IGHI hosted a forum to discuss and disseminate research into diabetes and infection.
Leaving the EU poses ‘critical threat’ to NHS.
New Patient Safety programme launching for busy healthcare professionals.
IGHI launch new Centre to bring together health researchers in Africa .
WHO EURO ‘Consultation of the European Framework for Action on Integrated Health Services Delivery’
02-04 May 2016 Copenhagen, Denmark
Between the 2 and 4 May, Professor Salman Rawaf, Ms Federica Amati and Dr Sondus Hassounah participated in WHO Regional Office for Europe’s (WHO EURO) ‘Consultation of the European Framework for Action on Integrated Health Services Delivery’ — a high level international meeting and workshop aiming to strengthen people-centred health systems, as set out in Health 2020, that strives to accelerate maximum health gains for the population, reduce health inequalities, guarantee financial protection and ensure an efficient use of societal resources, including through intersectoral actions consistent with whole-of-society and whole-of-government approaches. (more…)
Preety Das is a Specialist Trainee in General Practice in the
Department of Primary Care & Public Health. She joined the King’s Fund as part of an innovative training post at Imperial College Healthcare NHS Trust.
Here she discusses the King’s Fund report she coauthored – Bringing together physical and mental health.
Integrated care initiatives in England and elsewhere have paid insufficient attention to the relationship between physical and mental health. Our report draws on a review of published research evidence, qualitative interviews and focus groups with service users and carers, and case studies of 10 services in England. We conclude by arguing that overcoming the longstanding barriers to integration of mental and physical health should be a central component of efforts to develop new models of care that bring together resources from across local health systems.
The case for seeking to support physical and mental health in a more integrated way is compelling, and is based on four related challenges: 1) high rates of mental health conditions among people with long-term physical health problems, 2) poor management of ‘medically unexplained symptoms’, which lack an identifiable organic cause, 3) reduced life expectancy among people with the most severe forms of mental illness, largely attributable to poor physical health and 4) limited support for the wider psychological aspects of physical health and illness. Collectively, these issues increase the cost of providing services, perpetuate inequalities in health outcomes, and mean that care is less effective than it could be. The first two issues alone cost the NHS in England more than £11 billion annually.
Examples of innovative service models described in the report demonstrate that there are opportunities to redesign care in ways that could improve outcomes and may also be highly cost effective. These include various forms of enhanced support in primary care, integrated community or neighbourhood teams, comprehensive liaison mental health services, physical health liaison within mental health services, and integrated perinatal mental health care.
All health and care professionals have a part to play in delivering closer integration. Our research with service users and carers highlights the importance of professionals being willing and able to take a ‘whole person’ perspective, and having the necessary skills to do so. Integrated service models can support this by facilitating skills transfer and shifting notions of who is responsible for what. Equally, a great deal of improvement is possible within existing service structures. New approaches to training and development are needed to create a workforce able to support integration of mental and physical health. This has significant implications for professional education; all educational curricula need to have a sufficient common foundation in both physical and mental health.
My involvement in this project provided a unique opportunity to relate everyday clinical practice to the range of barriers that have prevented wider adoption of integrated approaches. These include: separate budgets and payment systems for physical and mental health; the challenge of measuring outcomes and demonstrating value; and cultural barriers between organisations or groups of professionals. The report describes several enabling factors and practical lessons, including the value of having a board-level champion for physical health in mental health trusts, and vice versa. New payment systems and contracting approaches offer commissioners various options for overcoming some of the financial barriers.
In recent years there has been a welcome focus in national policy on achieving ‘parity of esteem’ for mental health. Colloquially, this phrase has often been interpreted to mean that mental health services should be ‘as good as’ services for physical health. We argue that there is a greater prize beyond this, in which mental health care is not only ‘as good as’ but is delivered ‘as part of ’ an integrated approach to health.
Specialist Trainee in General Practice
Department of Primary Care & Public Health
The Open Access Team are based in the Imperial College Library at South Kensington. We are the team that is on the ‘other end’ when you press the ‘deposit my publication’ button in Symplectic for uploading your manuscripts into Spiral, or when you make an application for support for article processing fees. We are here to help you comply with open access requirements, including the HEFCE Open Access policy.
Last month the Faculty of Medicine Newsletter drew attention to how important it was for research active staff to comply with the new HEFCE policy from 1 April 2016. Following on from that newsletter we thought it would be useful to clarify and highlight a few points about the policy and the process for depositing your publications in Spiral through Symplectic Elements.
- The HEFCE policy applies to peer reviewed journal articles and conference proceedings accepted on or after 1st April 2016. This means anything accepted or published before this date complies as far as HEFCE is concerned! (Phew. So it is okay if you cannot find the author accepted version of that article that was accepted 6 months ago! )*
- COMPLIANCE = ACTION ON ACCEPTANCE.
Please upload your author accepted version ( final draft without publisher’s layout etc.) into Spiral via Symplectic. It is this version and only this version that we can use, unless your article goes open upon publication ( the gold route).**The date of acceptance must be entered in Sympletic.This is where you start:
- Imperial corresponding authors. You know when your article or conference proceeding has been accepted as you get that all important email from the journal publisher. So please act as soon as you get this notification. You can send non-Imperial co-authors the URL you will receive (via email) once the version you upload has been checked and deposited in Spiral. Imperial co-authors will be notified via Symplectic when the publication details have been added to Spiral. Have an open access ‘conversation’ before submission if you can.
- Corresponding authors not at Imperial – Imperial co-authors should have that open access ‘conversation’ too. Open access policies affect all authors, not just in the UK. If the corresponding author can deposit the accepted version in a compliant open access repository (usually an institutional repository) then ask to be sent the link and enter the publication details in Symplectic adding the link when requested rather than a file. If your corresponding author cannot deposit the work themselves, then ask for a copy of the accepted version and advise them of what you need to do.
- The Library’s Open Access team will check your records. Nothing goes live until they do! We make sure you have the correct version, the correct licence, the correct embargo period. So please don’t worry: go ahead and upload.
Remember: compliance = action on acceptance
We strongly recommend that you upload your author accepted version as soon you are notified of acceptance. Action on acceptance needs to become a ‘habit’, the Open Access team are here to help. It is impossible to cover every scenario or eventuality in 5 points! So if you have any questions, need further clarification, please contact us.
