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Good morning, everyone. Welcome to the uh research Collaborative East Anglia Clinical Research Day. Um I'd like to welcome you to Cambridge. It's a fantastic city if you've never been here. But if for all the online delegates, this is just a taster of what Cambridge can bring for you. Um including a very collegiate experience as well as a beautiful city. So welcome to the Orca Clinical Research Day, some slight delays and technical issues as we go along for the day today. And uh I'm Ignatius Lee, one of the trauma orthopedic registrars in east of England. So um we've chosen now, this event is entirely free for everyone internationally and we'll introduce the international delegates later on. But if you would like to support our chosen charity, which is the orthopedic Research UK, uh This is the link you can use and it's all over Twitter so you can support us as well. This is our third clinical Research Methodology day. It is the first one and only in the U K run by trainees for trainees and we will continue on next year as well. And now let's thank all the committee members that have tirelessly helped us throughout this journey and we have, we've had a lot of fun uh planning the day for you today. Thank you to our partners including Ortho Hub, British Orthopedic Training Association acumen who unfortunately cannot be here because of clinical commitments. Uh O P Medical. So Holly Park, thank you very much and medal for providing us with this platform for any other research day resources. You can go on to the east of England website, which is E O E O R two dot co dot UK forwards last research day for all the slides that are available from our last face to face um clinical Research day. It also gives you the link to um the good clinical practice. So final slide for me, if you have any technical issues online, if you're east of England trainee, please contact Hamad. Uh otherwise go onto the med support at metal dot org. There are some issues that I understand uh about verification and you don't need to be verified to come on to the platform. Um The program is all online. It should have been sent to you through a link. Otherwise there's a nice QR code for you to look at it housekeeping, there's no fire alarm. So if there is a fire alarm run towards the front of the building, the feedback form will be automated towards the end of the event. And if you haven't registered for the event, it will unfortunately not be able to automate the whole process to give you the certificate, the face to face program will be available for everyone at two o'clock at the seminar rooms, 12 and three, we will have this lecture theater uh have a renaming of by the clinical dean at three o'clock. So it's unfortunate data. We've coincide with everyone, the organ east of England, uh annual general meeting will happen at 4 30 we'll have drinks afterwards. And frankly, so I'd like to welcome all of you and I welcome our course chair, Mr Vickers can do to who's uh consultant in Cambridge. He's also the clinical lead for electives. He's the British Hip Society chair and amongst all his accolades, he is also the Hunt Arian, uh professor for 2021. I'd like to welcome Professor Vegas can do to, I think first of all, thank you very much A G and the whole ORCA team for actually getting this off the ground. A phenomenal amount of work uh done over the last six months to get this day. Uh and a lot of to and fro whether we're going to do it face to face, whether we're going to do it uh as a complete virtual event. And finally, we've got uh a hybrid event. So big, welcome to all of you who've taken the time to come face to face here and also to all the 350 who've registered internationally and over 100 of you who are online already. A warm welcome to all of you uh from Cambridge. So this is where all our delegates are coming from. I think the Sudanese, but we have to give it to Hassan. He's got the whole university and he's paying them some money to attend actually. So, so welcome all of you from, from Sudan as as as well. So over 10 countries uh we're partnering with the Singapore Training program as well. So welcome to all of you from Singapore, uh India and Myanmar as well. So a warm welcome. Now, why, why this day and why orthopedic research? If you just look at it from 18 57 and you put orthopedic research and look at the number of publications. Uh it's over two million uh publications that you'll have on public just for orthopedic research. So it's certainly becoming more of a necessity rather than the question of why do you want to do orthopedic research? And as you go along the day, you'll actually find out the reasons. But if you're just in it for a tick box exercise, that's what it does as well for you. So you really need a research methodology course as a part of your C C T requirement. So if you've done this today and your certificate, then you get that uh tick box as well to get your C C T. But more importantly, um if you look at all these uh trials that are being running in the UK Ashok? What is the one common denominator that you can find in all these trials? Multi center. Okay. What else? What are all these gathering data? Okay. So data is key. Really? Now if you look at uh what's been going on in economic times, uh data is your real new oil and that's what it's all about. Okay. If you've got data, you are king. So essentially all these trials, big trials, multi center trials. Yes. But what are the gathering, gathering data? And the second bit which is important in data is what come back to you? What what does all this data do for you? He thought I can do what? Okay. I'll take it off from you to Hassan. Hassan. Why is data important? Why is it becoming the oil for the next generation potentially guide us in our future money? If you can't measure it, you can't improve it and you can't report it. Basically. That's Lord Kelvin. Okay. So if you've got data, if you got measurements, that's the only way you're going to actually impact your patient's, that's the only way you're going to improve things. Okay? And that's why data is important. And the final bit uh to take away from here is in research. If you broadly open it up, then there are two important things. What's your research question? And that question will only come if you've got clinical experience. So do spend time in the operating theater, do spend time in the clinics because that's where you get