Academy of Medical Sciences – Spring Meeting 2013

Posted on: April 7, 2013

Channel: Science and Environment

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Have you ever wondered what work doctors might be doing when they are not seeing patients? Approximately ten percent of doctors are clinical academics or clinical researchers and they divide their time between seeing patients and doing research.

Lucy Bradley travelled down to the centre of London to the Spring Meeting of the Academy of Medical Sciences. This is an annual conference which brings together trainee clinician researchers from across the UK to present their research. This meeting is also an opportunity for these doctors to meet each other and exchange ideas. Lucy spoke to some of the participants, who told her what the meeting means to them.

Katherine Sleeman: This meeting is such an amazing opportunity for clinician scientists to come along, see eachothers work, rub shoulders from the great and the good in academic medicine, and really, the main thing about this meeting that I love is, it’s so nurturing.

Rod Mitchell: These meetings are always very important for collaborating with colleagues and finding out about what people are doing in other areas of research which might have implications for what you do. I find that at all these meetings we are always able to meet people who can enhance eachothers research.

Shelley Potter: I think meeting other people who are research active and sharing with them the frustrations and joys of research. I think it’s just quite nice to get together, irrespective of what your specific field is. I’m finding such a breadth of research going on, it’s really nice to see what other people are doing and gain different perspectives.

Tosan Okoro: This is my first Spring Meeting. It’s a different audience to what I’m used to. It’s mainly to do with networking, so it’s about different ideas and working out other ways you can collaborate and do reasearch that can improve on your practice in different ways.

Katie Marwick: Today we’ve aready heard a talk about the pharmaceutical industry, which I have to admit my bias is towards being very negative about, but it’s really made me think about some of the benefits one might get from interacting more closely with the pharmaceutical industry. I’ve also had some really good chats with people about this poster and some suggestions about other things we could look at, so that’s been really useful.

Paul Pfeffer: Well, I think it’s just an opportunity to meet people to don’t expect youre going to meet. It’s a very friendly atmosphere and there’s a lot of collaboration. So it’s about meeting people you don’t know and seeing techniques you don’t know.

Lucy asked John Tooke, President of the Academy of Medical Sciences, to explain a bit more about the importance of the meeting and who it’s for.

John Tooke: The Spring Meeting for clinician scientists in training is an incredibly important event from the Academy of Medical Sciences perspective. Some fifty percent of our fellowship are doctors who undertake medical science, and this particular meeting is aimed at supporting the particular needs of those who are medically qualified and who are persuing a career, both as a clinician and as an academic scientist. Many of the challenges come from combining those two roles, and of course the academic role is complex in itself because it involves teaching and research, and as one advance up the career ladder, often you can throw in administration and management into the mix as well.

LB: And what is one of the great benefits of being in both camps, being a practitioner and a researcher?

JT: That’s a very good question. I see the most important advantage of being in both camps is that your research is informed by genuine clinical need. Thats important on many levels. It’s incredibly important to understand that need very closely, and it’s only by being close to what matters to patients that you can really address the issues that are going to improve their experience, their capacity to cope with an illness. Second, I think that a lot of medical advance comes from understanding or observing first hand the extremes of presentation of particular conditions. It’s often the case that rare diseases give remarkable insight into the mechanisms which are of more generic significance to pathology. It’s only by being clinically connected, and actually having significant commitment to clinical activity that you will come across those infrequent occurrences.

LB:  I’m just entering the room where all the posters are exhibited, as you can here there is a lively and buzzing atmosphere full of people, so let’s go and take a look.

Dr Katie Marwick:  I’m a psychiatry trainee, so I’ve been qualified as a medical doctor for five years, I’m also pursuing a career in medical research. My poster today is about sensitivity to cuteness in baby faces and how this is not affected by being pregnant. So I was interested in this because of the possible link between reproductive hormones and post-natal depression. We felt if it was possible that the ability to tell the cuteness of baby faces apart was a response of the brain to reproductive hormones, it may be if the response during pregnancy was not what was normal, that could perhaps predict a risk for post-natal depression. That was why I was particularly interested in it.

LB: I have your poster infront of me and there are two pictures of the same baby side-by-side, who decided which face was the cuter face and how did you decide? 