Scholarly Communication Support Manager
Imperial College London
*If you have a really good filing system (or your corresponding author does) and you can lay your hands on an author accepted version of an article, then please do upload it as soon as you can. We want as many open access outputs in Spiral as possible and remember that there are other research funders such as RCUK and Charities Open Access Fund who have their own requirements. You can find out more about other research funder open access policies on the College Open Access support pages
** Going open on publication: you can apply for funding via ‘deposit your work’ in Symplectic. If you go open on publication without funding from the Library, please still upload your article, using the final published version. It is important that you enter the date of acceptance in Symplectic for compliance purposes.
- How do infectious diseases affect diabetes patients?
The focus for the March IGHI Global Health Forum was on infections and diabetes.
- New test for TB claims first prize in the IGHI Student Challenges Competition.
A new way to test for tuberculosis claimed the £5000 top prize in this year’s competition.
- Patient Safety Global Action Summit 2016.
During Patient Safety Week, experts from NIHR Imperial PSTRC teamed up with the UK government to create a global movement to transform patient safety.
- Read our new prospectus/brochure
- Healthcare and Design: New Masters programme launching for healthcare innovators.
Our HELIX Centre for Design in Healthcare to launch new Masters programme.
- Too many avoidable errors in patient care, says report
- New report on patient safety
- Researchers and Google DeepMind collaborate on app to support busy medics
IGHI Researchers have developed an app to help medics manage the thousands of individual clinical tasks that need to be organised daily across a hospital.
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Institute of Global Health Innovation
The Global eHealth Unit at the School of Public Health is introducing a range of new training programmes in data science and eHealth for healthcare professionals expected to start in March 2016.
The Unit plans on delivering five new continuing professional development courses in 2016 as part of an ongoing partnership with the European Institute of Innovation and Technology (EIT Digital).
After organising two successful pilot courses and six student cohorts in 2015, the Global eHealth Unit is responding to the growing demand for data science and eHealth training by expanding on the initial courses and introducing new and advanced topics such as:
· Exploring and generating data visualisation methods for healthcare data analysis
· Practical implications of Information Governance policies
· The potential for eHelath and mHealth to improve the quality of healthcare systems
· Governance and management of eHelath and mHealth initiatives in healthcare organisations.
· Improving education in health care through eLearning
Each of the five new courses will be delivered via blended learning which will include five weeks of online training and two days of face-to-face interactive workshop style training in London.
The face-to-face training will present students with an opportunity to explore the course concepts in depth, and consolidate learning.
Professor Azeem Majeed, Head of the Department of Primary Care & Public Health said: “We are very pleased to continue spearheading this initiative with our partners from the European Institute of Innovation and Technology. After training over 60 students in our pilot courses last year, we are looking to continue to deliver training.”
Dr Josip Car, Director of the Global eHealth Unit added: “The healthcare sector is no exception to the growing demand for data scientists and IT professionals. With these courses we are looking to bridge the gap between these two fields in a unique and innovative way.”
See programme website – https://gehu.training/FoM for more information about the courses, faculty and teaching schedule.
Global eHealth Unit
Department of Primary Care and Public Health
On Wednesday 3 February the Department of Medicine hosted Young Scientist Day 2016. This annual event, designed to benefit both PhD students and Postdocs, saw a full programme of activities which included a PhD poster competition, a Departmental ‘3-minute thesis’ competition, guest speakers and a networking drinks event for all attendees.
The event was hugely popular and welcomed a large number of research students and a handful of MRes and MSc students who joined in the day’s events.
The morning was dedicated to poster presentations where research students from all five divisions had the opportunity to display their recent work to their colleagues and the judges who circulated throughout the morning.
The standard of posters was very high and after careful deliberation the three winners selected were:
First Prize: Vera Pader, (Microbiology) ‘Characterisation of a cryptic daptomycin-resistance mechanism in Staphylococcus aureus’
Second Prize: Alan Liu, (Clinical Neuroscience) ‘Clarifying the human brain’
Third Prize: Miles Priestman, (Microbiology) ‘Drug-Tolerance in Mycobacteria’
The afternoon was dedicated to the Department’s ‘3-Minute Thesis’ competition which saw one PhD student from each Section Cohort present their thesis research to a judging panel in only three minutes. The challenge included twelve students from different divisions who communicated their research to the judges and answered questions from the audience.
After a series of entertaining presentations, the prizes were awarded to Iris Scherwitzl for her presentation ‘The role of Mucosal- Associated Invariant T (MAIT) cells during dengue infection’ and Leor Roseman who spoke about ‘Reconstructing eyes-closed psychedelic imagery’.
Both Iris and Leor will progress to the College’s ‘3-Minute Thesis’ competition hosted by the Graduate School and we wish them the best of luck.
We also enjoyed two entertaining talks from Postdoc Laura Nellums and Research Fellow Bryn Owen who provided some useful and good-humoured advice about life after a PhD and their experiences in further research, both of which included international career paths. PhD students had the opportunity to ask Laura and Bryn questions about their respective careers in research before the evening was rounded off by a networking drinks session which provided a more relaxed setting for students, judges and speakers to socialise and muse over the day’s activities.
Young Scientist Day 2016 would not have been possible without the generous support of the Graduate School, who provided funding for refreshments and prizes in support of the day’s cohort building activities. We also express our thanks to Dr Kevin Murphy, and to a number of other academics and Postdocs, who gave up their time to act as judges for the poster and presentation sessions.
We look forward to making Young Scientist Day 2017 even bigger and better.
Department of Medicine
Workshop exploring zoonotic disease at the human-wildlife-livestock interface
In early February Professor Christl Donnelly organized a workshop, funded by the EU-FP7-funded Predemics project, for 25 participants from 9 countries near Lake Manyara, Tanzania. The theme of the workshop was zoonotic disease and attendees included academics, veterinarians, and individuals from NGOs, research institutes, WHO, CDC and government units. The aim was to strengthen strategic interdisciplinary partnerships to improve the understanding and control of zoonotic diseases.
A plenary talk by Professor Sarah Cleaveland kicked off the meeting speaking about zoonotic diseases and the human-wildlife-livestock interface in Africa. Over the next four days participants further explored this topic with a series of talks covering the challenges of controlling zoonoses in wildlife including One Health and conservation programmes, the impact of wildlife trade and the risks around food safety.