your clinical questions because those are real world problems that you need to sort. And the second important it is for that important question. What research methodology are you going to use to answer that question? I think those are the two beds. If you get those two bits right, then your research project is going to be a flyer because you're gonna make an impact with answering an important clinical question which there exists in the clinical. And you're gonna use the right methodology to answer that question, which is what today is all about the right methodology and that's what we'll be going through. So on that note, be inspired, be inquisitive. If you're attending online, do drop in your questions online, we'll, we'll try and answer as many of them as possible. And B Inuit, if you've got ideas, then we've got fantastic faculty actually throughout the day, quiz them, get in touch with them over coffee and have a chat with them and get those questions answered. On that note, a big thank you again to the Oak A team and Iggy for getting this off the ground and to all our faculty have come from all around and Germany as well and we'll introduce you to them in a minute. Thank you and enjoy your day. Thanks. I spent quite a lot of time on this animation. So I'm just going to run it music or not sure. Anyway, welcome to. So we're at the University of Cambridge School Clinical Medicine. Um So allow me to, with great honor, allow me to invite our first international faculty and speaker, Dr Mustafa Sitar, who's associate professor at Endo Clinic in Hamburg. Thank you very much for joining us. If you've read the International Consensus Meeting for paraprosthetic joint infections, he's been part of it. So he's internationally renowned for prosthetic joint infections. And for those of you who have a keen interest, please do catch him or any research questions or any experience that you want at Endo Clinic in Hamburg. He's the C called Research grant committee chair as well and is with great honor to invite him on the stage. Thank you. Uh And that's why he's been invited uh network with. Thank you the cash for the invitation. Um It's a great honor for me to give a talk here in Cambridge. Uh I'm an automatic surgeon and it's for me. Also the first time talking about how to be a research influencer. I get the invitation, I think one month ago, I said of course, I will do it. But once I accepted it, I was thinking about what should I talk 30 minutes about how to be a research influencer. So the first question, what we have to answer, what is exactly an influenza a research influencer. So this is a very good example I think on the on the left hand side, you can see the sexiest doctor life. This is Doctor Mike. Uh he is very famous in the social media. And on the right hand side for me, the sexiest researcher life, this is jape are busy. So if you compare both the social media, the Instagram account, Doctor Mike has 4.4 million followers. J Parviz the only 6 650 but more interesting right now, you can see look at the apartment results, Doctor Mike has zero results, but J Parviz has 1000 hits. So we have to talk if you talk about what is exactly a research influencer, we have to divide between social media influencer like Doctor Mike, he's promoting himself. On the other sense side, we have to divide between a clinical practice changer. Jape are busy has published more than 500 articles only on infection in orthopedics. So he's changing clinical practice. So if you talk about influencing research, we have to divide between social media, self promoting guys and the guys, they can change clinical practice. He is also a friend of mine, Professor Might Bhandari from the mcmaster University and he's doing both. He's a clinical practice changer because he has published a lot of important articles also at New England Journal of Medicine Lancet and he's also influencer. He has at least uh a minimum 20 25,000 followers. He has much more than me of course, and he's using his own platform, the auto evidence I should recommend this. You can just sign up and you can see the most important articles just summarize in this uh platform. So um he, as I mentioned, he has published important articles and he has also almost 900 articles in palm it. This guy I found, I followed him. I don't know why, but this is a guy, Ben Rain. He's a phd. He has, if you, if you see his timeline development on part mitt, he increased his permitted uh since he get active, more active on Instagram, I think he motivated his himself and he increased his permitted. Of course, there's more than Instagram on social media. We have we cash. It's a screenshot from Vikash account. It's linked in and Twitter. He has also Instagram, but I think he's more active in linkedin and Twitter. Once I prepared this presentation, I made also a Twitter account, I will show you later why it is important to have a Twitter account. I have it since five days and because it was my first follower, I have now six followers. So uh we cash mentioned already. So um about the timeline and oughta peed IX and we have the same time, the same increasing in social media, in medicine. If you look, for example, in 2021 you have 9174 articles only on social media. And it's a quite huge number. So here's an article published by Vikash 2015 social media and orthopedics. He is from his article the some screenshots, well, media sermo, there's more and more and more applications, more, more websites platforms you can teach, you can upload your videos and your presentations. And also the social media use for orthopedics versions is increasing in the recent years. Once I prepare the presentation, I recognize there are so many platforms, I've never heard about it. So if you look at uh 2021 137 hits, only social media orthopedics. So the attention in social media use for orthopedic surgeons is increasing. So I asked me, I asked the question, can social media post affect academic citations and automatic research? I didn't expect a study but I found someone. So yeah, there's really a correlation between social media posts and academic citation. It's a positive correlation. And interestingly the use of social media defense among journals and authors. And this is important he the authors concluded which may represent opportunities to leverage social media platforms, to more effectively dissemination noble research findings. I think for you, for you, for the young colleagues, I think it's