KM: That’s a question that everyone asks! It’s the power of the human eye, basically. We got a sample of baby photos and then got a group of women and men, young and old, about forty people, to just rate the face: how cute is this baby? You think it might be quite subjective, but actually everybody agreed, there’s a very strong correlation- a statistical test to see how strong the agreement was. So there are infact underlying principles that everyone does find cute which tends to be having big eyes,  having eyes not more than half way up the face, nice rounded cheeks, small nose, small mouth… if you think of Mickey Mouse, those kind of features- without the big ears!

We’ve been looking at cuteness discrimination- so that’s not how cute you find a face- but if you have two faces side-by-side, can you tell which is the the cuter? We’re able to use computer software to morph babies faces to be more cute or less cute, and you can make that a big difference or a small difference. If it’s a big difference anyone can do it [tell the difference], but if you make [the difference] really subtle, we start to find that men just can’t tell the difference between the two pictures of the [same] baby, but women remain able to do it at quite a subtle distinction. Interestingly, premenopausal women are better than postmenopausal women, and women on the pill are better than women off the pill. So that made us think that reproductive hormones, like oestrogen and progesterone, may be important in determining the ability to tell the cuteness of baby faces apart. That led us to think about pregnancy. Pregnancy is a time when naturally the levels of these hormones vary substantially; oestrogen goes up fifty fold, progesterone about tewlve fold, so if it really is these hormones that are important in helping you tell the cuteness of baby faces apart, you’d expect women to get much better at it as pregnancy progressed. So we got a group of lovely pregnant ladies, who agreed to let us visit them four times – twice during pregnancy and twice after- and went through our test procedure which is looking at 100 pairs of baby faces and pointing to the cuter one, and were able to get a measure of how accurate they were at distinguishing the cuteness. What we found was unexpected in that infact there was no difference across pregnancy and after delivery. We also compared them with a group of young women that were not pregnant, matched for age and number of children etc, and there is no difference between them and the women who are pregnant either, despite these large differences in levels of reproductive hormone. Given that we didn’t find the link we expected, it’s probably not simply that higher levels of hormone make you better. It’s probably more complicated.

LB: Did the inspiration for this research stem from your experience as a practitioner?

KM: To be completely frank, I just thought cute babies sounded really interesting!

LB: As a clinician researcher, for you what is the most important thing about being in both camps, seeing patients and doing the research?

KM: I’m going to be a psychiatrist, and we don’t really know why we get many of the disorders that so badly affect the patients that I care for. I think we are starting to chip away about the causes and mechanisms and finding out more about that really gives me hope that we can improve the lives of people that are so devastated by severe mental illness. I think I might find it harder to go to clinic everyday and do the treatment if I didn’t feel at the back of my mind we are making progress for the future for these people.

Dr Paul Pfeffer: I’m Dr Paul Pfeffer, a clinical training fellow. My project is looking at whether vitamin D, the sunshine vitamin, can protect against air pollution that might otherwise drive asthma. Asthma is a disease that is increasing globally and the question is why, and we think it’s environmental factors and two ones we know are important are vitamin D and air pollution. This particular research is looking at the cells lining the lungs to see the effect of vitamin D on those cells, as opposed to many other cells that are involved in asthma.

LB: Where did your interest for this project originate?

PP: My interest in ashma comes from my clinical side. It’s a disease which I think is undertreated, there isnt enough research into it, and where you can really make benefit to the patients if you treat it correctly. I approached some people in the field at the MRC & Asthma UK Centre and that’s really what led into this project- looking at the form of vitamin D- and then I chose air pollution because it’s something that stimulates the lungs everyday outside. A lot of people use other types of cell stimulation that are really quite artificial whereas pollution is real, you go out side on a smoggy day and breathe in loads of it.

LB: What did you discover-what were your findings- and what is the significance of your results?

PP: What we found is that air pollution, being inhaled by the lungs- and certainly in our cell cultures- causes them to release chemicals that we know would otherwise drive asthma attacks, and the vitamin D added to these cultures can reduce some of these inflamatory chemicals. The significance is, if we can target these pathways, we can treat asthma, but also hopefully reduce the amount of asthma, hopefully with a relatively simple intervention of giving vitamin D or something very similar to vitamin D. The idea is to keep it nice and simple but effective.