Breakout groups identified burning research questions and control needs for Rabies, Livestock Zoonoses, Zoonoses & the Environment and Vector-Borne Diseases. These group sessions helped evaluate the current situations for these areas and highlighted key concerns. The early findings informed Dragon’s-Den-style pitches for a (sadly fictional!) research grant of $1million. A programme for control of livestock zoonoses which directly consulted the community to identify their concerns, before developing a scalable and sustainable model for control of zoonoses won the day.
You can’t go to Africa and not go on safari: luckily the participants were able to fit in a visit to the Ngorongoro Crater National Park. This beautiful park is home to a huge number of species, including rhinoceros. The safari was followed by a talk by the Director of research at the Tanzania Wildlife Research Institute, Dr Julius Keyyu, who described the challenges of effective health governance in the context of protected areas and risky cultural practices.
The mix of formal talks and breakout groups explored key topics and allowed time for plenty of discussion and debate. Following the workshop, many participants have made plans to meet again and form new collaborations. There is already talk of a follow-up workshop (funding permitting).
Harriet L. Mills
Department of Infectious Disease Epidemiology
In 2015 the Department of Medicine launched the new Biological Imaging Centre (BIC) at the Hammersmith Campus. The centre is dedicated to high-quality imaging research in preclinical models of disease using PET/CT, MRI and optical imaging. Our goal is to translate discoveries from the bench, efficiently and confidently, to realise their potential to improve health.
The centre houses a top of the range Bruker BioSpec 9.4T MRI system which allows high resolution in vivo imaging of all murine models of disease and therapy, from diffusion tensor imaging of brain connectivity, measures of tumour burden, through to live assessment of cardiac function and viability.
The Inveon system is a versatile platform allowing Computed Tomography (CT), Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) studies to be carried out on a single integrated gantry.
In addition to our MRI and PET/CT capabilities we also provide two optical imaging systems. Fluorescence molecular tomography (FMT) is a novel tomographic near-infrared (NIR) imaging modality that enables 3D quantitative determination of fluorochrome distribution in tissues at any depth. The PerkinElmer IVIS Lumina XR III on the other hand provides an expandable, sensitive bench-top imaging system that is easy to use for both fluorescent and bioluminescent imaging in vivo.
Led by Dr Lan Zhao, with a dedicated team of staff, the centre provides access to and support for scientists from across Imperial College to conduct research in a broad range of preclinical areas. If you are interested in preclinical imaging and would like to discuss potential projects please contact us at email@example.com.
Further information about all of our modalities can be found on the Biological Imaging Centre website.
Divisional Operations Assistant
Divisions of Experimental Medicine and Brain Sciences
The CSC’s Suffrage Science film night
It was an evening designed to inspire. This was a chance to celebrate the first five years of the CSC’s Suffrage Science scheme, which aims to encourage women into science, and to stay there. With Helen Pankhurst involved, it was also a chance to explore the role of activism today, and the changing nature of women’s activism since her great grandmother’s time as a Suffragette.
The evening, hosted by the Tricycle theatre in North London, began with a screening of Suffragette the film – to remember those who gave the Suffrage Science scheme its name. The film features Carey Mulligan, Helena Bonham Carter, Meryl Streep and others in a frank portrayal of the fight for Votes for Women. It was an uncomfortable watch. Historical details, such as the Cat and Mouse Act, rendered so much more powerful when portrayed in unflinching detail on the big screen.
Before the film head of Communications and Public Engagement at the CSC Susan Watts, sat down with Helen, and talked about how her famous Pankhurst predecessors might view today’s activists; about who inspires her and about whether she sees signs of activism in science and medicine today.
“I think the whole of science is about activism. It’s about looking at a particular discipline and pushing the boundaries of what that discipline can deliver – and often it’s about the relationship between science and humanity and what science can do in terms of changing the world that we humans live in. So to the extent that it enables society to benefit in a hundred ways, that is activism.
CSC scientists have also published their findings in several high profile papers this month.
A study in Nature Cell Biology shows that we do not yet have the whole story about how fertilised eggs produce the many different types of cell that make up our adult bodies. It is widely accepted that an enzyme called Tet plays an important role, but something else seems to be at play, according to the study.
Scientists including the CSC’s James Ware have found that women who suffer unexplained heart failure towards the ends of pregnancy or shortly after giving birth share certain genetic changes. The finding provides some explanation for this mysterious condition, and suggests that by testing relatives, other women who carry the same genes, and who might face similar risks, could be identified early. They could then be monitored closely and treated more swiftly if needed. In the future preventative treatment might be developed too.
And a study published in Nature Communications is the first to show that an enzyme crucial to keeping our immune system healthy “surfs” along the strands of DNA inside our cells.
Science Communications Officer
MRC Clinical Sciences Centre
Dr Claire Fletcher, of the Androgen Signalling Laboratory, Division of Cancer, has been awarded a prestigious Young Investigator Award by the Prostate Cancer Foundation of the USA. The stated aim of the PCF in creating these awards, which are very rarely awarded outside of the US, is “to identify a cohort of future research leaders who will keep the field of prostate cancer research vibrant with new ideas.”
Claire will be using the award to pursue her innovative translational research programme at Imperial College, mentored both by Professor Charlotte Bevan in her host laboratory and also by Prof Johann de Bono at the Institute of Cancer Research, cementing and developing the collaboration between the 2 laboratories and indeed institutes. Her work focuses on identification of microRNA drivers of therapy resistance in prostate cancer, with the aim of both increasing therapy options and also of providing biomarkers to enable effective patient stratification.
“I am thrilled to have received a Prostate Cancer Foundation Young Investigator Award. This grant will allow me to vastly accelerate our promising research into the mechanisms through which prostate cancers continually evolve to develop resistance to even the most effective drugs – an area which remains poorly understood.
In the future, this knowledge will help us to develop more effective therapeutics and tailor treatments to individual patients.” – Dr Claire Fletcher.
Systematic Identification of MicroRNA Drivers of Resistance to Novel Therapeutics in Advanced Prostate Cancer – Exploitation as Stratification Biomarkers and Drug Targets
Prostate cancer (PC) is the most prevalent malignancy of Western males, affecting 1 in 8 men in their lifetime. Relapse on first-line anti-androgen treatment occurs almost invariably, leading to advanced ‘castration-resistant PC (CRPC), metastasis and patient death. Next-generation therapeutics that target the androgen receptor (AR) or alternative oncogenic signalling pathways, alongside taxane-based chemotherapeutics, demonstrate efficacy in the CRPC setting. However, only 50% of men respond to taxane-based chemotherapy, and acquired resistance to novel AR-targetting agents is emerging due to intra-tumoral androgen production or AR amplification. This necessitates urgent identification of new therapeutics and drug targets for CRPC, and discovery of resistance-predicting biomarkers.
