and hospitalisations and significant improvements in patient quality of life. The benefits are in addition to those of standard pharmacologic therapy. As a result of the CARE-HF trial, international and NICE guidelines have recommended the use of cardiac resynchronization therapy in patients with heart failure and dyssynchrony resulting in an increased use of cardiac resynchronisation throughout the world and significant improvements in quality of life and survival for heart failure patients.
Research conducted at the University of Bristol between 2002 and 2006 directly influenced a significant commercial decision about use of a food additive to aid appetite control, which protected consumers from an ineffective product. Concerns about increasing levels of obesity worldwide and the toll this takes not only on human health but on health care costs, have led to the development of food ingredients that satisfy hunger for longer (enhance satiety). One such major new ingredient, Fabuless, which is owned by DSM (Dutch State Mines), a leading global manufacturer of food ingredients, was being considered by Unilever for inclusion in its range of diet foods. DSM and Unilever contacted Professor Peter Rogers, who is known for his novel methods for the experimental study of appetite control, to test the effectiveness of Fabuless. Rogers demonstrated no satiety effect of Fabuless when consumed in realistic products, which caused Unilever to abandon Fabuless as a potential food ingredient in 2009. Publication of the research also meant that other food manufacturing companies and regulatory authorities were informed about the ineffectiveness of Fabuless.
Research at Strathclyde has brought about a change in eye surgery practice throughout Europe and worldwide. A four-year cross-Europe study in collaboration with the European Society of Cataract and Refractive Surgery (ESCRS) investigated antibiotic treatment to prevent endophthalmitis, a complication arising during cataract operations which typically results in loss of sight. The findings showed that when the treatment is given at the start of surgery it leads to a 5-fold reduction in the risk of endophthalmitis. The European Society of Cataract and Refractive Surgery has endorsed the discovery and widely promoted the uptake of the treatment through publications and guidelines, which over the last 6 years has led to the prevention of loss of sight in thousands of patients. In Europe alone it is estimated that each year there have been 7500 fewer cases of blindness following cataract surgery as a result of the ESCRS guidelines.
Hull researchers conducted the key trial demonstrating that cardiac resynchronization therapy (CRT), a specialised type of pacemaker, significantly reduces morbidity and mortality and improves the quality of life of selected patients with heart failure. CRT has become a cornerstone of treatment for heart failure and a standard recommendation in clinical guidelines world-wide. Over a 5 year period about 40,000 people in the UK have had pacemakers implanted; about 8,000 of these patients would be projected to have died within 5 years if they had not received CRT. The world market for CRT devices is projected to grow to $2.8 billion annually by 2015.
Impact: Health and wellbeing; improvement in mortality and morbidity; changes in policy and guidelines.
Significance: Clinical trial findings have led to 1160 fewer deaths and 780 fewer severely disabled patients each year in the UK; rationalising feeding policies saves over £12M annually.
Beneficiaries: Stroke patients, the NHS and healthcare delivery organisations, the economy.
Attribution: Trials were designed and led by Professor M Dennis, UoE.
Reach: Worldwide: revised national guidelines in UK, Europe, North America, South Africa, Singapore, Australasia.