So I look at lots of different types of vitanim D, because there are lots of different types, lots of different doses; you can get it from the sunlight and you can get it from your diet, and it’s probably very important which type you have. If you have the wrong type that might be quite dangerous. So I’m looking at two types, one which is precursor- which is like pre-vitamin D- and one which is the active form of vitamin D and comparing them and trying to really see if the lungs itself can decide what to do with the vitamin D. Vitamin D really helps your body to repair any damage and it’s very important that if we use it as a treatment we don’t overcome the bodys own way of responding to damage.

So therapies could involve either giving you back the type that normally circulates that most of are defficient in because we don’t get enough sunlight, or it could involve giving us the active form locally where we need it- but trying to tell that apart is a very important question. There are several other studies going on in our group looking at different forms and we will put all the results together hopefully in the next couple of years and get an answer.

LB: And what are the wider implications of your findings for the medical profession in general, perhaps in terms of developments in treatments that it might lead to?

PP: Well the beautiful thing about vitamin D is, if we can work on the correct form, it’s going to be a low cost treatment which would not just improve asthma; it’s really important in any immune disease but also with your bones, with your heart… Really, vitamin D is one of the key molocules, the key chemicals of the current century. Trying to understand it’s role and trying to work out what we can do about the fact we don’t get enough sunshine, and if we get too much sunshine well then get skin cancer- which isn’t great either.

LB: So it’s a fine balance. 

PP: Yes.

LB: What do you find particularly rewarding about being in both camps, seeing patients and researching, and what are the challenges? 

PP: So I think the beauty about being in both camps is you can do research that is really targeted at the disease. It’s very easy on the science side to research something that turns out to have no connection to the actual disease, just to be in… cloud cuckoo land! Whereas when you are a clinician and a scientist you can make sure that your research is directed at the patient and will have real benefit…You can imagine how, in five or ten years time, this is going to help your patient you saw in clinic yesterday.

Dr Nadia Micali: My research is mainly about eating disorders. The title of the research is the Incidence of eating disorders in the UK: findings from the UK General Practice Research Database.

Looking at this large database, which is representative of the UK population, the study finds that between 2000 and 2009 the number of new diagnoses of eating disorders increased across the UK. This is clearly very important and this might mean two things; on one hand it might mean more people develop eating disorders- some studies across the world have shown that eating disorders are increasing. It might also mean that general practitioners are better at diagnosing eating disorders in 2009 than they were in 2000.

The interesting thing about the study is that when we look at the break down of which eating disorders increase, the one that really increases for both males and females is called Eating Disorder Not Otherwise Specified. Basically, Eating Disorder Not Otherwise Specified is a clinical eating disorder; you need to have all the symptoms of anorexia, but one. Clearly, it is important that we recognise that those eating disorders are increasing in the UK as this will impact on our understanding, but also [indicate] whether we are providing enough services for people who might need them. My research might mean that we have to increase provision of more specialist services and know more about eating disorders than general psychiatric services. Often my greatest frustration in my scientific life is that I think, in general, the medical profession doesn’t take eating disorders seriously enough… People think eating disorders only affect a small number of people, infact, we found- and I think this is very important- about 3,500 girls are newly diagnosed in the UK every year. That is a huge amount.

LB:  And how are the numbers distributed between males and females, in terms of developing an eating disorder?

NM: Eating disorders are generally very gender patterned which means that females are at higher risk than males; overall it’s about 10:1, ten females to one male.

Dr Rod Mitchell: I’m Dr Rod Mitchell and we are interested in the effects of environmental chemicals on testicular development and reproductive health for the subsequent offspring.

The results of this study might have implications in terms of determining the potential health effects of exposure to paracetamol during pregnancy. We are particularly interested in the effects of paracetamol on the development of the testis in the fetus and so we have a model system where we can test the effects of these chemicals on testis development. In rats, if we expose the testis to paracetamol, we find a reduction in testosterone production and we are currently working on the effects of paracetamol in the human testis to see if these effects are also seen in humans.

So the model system that we use to check the effects is called a xenografting approach and involves getting human tissue from fetuses and grafting them into a host animal inorder for it to develop. During that period of development we can expose the tissue to various different potentially endocrine disrupting chemicals to determine the effects, and this gives us a huge advantage in terms of looking at the effects on human tissue rather than the previous research, which is largely focused on the effects in rodents, which we know are significantly different. I expect we will have an answer as to whether or not there is an effect on testosterone- which is the biggest question- in the next six months or so. Further work on the mechanisms behind how that happens will take a lot longer.