MiRs are small 18-22nt RNAs that negatively regulate gene expression. They can function as ‘oncomiRs’ or tumour suppressors and show altered expression in CRPC. They are readily detectable in bodily fluids from patients, demonstrating considerable biomarker potential, and represent ideal therapeutics due to their small size, high stability and low toxicity. I have previously demonstrated that miRs dramatically alter AR activity, growth and metastatic potential in CRPC and that levels of putative oncomiRs are altered by novel CRPC drug treatment. Further, miRs are associated with chemotherapy resistance.
This project will use small RNA sequencing and functional assays to identify miRs that play fundamental roles in development of resistance to mechanistically-distinct novel CRPC agents in clinically-relevant CRPC models, and will generate miR biomarker ‘signature’ arrays that can predict resistance to such therapeutics. This will inform clinical management of PC and avoid the considerable morbidity and toxicity of agents that may not benefit a given patient. Development of therapies targeting resistance-promoting miRs may provide an additional treatment option for CRPC patients, increasing disease survival.
Professor of Cancer Biology
Androgen Signalling Laboratory
We are looking to support outstanding early-career clinical professionals wishing to undertake research, at least in part overseas, to improve the health of people and reduce health inequalities in developed and developing countries. Through the provision of clinical training fellowships in global health, we aim to provide opportunities for the most promising clinical academics, at the very beginning of their careers, to develop bids for independent fellowship funding. We anticipate that each fellow will be supported by two mentors, one based at an Imperial Campus, and one based overseas. All fellowships must commence by 1 September, 2016.
How to apply?
Please refer to the Wellcome Trust Institutional Strategic Support Fund webpage for application forms and guidelines.
If you have an Imperial and overseas sponsor, please contact ISSF@imperial.ac.uk for an application form and further information. Should you be an interested applicant looking for a sponsor, please provide a max 500 word summary of your interests, brief summary of project and research experience to ISSF@imperial.ac.uk by 25 January 2016. We cannot guarantee that all interested applicants will be matched with an overseas sponsor. Full applications would need to be submitted by 4 March 2016 to ISSF@imperial.ac.uk. Interviews for shortlisted candidates are expected to take place the week commencing 2 May 2016.
This Fellowship program is funded through the Global Health Stream of the Wellcome Trust Institutional Strategic Support Fund, and lead by the Imperial Wellcome Trust Global Health Research Centre in conjunction with the Institute for Global Health Innovation.
For further information please contact:
Dr Kimberley Trim, Faculty of Medicine,
Imperial College London SW7 2AZ UK
Tel: 020 7594 9826
Committed to equality and valuing diversity. We are also an Athena SWAN Silver Award winner, a Stonewall Diversity Champion, a two Ticks Employer and are working in partnership with GIRES to promote respect for trans people.
Congratulations to Dr Beth Holder on getting this beautiful paper published and thanks to the collaborators within and outside of the department who helped to facilitate the work with all the various techniques.
Beth recently presented the work at the International Symposium for Maternal and Neonatal Immunisation and her talk was praised as an outstanding contribution, particularly by our US attendees. This work was funded through the Imperial NIHR Biomedical Research Centre (BRC) and the Medical Research Council.
During pregnancy, the placenta forms the interface between mother and fetus. Highly controlled regulation of trans-placental trafficking is therefore essential for the healthy development of the growing fetus. Extracellular vesicle-mediated transfer of protein and nucleic acids from the human placenta into the maternal circulation is well documented; the possibility that this trafficking is bi-directional has not yet been explored but could affect placental function and impact on the fetus. We hypothesized that the ability of the placenta to respond to maternal inflammatory signals is mediated by the interaction of maternal immune cell exosomes with placental trophoblast. Utilising the BeWo cell line and whole placental explants, we demonstrated that the human placenta internalizes macrophage-derived exosomes in a time- and dose-dependent manner. This uptake was via clathrin-dependent endocytosis. Furthermore, macrophage exosomes induced production of proinflammatory cytokines by the placenta. Taken together, our data demonstrates that exosomes are actively transported into the human placenta and that exosomes from activated immune cells modulate placental cytokine production. This represents a novel mechanism by which immune cells can signal to the placental unit, potentially facilitating responses to maternal inflammation and infection, and thereby preventing harm to the fetus.
Secretary for the Section of Paediatrics and Personal Assistant to the Head of Department, Professor Andrew Bush.
Kiara Chang presented her work on the Impact of the NHS Health Check on global cardiovascular risk, individual risk factors and prescribing. Dr Raffaele Palladino presented his work on the Association between Framingham Risk Score and work limitations in health surveillance. Lastly, Thomas Hone presented his work on The Introduction of Family Medicine in Turkey 2005-2013.
The conference was an excellent opportunity to showcase the work of the School of Public Health at an international level, as well as enjoying some Italian culture and food!
Department of Public Health and Primary Care
Guest Presentation from Mr Shuhei Nomura, PhD candidate in the Department of Epidemiology and Biostatistics, ICL
As part of the Department of Primary Care and Public Health’s effort to develop and engage doctoral students and fellows to debate and discuss their work, the WHO CC holds weekly seminars. On Oct 21, 2015, Dr Alex Chen (PhD candidate), the seminar organiser, invited Mr Shuhei Nomura, PhD Candidate in the Department of Epidemiology and Biostatistics – ICL, to share his research projects about Fukushima Dai-ichi nuclear power plant disaster.
Mr Nomura delivered a presentation on current radiation levels in Japanese coastal cities (Minamisoma City and Soma City, 15-40km north of the nuclear plant), as well as key issues and challenges facing the residents of these cities. He presented data from the internal and external radiation screening programmes for residents of these cities – work in which he has been involved since it was launched in Japan in July 2011.
On 11 March 2011, Japan experienced an unprecedented catastrophe compounded by a radiation-release incident at Fukushima Dai-ichi nuclear power plant in the wake of the massive earthquake and subsequent tsunami, which was later assessed as a Level 7 on the International Nuclear Event Scale – the worst possible rating.