Dr Shelley Potter: My research is looking at the feasability of clinical trials in breast reconstruction. Breast cancer affects one in eight women and forty percent of women who are diagnosed will need a mastectomy. Different types of reconstruction are broadly implants which are inserted under the muscle [and are taken from] flaps from the back or flaps from the tummy. They all have slightly different risks and benefits. Having a mastectomy can have dramatic impact on peoples quality of life, and what women decide to have depends on what women want to gain from their breast reconstruction.

So I looked at how women make decisions for breast reconstruction, looked at the quality of the information available to women considering reconstruction, and how how their decisions were made. We also looked at the feasibility of doing clinical trails to gain high quality evidence in breast reconstruction.

I reviewed the literature and found that the literature was actually quite poor quality in terms of helping women decide what type fof breast reconstruction was right for them. I then spoke to patients and healthcare professionals about how they made decisions about breast reconstruction, what they thought of the quality of the information that was available and whether they would agree to participate in clinical trials. I found that once women had decided which type of reconstruction they wanted, they would be happy to be randomised within that type, which is really useful for us in terms of designing future trials to improve the quality of information for women thinking about surgery.

My research is leading on to a number of different projects. One of the projects called Bravo, is to develop a core outcomes set for breast reconstruction, which means that we get surgeons and patients together to decide on which outcomes of breast reconstruction are the most important, and will be measured in all future research and audit studies which will improve the quality of information to women in the future. We are also working towards a clinical trial comparing a new form of implant based reconstruction- which maybe better for patients- with the traditional implate based form of reconstruction. Information in this study [presented today] is the basis for that study.

LB: Where have you presented your research?

SP: It’s been presented all around the world, but this is the first proper academic meeting it’s been presented at rather than a surgical meeting, so it’s a slightly different emphasis

LB: For you, what are benefits of being a clinical researcher?

SP: I’m passionate about trying to make a difference. So for me that’s the benefit. Not only can I make a difference on an individual level to patients, managing them as I would clinically, through my research I can potentially make a difference to a much larger number of people and improve the outcomes.

Dr Rod Mitchell: I’m Dr Rod Mitchell and we are interested in the effects of environmental chemicals on testicular development and reproductive health for the subsequent offspring.

The results of this study might have implications in terms of determining the potential health effects of exposure to paracetamol during pregnancy. We are particularly interested in the effects of paracetamol on the development of the testis in the fetus and so we have a model system where we can test the effects of these chemicals on testis development. In rats, if we expose the testis to paracetamol, we find a reduction in testosterone production and we are currently working on the effects of paracetamol in the human testis to see if these effects are also seen in humans.

So the model system that we use to check the effects is called a xenografting approach and involves getting human tissue from fetuses and grafting them into a host animal inorder for it to develop. During that period of development we can expose the tissue to various different potentially endocrine disrupting chemicals to determine the effects, and this gives us a huge advantage in terms of looking at the effects on human tissue rather than the previous research, which is largely focused on the effects in rodents, which we know are significantly different. I expect we will have an answer as to whether or not there is an effect on testosterone- which is the biggest question- in the next six months or so. Further work on the mechanisms behind how that happens will take a lot longer.

LB: At the end of the room I’ve just spotted Dimitrios Siassakos and his poster is: Improving team training in acute healthcare: critical synthesis of seven mixed-methods studies.

Dr Dimitrios Siassakos: So we have been looking at ways to improve patient outcomes and patient experience during and after obstetric emergencies, using mixed methods studies to identify the characteristics of effective teams and leaders, and then use them in a comprehensive programme of training to improve that management.

LB: So what did your research show, what did you find?

DS: What we have found is that clinical training works in improving outcomes and patient experience, particularly if you conduct training using patient actresses to make it more realistic and to remind people that they have to communicate with the patient when you have an emergency.

LB: And what type of communication?

DS:  That’s exactly what we were interested in. So one of the seven mixed methods studies was looking at identifying what we have to say to patients during an emergency to improve patient experience. We found it doesnt have to be long episodes of communication where you try to explain everything, because often you don’t have enough time, it was just brief sentences explaining three or four simple things that are important to explain to the rest of the team. And sometimes, even if you didnt explain to the patient directly, as long as you kept the team informed by explaining everything loudly, the team functioned better and improved patients’ experience and also for their partner or the family that were present at the time. And actually one of the critiscisms is that expaining what is happening and what we are going to do is common sense, so it’s surprising that these behaviours are often missing from front line teams, and it’s so easy to address this with training.