1st International Conference of Primary Care and Public Health & 3rd International Congress of Person Centred Medicine “Celebrating Primary Care Achievements: Seeing the person behind the patient”
The 1st International Conference of Primary Care and Public Health, 3rd International Congress of Person Centred Medicine, was held at Imperial College London, United Kingdom, from the 29th to 31st of October 2015.
The conference covered five central themes: Primary Care in the 21st Century, Ageing and Ageism, Children and Adolescences, Integrated Care, and Public Health in Primary Care. The programme comprised of keynote lectures, brief oral presentations and posters, featuring prominent figures as well as members of local communities from numerous global settings, including the UK, US, Middle East and Mauritius. Over 250 individuals attended from countries all over the world.
The importance of this conference was laid out in the opening remarks from Imperial College President Alice Gast together with Dr Derek Bell of NIHR CLAHRC NWL and His excellency Professor Ala Alwan Eastern Mediterranean Regional office for the WHO. The trans-boundary issues which threaten health warrant an international response, and events such as this conference are crucial for knowledge exchange and the planning of action.
A summary of the calls to action from the conference below and more information from each speaker can be found on the conference website www.icpcmlondon2015.org
i. Establish a shared goal of improvement in the health of the population through person and people centered care, taking into account biomedical, socio-cultural, psychological and spiritual elements that form part of the whole person and the demography of diverse populations.
ii. Primary care and Public health professionals should create and enhance local links and build relationships with each other and local stakeholders.
iii. Prevention programmes at all levels should be fully integrated within primary care.
iv. Create health care databases and identify new data sets, creating from these a consolidated information system a platform for sharing and displaying local population health data that could be used by communities.
v. To create common research networks to foster and support the integration of primary care and public health to improve population health.
vi. To develop multidisciplinary educational programs developing the curriculum and clinical experience that ensures the integration of primary care and public health.
i. That primary care should be delivered within the social networks of each person, alongside the provision Social Care and recognized as being part of a complex adaptive system with many components that reciprocally influence one another.
Primary Care in the 21st Century
This theme was explored throughout the conference both in addressing the complexity of a world in which displaced people’s health needs require action and in widening our understanding of what it means to be healthy. From Professor Ted Epperly’s insight to the American Health model and how our spending on medical services is not in line with what maintains health, through to Professor Marisa Papaluca’s clear explanation of how Regulators are driving innovation in providing personalised medicines.
Ageing and Ageism
The fact that the world’s population is ageing and the need to account for increasing longevity a known fact, exploring attitudes to ‘casual ageism’ both in the elderly and the often overlooked adolescent group was integral to Professor Jon Snaedal’s talk. Professor the Baroness Ilora Finlay brilliantly summarised the importance of palliative care and highlighted the lack of focus and expertise which health systems provide for end of life care. The one time all people will require healthcare is at the time of death so it is important to focus on the end as well as the beginning.
Childhood and Adolescence
Sir Al Aynsley Green delivered a powerful and important talk on the most important significant and influential period of an individual’s life: childhood. With changing population demographics it is more important than ever to invest in children and nurture them taking inspiration from the holistic methods of childcare in Finland. The importance of person centred medicine was emphasised by Professor John Cox with particular regards to perinatal depression. This is an issue which can have enduring effects on families involved and it must be addressed in order to ensure every child has a good childhood.
Professor Mitch Blair, in his inspirational talk, stressed the need for doctors to pay attention to the beginnings of life and the crucial first years and seeing the patient in the wider context of family, school, immediate community circumstances.
Professor Azeem Majeed raised important points about the need for research and innovation in primary care, and explained the proposals for family practitioner led and hospital led integration. Professor the Baroness Sheila Hollins spoke compassionately about the need for person centred medicine and the imperative for care givers to work with the patient and their family and loved ones, to see the person behind the disability. Using integrated care for the treatment of atrial fibrillation was informatively described by Dr Abdul-Majeed Salmasi.
Public Health in Primary Care
Building health systems on a foundation of primary care and public health is vital for universal health coverage and improved population health. Professor Salman Rawaf spoke passionately about how crucial primary care is in order to tackle the growing prevalence of non-communicable disease and for ensuring healthcare is family and person orientated. The importance of primary care in public health was stressed in a video message from Professor Ala Alwan, director of EMRO, who highlighted that primary care is at the core of the region wide priorities for EMRO, including health system strengthening, addressing non-communicable disease, promoting health security and building capacity.
The conference was attended by over 200 attendees who benefited from the event and enthusiastically spoke about the experience.
“On the occasion of conclusion of the 1st International Conference of Primary Care and Public Health which was held at Imperial College, London (29-31 October, 2015), I would like to express the highest of my appreciation and gratitude to the marvelous efforts exerted on your part to have this extremely valuable conference in the best shape with this outstanding and remarkable success.
My very cordial congratulation for the success of the conference which is considered a turning point in primary care and public health march at the global level.
The success of the conference was evidenced by the broad participation from every corner on earth, it was a global demonstration about primary care and public health.
The themes and the scope of the conference encompassed a lot of interesting issues that were so vital to primary care and public health & the presence of such group of elite scientists and experts of the field crowned these efforts and was a real added value.” Professor Tawfik Khoja – Director General Executive Board, Health Ministers Council for Cooperation Council.
“Although I could not participate fully from the beginning to the end; I am so pleased to have taken part of this rich intellectual and scientific activity. I would like to take this opportunity to congratulate you and your distinguished team on the quality of the technical as well as operational arrangements of the successful conference.” Dr Atef El Maghraby – Technical Lead, Health Systems, World Health Organization.
Advanced Leadership and Health Management training: 1-5 September 2015
Chinese Guanghua Foundation, whose mission is to stimulate Chinese youth to contribute to China’s Science and Technology development through various programmes and awards, approached WHO Collaborating Centre for Public Health Education and Training in search for a bespoke Advanced Leadership for Healthcare course. The WHO CCentre delivered the training on 1st-5th September 2015 for 16 delegates. The course included visits to NHS trust Hospitals, Research hubs and local practices as well as a series of carefully selected exercises addressed at the needs of the participants.
The intensive 5-day course was the first in the series of the regular trainings for Chinese healthcare professionals and Hospital Managers. The next course is planned for April 2016.
Family Medicine in Sudan
The Republic of Sudan has made significant strides in developing its health sector, especially in terms of family medicine; the country aims to achieve universal health coverage as part of its post MDG 2015 agenda. In this regard, the Federal Ministry of Health (FMOH) has embarked on an ambitious plan for the expansion of primary health care network and the national health insurance fund is drawing its agenda for universal coverage. As such, the WHO CC was asked by the Eastern Mediterranean Regional Office for the WHO (EMRO) to technically support the finalization of the family medicine policy currently being developed by teams at the Sudanese FMOH and Public Health Institute (PHI). Professor Salman Rawaf and Dr Sondus Hassounah from the WHO CC were joined by Dr Hassan Salah (Technical Officer-EMRO) from the 15th-21st August in Khartoum to meet and assist the FMOH and PHI in that regard.
Indus Foundation Healthcare Excellence award
Congratulations to our Director, Professor Salman Rawaf for achieving the Lifetime Achievement Award in Healthcare Excellence from the Indus Foundation.
The Indus Foundation has initiated the Healthcare Excellence Awards – country’s most authoritative awards for the healthcare industry. Each of the Awards recognizes “excellence in medicine and healthcare” as manifested in the varied ways that may significantly impact the health and well-being of our citizens.
Heba Awadh from Oman started her PhD in October 2015 and will be focusing on Patient safety in the Gulf Region
Asma Alnuaimi from Qatar joined WHOCC on 1st September 2015 as a WHO CC Fellow. Her two-year training programme will focus on health promotion, health education, public health and epidemiology. As part of her Fellowship, Asma will also work on a research question of her choice.
Ahmed Sulaiman AlMujil joined WHOCC on 1st October 2015 as a WHO CC Fellow. His training will be centred on: medical education, research methodology and publication process, healthcare management.
WHO CC Fellow: Dr Saad Al Saad from Saudi Arabia finalised his fellowship on 23rd September 2015.
Worming our way to a new understanding of behaviour
The wriggling and writhing of worms may hold clues to the inner workings of our brains, according to scientists at the MRC’s Clinical Sciences Centre (CSC). The researchers have developed a pioneering tool to analyse a worm’s posture as it wriggles, and will use the tool to investigate how exactly the worm’s brain controls its movements.
Postdocs were freed to ask “stupid questions” at the inaugural postdoc retreat. The day-long event was organised by postdocs for postdocs.
“The science was great, but I think the biggest benefit is networking and getting to know the community in which we work. Finding out what people are working on so you know who to approach when you want to speak specifically about an area of research that you’re unfamiliar with is invaluable,” said Dr Angela Woods, a senior investigator scientist in the CSC’s Cellular Stress group.
Watch a video of the postdoc retreat at https://www.youtube.com/watch?v=tjH_Ybjtiqc
Vahid Shahrezaei is the new mathematician–in-residence at the CSC.
He’s been running a biomathematics group in the maths department of Imperial College since 2008, and is now taking up a visiting position that teams him up with the CSC’s biologists.
He’s looking forward to bumping into biologists day-to-day, and though hasn’t yet sat in a lab with the CSC’s scientists, he’d like to try that out too. Regular interaction with biologists, Vahid says, is an important part of the atmosphere of the CSC, and key to creative collaborations.
Watch Miguel-Aliaga’s interview at https://www.youtube.com/watch?v=0ewZtr4H7zY
The Journal of Cell Science has selected Irene Miguel-Aliaga, who leads the CSC’s Gut Signalling and Metabolism and is a Reader at Imperial College, as a ‘Cell Scientist to Watch’.
Miguel-Aliaga is one of four chosen so far by the journal for a series it says will “support the next generation of cell biologists.”
Last week, the journal published a two-page article and a video interview with Miguel-Aliaga in which she discusses how a TV series about lizard aliens invading Earth inspired her to become a scientist.
She also talks about setbacks in science. “I think sometimes the roadblocks are your own set of preconceptions,” says Miguel-Aliaga. She also thinks that we can be our own worst enemy: “Human nature means that, even if we try not to be, we tend to be too hypothesis driven.”
Also this month
In our series of scientific seminars, Art Arnold from the University of California, warned CSC scientists that preclinical experiments must not exclude female cells and animals. He said that it has traditionally been thought that females, with menstrual cycles and fluctuating hormone levels, are poor test subjects. But research in his lab shows that this is a myth. According to Arnold, when it comes to scientific research, women and men are comparable subjects.
Find out more about the latest news, events and activities at the CSC: http://csc.mrc.ac.uk/news/
Science Communications Officer
MRC Clinical Sciences Centre
What can we learn from surgical history and can we use this knowledge to consider what the future of surgery might look like? These are the questions we are aiming to answer by taking our Time Travelling Operating Theatre across the country as part of a Wellcome Trust-funded research project.
Imperial College London’s Centre for Engagement and Simulation Science (ICCESS) are using real clinicians working together in re-enactments of three eras of surgical history – 1884, 1984 and 2014. These periods represent the beginnings of abdominal surgery, keyhole surgery and more recent developments such as the iKnife. The Time Travelling Operating Theatre not only immerses members of the public in a world that is usually closed to them but also demonstrates some of the cultural, social, technological and environmental changes that have occurred in surgery.
Following their trip through surgical time, the public then get the opportunity to discuss the changes they have witnessed with the participating clinicians and others including ethicists, medical defence layers and policy-makers. The rich discussions that have come out of the experience have covered a wide-range of topics, a key one being the ethics of medicine past, present and future.
To date there have been three events (at the Science Museum, London; Royal College of Nursing, London; Thackeray Museum, Leeds) with the final event taking place at the National Museum of Scotland in Edinburgh on 10th October. The data collected from the events will aim to understand if this unusual methodology is an effective way to involve the public and patients in policy-making decisions.
For more information please visit www.timetravellingoperatingtheatre.com
Senior Research Officer
Department of Surgery and Cancer
As part of their ongoing effort to support and nurture postdoctoral staff in the Department of Medicine, the Early Careers Committee (a subcommittee of the Development and Opportunities Committee) procured funding to enable postdoctoral research scientists and research fellows in groups without such funding to present their research at conferences. The Postdoctoral Travel Awards are open to all postdocs and academic research fellows in the Department of Medicine, particularly those who need assistance with extraordinary costs relating to caring responsibilities.
Numerous applications were received for the most recent deadline and after careful deliberation the committee decided to allocate funds to Drs David Hodson, James Cole and Jason Long.
Dr David Hodson
“The Postdoctoral Travel Award allowed me to attend the 75th Scientific Sessions of the American Diabetes Association in Boston USA, to which I was invited as a symposium speaker. This will be critical for my future career progression, since indicators of esteem such as this are important for obtaining grant funding and academic promotion.”