LB: When did you start rolling out the training programmes?

DS: We have now been training for several years around the UK and around the world as well. Training in maternity has now actually been disseminated to most units in the UK, we started rolling the programme out about four or five years ago. In Africa we started last year, but we have been to other places, for example the United States we started in 2008/9, weve been to Australia, New Zealand, countries like Somalia, glamorous places like the Soloman Islands, Hong Kong, China… And as I said, it’s not just the programme of training, it’s the principles of training. For example in Zimbabwe, we are looking at the results now, but it already looks as if we can improve outcomes like maternal mortality- whether women die or not. So when we have the final analysis what we need to see is whether we can use the same model of training in other countries as well, but with differences. Obviously it is different how you train someone in the UK is different from how you train someone in the developing world, but there are some common characteristics: that you have to train in a realistic environment in a team, because when you are faced with an emergency you need to learn how to manage an emergency as a team.

LB: Did the inspiration for this project come from your experience as a practitioner?

DS: I’m a clinical academic so I work fifty percent of the time as a clinician and fifty percent in research. The advantage of being a clinician is that you identify problems as they happen; either from my own personal practice and experience or sometimes from national enquiries or from the media or analysis from within our own unit. If something goes wrong, we analyse it and see how we can improve it.

LB: What changes do you envisage happening in your clinician career related to research and how are you planning ahead to meet these?

DS: In terms of research, I think what is happening now increasingly is collaboration between different research teams across the UK and teams around the world. You have to get a team of experts; clinical experts, social scientists and approach the subject with mixed methods research, and it’s going really well so I’ll keep you posted and within a couple of years I will have an update on what is happening with that.

Dr Katherine Sleeman: My particular interest is dementia and I’m looking at where people with dementia die, over a ten-year time span, and looking at the factors that might be associated with dying in one place or another. I’m using a very large dataset including all deaths in England over a several year timespan

Most people in this country would prefer not to die in hospital, but the sad fact is that a very large proportion do die in hospital. So we need to work out: what is it that facilitates someone dying at home or in a hospice, and what are the factors that might actually precipitate hospital admission?

So I have been doing an analysis, which isn’t quite complete, of this large dataset looking at place of death and have identified a few factors that are associated with dying in one place rather than another. The next step will be to look at whether we can fix that; if one factor means patients are very very unlikely to die at home, is there a way of directing policy at that factor in order to improve those patients chance of dying at home.

LB: What types of factors have you looked at?

KS: The sort of factors I’ve looked at are personal factors like age of the patient, the sex of the patient, the marital status- which is really important in terms of social support. I’ve also looked at regional factors, so do patients live in an area which is deprived or affluent? Do the patients live in an area where there are lots of care home beds or very few care home beds? Do they live in rural areas or urban areas? Also, it’s really interesting to look at how trends are changing over time: if a certain factor influenced place of death in 2001, does it have the same influence in 2010, or has actually that melted away and something else has become more prominent? So there are three main sorts of factors that I am able to look at. A different type of research would be needed, as is needed, to really drill down after this on what is the quality of those deaths and what influences that?

LB: What do you find rewarding about being a clinician researcher?

KS: Combining clinical medicine with academic work is an extraordinary job, and my bottom line is, I love my job…I didn’t love my job when I was a clinician one hundred percent. It’s not for everyone though, I find it’s a really difficult job especially if you have kids, as I do. So I have three jobs to juggle; I’m trying to be an adequate mother, a good clinician and an exceptional researcher, and that’s an incredibly difficult balance! But it’s exceptionally rewarding and I adore my academic time and I feel extremely lucky to be employed to spend half my working hours on something that I find intellectually stimulating- I think that that’s very rare in a job, but I would have to say, it’s hard, you never put your work down, you never completely switch off from your academic work.

LB: The last person I’m going to speak to is Tosan Okoro and his research is: Does muscle inflammation influence recovery of muscle strength and function in patients undergoing total hip repalcement? So, what’s your research about?