Gene variants in or close to the gene encoding ADCY5 are associated with an increased probability of developing type 2 diabetes, a socioeconomically-costly disease state. To better understand how this gene may influence insulin secretion in man, David and his group employed molecular biology techniques to silence ADCY5 expression specifically in human islets. Using these approaches, they were able to show that ADCY5 is indispensable for coupling glucose to insulin secretion in beta cells through generation of the signaling intermediaries cAMP and ATP. In addition, they also demonstrated that samples from human donors who harbor risk loci for ADCY5 present with lowered mRNA levels. Thus, ADCY5 variants in or near to ADCY5 are likely to impair gene expression, elevating type 2 diabetes risk.
Dr James Cole
“The travel award allowed me to attend this year’s OHBM meeting, held in Honolulu, Hawaii. OHBM is the premier international conference for the field of neuroimaging, and thanks to the travel award, I was able to attend this meeting for the first time in my career. The meeting attracts the world leaders from across areas of research relating to neuroimaging, and it was an excellent experience to be able to see the latest developments in my field all showcased in one event. As well as the many senior neuroimaging scientists in attendance at OHBM, I was able to meet with a number of more junior researchers with common interests to me, allowing me to get a broader view on the type of work being conducted by people at my career stage.
The research I presented at the conference was an analysis from the EU project I work on, known as COBRA (ComorBidity in Relation to AIDS). The opportunity to present this work at OHBM 2015 was invaluable as I was able to get insightful feedback from a range of researchers in the field. Furthermore, there is an important HIV research group based at the University of Hawaii, led by Dr Linda Chang. I was able to meet with Dr Chang and her colleagues, display my findings to them and discuss potential future collaborations.
The advent of combination anti-retroviral therapy (cART) means that human immunodeficiency virus (HIV) infection is no longer a death sentence. For the first time, HIV-infected individuals are living into old age. Nevertheless, despite improved life expectancy, research conducted into groups of ageing HIV-infected people reports a concerning increase in the development of age-related diseases. Importantly this includes mild cognitive impairment, itself a key risk factor for dementia. As the number of older adults living with HIV increases globally, it is vital to understand what might underlie this increased risk of disease and cognitive decline.
James and his colleagues use magnetic resonance imaging (MRI) to measure brain structure and function in HIV-infected people. They then compare these brain measures with carefully selected uninfected people, with similar demographic and behavioural characteristics. Using structural MRI, they have accurately predicted chronological age in a large, separate group of 1500 healthy people, by employing a computational technique called ‘machine learning’. They then made predictions of age in a group of 134 HIV-infected people, aged between 45 and 78, by comparing their brain scans to this predetermined machine learning model. On average, HIV-infected individual’s brains were predicted to be two years older than their chronological age. The uninfected group did not show this ‘brain ageing’ effect.
This result indicates that, despite successful treatment with cART, individuals with HIV-infection have changes in brain structure that resemble those seen in normal ageing. Age itself is an important risk factor for cognitive decline and subsequent dementia. If there are ‘age-like’ alterations to brain structure due to HIV, these individuals may well have a higher risk of future health problems. Using this brain age model, they intend to further investigate which characteristics of HIV-infection may influence brain age, such as specific cART drugs, levels of residual HIV or behavioural and lifestyle factors.
Dr Jason Long
“We’ve recently come across a very interesting finding in the lab and are hoping to publish in a high impact journal soon. So we’re looking out for relevant conferences to go to in order to share this knowledge; it’s vital we let the field know about this and get collaborators on board. There’s never enough money for travelling, so receiving the PostDoctoral Travel Award really helps. In particular I’m using this award for a conference aimed at ‘younger’ scientists in the beginning stages of their careers, so I hope to benefit from being surrounded by others who are at a similar stage as I am, make connections and chat about options!”
Influenza (flu) viruses originate in wild birds, and have crossed over to human hosts in pandemic events after which they adapt and continue to circulate causing seasonal epidemics. In addition there are frequent dead-end jumps from bird viruses into humans, such as the current H5N1 situation in Egypt and H7N3 in China. Yet these viruses have not yet made that extra leap to become pandemics. This is because the virus needs to make several changes in its genes in order to adapt to humans, a hard task for a virus. One such change that Jason and his peers have researched is the change in the polymerase (this is the virus machine that copies its genes inside the cells of the host). For many years we have known that bird flu viruses mutate a gene in its polymerase that allows it to replicate in humans. But until now we have not understood why.
They took cells that were part mammalian and part avian. By looking to see if bird flu polymerase could or could not work in these cells, and comparing the genes between the different cells, they identified a chicken gene that bird flu polymerase can use in avian cells, but cannot use the human equivalent in human cells. This identifies the point at which the virus has to mutate in order to copy its genes and adapt to humans. This finding is very important for the development of antivirals against the flu polymerase, as well as understanding which bird flus may be able to make the jump from birds to humans.
Scientists at the MRC’s Clinical Sciences Centre (CSC) in West London are the first to show that a small molecule circulates in the blood of people who are in the early stages of type 1 diabetes. A simple blood test could detect this biological marker years, maybe decades, before symptoms develop.
“If we can identify and treat patients earlier, we may be able to help them to avoid secondary complications. This could ultimately extend a patient’s life,” said Mathieu Latreille, who leads the CSC’s Cellular Identity and Metabolism research group, and who carried out the research in collaboration with scientists at the Swiss Federal Institute of Technology. Latreille presented the results to doctors at Hammersmith Hospital this month.
Further interesting findings came from a CSC study which has shown that a gene, called Jarid2, may play a wider role than previously thought in co-ordinating the way that stem cells change in a developing embryo to form the specialised cells that make up our bodies.
Scientists know already that Jarid2 is important in organising the healthy formation of many organs, including the neural tubes that become the brain and spinal cord, the liver, spleen, thymus and cardiovascular system. But its central role very early on in embryo development is “surprising”, according to professor Amanda Fisher, director of the CSC, and head of the Institute of Clinical Science at Imperial College London, whose team published its findings in Cell Reports on July 16.