Dr Tosan Okoro: The reseach is trying to understand the recovery process in muscle. We assume that because the hip is replaced and the pain goes away that everything is more or less ok. But we know that by the time the patient has the hip operation there’s inflammation, there’s pain, and if they have functional deficit they have reduced strength in their muscles… So we were trying to see if we can characterise what happens around that hip joint, but this is just a first step in the process of trying to get a better understanding of what actually happens around the hip joint itself during the recovery period after the operation.

This particular study is part of a larger study, so we were trying to see whether a home based exercise programme can improve muscle strength and function. So the patients that are part of the larger study comparing a home based exercise programme with standard physiotherapy to see which one promoted better strength and function. We know if people have low function they stay low function, so the objective is to get those people who have low function to get better function.

LB: And what are you findings, broadly speaking?

TO: We found that there is a relationship between the inflammation going down and the strength of the muscle before and after operation. There is also a trend, if you took the change from before the operation and six weeks afterwards. But in terms of statistics the [results] are not significant but there is a trend to correlation. So we don’t fully understand these mechanisms at the moment, so there’s more work that needs to be done in this particular area to understand it better.

LB: Offering some concluding thoughts on the day I caught up with Richard Horton, chief editor of the UK medical journal The Lancet. He started by explaining why The Lancet supports the Spring Meeting.

Richard Horton: I’ve been with the Academy since it was created in 1998. The Academy has made the most incredible influence in UK medicine in its very short life. But the Academy will only survive and thrive by the support and participation of all of its fellows. So as someone who’s part of the Academy, I want to see it do really well and The Lancet can be a platform for the work of the Academy and the science that it is supporting, to be transmitted and amplified worldwide. So that’s why I want to be involved with this, I want to take UK biomedical science, which is second to none in the world, and use The Lancet as a way of transmitting it.

Today’s Spring Meeting has been phenomenal. I think the quality, the depth and the breadth of the science has been absolutely superb. We’ve seen wonderful presentations, great posters, this shows UK biomedicine has the most incredible future, and we need to go out and tell the world about it, because it’s a great story about this country and we should be really proud of it.

So I think for all of the researchers who have come and presented today, first of all it’s a great discipline to come and present their work, have it critiqued and debated by their colleagues and more senior academics. Second, it’s an opportunity for them to network amongst each other. Science is now interdisciplinary, it depends upon teams- the days when a single scientist worked in a lab and got a Nobel prize are long over- and you need to create those opportunities for young people to network. So I think on those grounds that is why this kind of meeting is so important, face-to-face presentation, it’s been a great day.

I’d like to underline two points about the research because I think it shows us two particular strengths about UK biomedicine. The first is the fantastic range of universities that we have in ths country, and we are so lucky, we should never forget how fortunate we are. We have a wonderful, broad group of universities across the country that are doing world class science. These universities need to have government and public support, so at every opportunity we should celebrate their success. The second area where we are extremely lucky is, again, the depth and breadth of our funding organisations. In many counties, even in western Europe, we see a landscape where the funding of biomedical research isn’t so easy. We have fantastic funding, we have got hundreds of millions of pounds being invested in research. At this meeting there are well over fifty funders supporting this work. So I think we have a culture medium, so to speak, for research in the UK, again which is second to none, and that’s why we produce these great researchers.

What you’ve seen today is an incredibly diverse range of subjects across all medical specialties, but I think what typifies research today which is different from even ten years ago, is if you want to do really good research, you need to have multiple methods, multiple disciplines working together- whether it’s somebody who is a molecular biologist, with an imaging scientist, with a clinical- to do great work you have to have a mix of skills, and I think that is what has really come out today and why again, our universities and our NHS are such good culture media for that because they promote that inter-disciplinarity.

And I’ve got to say, the verdict on today is, ten out of ten!

LB: Well that concludes a very interesting and insightful day at the Spring Meeting, which has highlighted the interdisciplinary nature and the rich variety of research that trainee clinician academics are carrying out across the UK and their valuable contribution to UK biomedical science.

You can access a diverse range of podcasts of academic research via the Pod Academy website at www.podacademy.org

Pod Academy would like to thank all the contributors to this podcast.  Here is a list of the clinical researchers Lucy talked to, with links to their research:

 

Podcast produced by Lucy Bradley.

Photos by Charlotte Bromley Davenport for the Academy of Medical Sciences Spring Meeting, 2013.

 

 

 

 

 

 

 

 

 

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