Also this month, in our series of scientific seminars, Simon Andrews of the Babraham Institute in Cambridge, warned CSC scientists that experiments to sequence human genes can, and do, go wrong. Rapid advances in technology mean scientists can now sequence entire human genomes in a matter of hours, and for less than £1000. But Andrews explained that even the latest technology doesn’t stop scientists from making mistakes. “I’m showing you some of the ugly sides of sequencing experiments,” he said.
Another seminar in the series saw James Ware, who works with the CSC’s Cardiovascular Magnetic Resonance Imaging and Genetics research group, update researchers on the latest in his quest to understand the genetics of dilated cardiomyopathy, a heart condition which affects 1 in 250 people and can lead to sudden death.
Outside of the lab, CSC scientists and staff competed in the Institute’s annual rounders tournament, a relaxing interlude from serious science. Defending champions team ‘Mansfield’ came out on top.
Find out more about the latest news, events and activities at the CSC: http://csc.mrc.ac.uk/news/.
Professor Mitch Blair and Professor Michael Rigby from the Section of Paediatrics of the Faculty of Medicine at Imperial, together with European colleagues, have been awarded almost 7 million Euro by the European Commission – Directorate General for Research and Innovation Horizon 2020 programme to study and evaluate models of child primary care in Europe.
The project: MOCHA Models of Child Health Appraised will see Imperial College project staff working with 19 scientific partners from 10 European countries, plus Switzerland, the United States and Australia; as well as with country agents in 30 European Commission and European Economic Area countries.
The project began on 1st June with a three-month preparation phase, including creating a project website, prior to an active research programme commencing on 1st September 2015 continuing until the late autumn of 2018.
Principal Investigator Professor Blair explained:
“Children are an important population group in their own right, but also are the future of Europe, its society and its workforce. Thus children’s health is vital to children and for a healthy Europe”.
“However, there is no consensus on the best way of providing primary health care for children. Different countries favour different models, of which two main ones are generalist general practitioners seeing the child in the family context, and primary care paediatricians with focused expertise. Until now there is no research which shows which model is most effective, which also implies that some children are likely to be receiving sub-optimal care.”
MOCHA will obtain and analyse key information on a range of child primary care topics, such as:
- Models of primary care delivered to children (including urgent care)
- Delivery of care across organisational boundaries (with secondary care, social care, education and so on) including complex care, and services for child protection
- School health services, and direct access services for adolescents
- Identification of innovative measures of quality and outcome
- Identification of derivatives from large data sets to measure quality and outcome
- Economic and Skill Set analyses
- Ensuring Equity for all children
- Use of electronic records in child health
An independent Expert Panel from 10 countries and 15 different organisations or paediatric and public health associations will validate the scientific enquiries made of country agents, and review the findings. Views of service users will be sought throughout the project, and there will be an active engagement and dissemination programme.
The project will be managed from Imperial College, coordinating the work of 11 separate work packages run by experts from European research institutions, including researchers from Imperial College.
This will be one of the largest and most ambitious project to look at child health services in Europe. Focusing on prevention and wellness, its results will demonstrate the optimal model(s) of child primary care. Alongside the results, the MOCHA project will analyse the factors (including cultural factors) which might facilitate the adoption of recommendations, and indications for policy makers of both the health and economic gains possible. Throughout its life, the project will have a strong dissemination programme, ensuring that dialogue with the public, professionals, policy makers and politicians is maintained and taken into account during the research.
Within its 42-month timescale, the MOCHA project will deliver major awareness and potential benefit for European children’s health and a healthy society.
For further details contact:
The ability to adapt to environments of fluctuating nutrient availability is vital for bacterial survival. In response to nitrogen limitation, Mycobacterium tuberculosis alters nitrate/nitrite metabolism, aspartate metabolism and cell wall biosynthesis. GlnR is a key regulator involved in this response, controlling the expression of genes involved in nitric oxide detoxification and intracellular survival, markedly different to the GlnR-mediated nitrogen scavenging response seen in non-pathogenic mycobacteria. This has implications for Tuberculosis (TB) control in terms of designing new drugs to treat infection.
All Faculty of Medicine students and staff are warmly invited to our forthcoming Revolutions in Biomedicine Summer Lecture Series.
Each of the lectures will be followed by a drinks reception. There is no attendance fee for Faculty of Medicine students and staff, but we do ask that you register beforehand to help us plan catering.
If you have any questions about the lectures, please contact Jim Osborne (firstname.lastname@example.org).
PROFESSOR SIR STEVE BLOOM
Interfering Factor to World Drug
Blockbuster – Can Imperial Manage?
Monday 29 June 2015, 17.00-18.00
G34, Sir Alexander Fleming Building
PROFESSOR BEATE KAMPMANN
Vaccines, Immunity and Global Child Health
Wednesday 1 July 2015, 17.30-18.30
G34, Sir Alexander Fleming Building
PROFESSOR THE LORD ARA DARZI OF DENHAM PC KBE FRS
Innovation in Healthcare
Thursday 2 July 2015, 17.30-18.30
LT311, Huxley Building
PROFESSOR SARA RANKIN
Story of a Paper: Regenerative Pharmacology – Teaching the Body to Repair Itself
Monday 13 July 2015,
17.30-18.30 (registration opens at 17.15)
G34, Sir Alexander Fleming Building
The NIHR Clinical Research Network, which supports researchers and clinicians across Imperial College and Imperial College Healthcare NHS Trust, have helped recruit the first global patient into a surgical study. The trial, which is being conducted by Mr Ahmed Ahmed, Clinical Senior Lecturer in Bariatric Surgery, will compare types of surgical stapler, to investigate whether a newer device will be more efficient and reduce complications for patients.
NIHR Clinical Research Network (North West London)
We are looking for healthy volunteers of West African descent to take part in an Imperial sponsored study called ‘Genetic Studies of the Heart and Circulation’, which aims to develop an atlas of the human heart to help scientists to determine the effect of different DNA and genes on heart shape and function. The research has been given ethical approval by the Research Ethics Committee (approval reference number 09/H0707/69).
Volunteers must be:
- registered with a UK GP
- have no heart-related health problems
- be between the ages of 18 and 80
The study will involve some general lifestyle questions; height, weight and simple heart test function measurements; a three dimensional heart scan; and a blood (or saliva) sample. The appointment may take up to 90 minutes, and are held at Hammersmith Hospital, Du Cane Road, W12.
All participants will be reimbursed £25 and will receive a free CD of their scan.
For more information email: email@example.com
Laura Monje Garcia
Research Nurse, Cardiology
Robert Steiner MRI Unit