important to of course, to do research and to use social media platform. I started uh really early. So at this time, it was it was already beginning, but I was too late starting with social social media. That's the reason why I'm telling it to you. Now, if I would go back, I would do it differently. So then I heard the term l metric attention score. I would like to ask you in the audience. Have you ever heard the al metric attention? So if yes, please hand hands up. So two people maybe 5% of all. So I I asked the same question on Instagram because if you use Instagram, you can do the votings process. And uh my followers, I have around 800. Most of some our automatic surgeons or medical doctors and 50 percent have never heard the term metric attention score. So what is the metric attention score? We always see the donut with different colors. And the thing is if the number in the middle is higher and if you have more colors, it's better. Uh How do you say um receive more attention in social media? That's the reason you can see that the different colors of the donor, for example, Facebook linked in read it as a different color Pinterest. So if you have different platforms and if you have a better connection to people, you can increase your metric attention score. So here's an example from one of our studies which I have published together with J Parviz this resuming elective orthopedic surgery during the COVID COVID 19 pandemic. It's the group of the international consensus as international condenses group and I checked on the website, this is published in JPs American and you can see the button metrics. And if you put on the button metrics, you can see your personal or the metric attention score of this article. In this time, it was 81 you can see has only two or three colors. So it's uh had received, has received a lot of attention but not in all social media platforms. But if you look here, you can share your articles. And in J B J S American, every journal, as the author said already have different share ing processes for JBs American, you can share it with our mail, Facebook, Twitter or linked in. But some journals have different, for example, uh Mandalay or read it. So you can increase your social attention in those platforms. And there is also a positive association with citation rates of your articles if you increase your l metric attention score. And this is just recently published from a colleague of mine. He's uh he was a research fellow in a Rush University in Chicago and they looked for the type of articles and technique articles receiving more attention than original article. This has been just published. I think two days ago, I saw this article on Instagram by the way, that's the reason why I put it here inside. So how to be a research influence. I have to talk about this. I think the best thing is to have a mix between Doctor Mike and Jape are busy on the one hand, you have a lot of followers and you do a good research. So you can publish a lot and then you will have, if you have both of them, you will have high metric score and you have a nice donut. So how to be a research influencer? First of all, we are um orthopedic surgeon. So if you want to have more attentions or the orthopedic community, uh here's an articles or what uh platforms are using orthopedic surgeons, Facebook, Twitter, youtube, I think it also differs from country to country. I think in Germany, it's more famous Instagram right now if Facebook was many years ago, but now it's Instagram. But if you go to, for example, Australia, I think more common is uh Facebook and I'm not sure what is more popular in UK, I think uh Twitter or Facebook. I don't know, but you have to tell me. But if you, if you see what content of uh those profiles, 22% posting publications or outer ships. Here's an article, social media for orthopedic surgeons published in American Academic of orthopedic surgeons. Now, October 2010 chef, I gave already 10 tips for getting started in social media. I didn't see this at this time. I saw it like uh last week. Uh I did it, I have my own way. That's the reason why I want to talk today about my story. My story is because maybe not everyone knows me, I just want to show you, share you my C V during my steps of my career. And I started my career in medical school, Unova, I'm uh did my uh university in the University of Leipzig is East Germany. And I did my doctorate easy uh with my brother. So I was lucky I had an older brother. He's uh many years ago, he became the professorship and he, I did my doctorate ease with him. So I grew up with him. I did my research with him. I had my first meeting with him in my younger age and this gave me the motivation to do more. So I was really early starting at 2005. It's like 17 years ago, I started doing research. So I recognize very early my English is not so good. So I have to do an into international fellowship. So my brother organized me a fellowship in 2008. Uh I finished my medical school in 2007, November and my first position was a research fellow at H S S. So I went to uh I worked with Dr Andrew Pearl 2008 and with it uh good studies about the robotic surgery like the ecosystem, which is getting more popular right now also in Europe. And I was one of the first guys doing those research with cadaver uh looking at the accuracy. And I met him last year in New York. I uh did a, again, a research fellowship not like in a different way with J Parviz in uh Philadelphia. And I just visited uh Andrew Pearl uh to, to, to have your collaboration. This is very important. I will go back to this during my fellowship. I also met Professor Daniel Kendo off. He's right now the surgeon in chief in Berlin. Uh he's uh my mentor also in research. And I remember my first case report was in a chair at H S S. It was a case report. I worked three weeks on it and I get everything back, everything was red. So I said like, okay, I can never do it but don't give up, you have to learn it by time, you cannot do research, you cannot right uh perfectly at the first if you start with the papers. So during my stay in the hospital for search the surgery, I went back in 2011. Again, for six months, I worked how to make a study, how to do like clinical studies, how to do experimental studies, how to do biomechanical studies. And again, I was at this time very, very young. Okay, I'm still young, but at this time, I was much younger. And if you look, that's the reason why I'm saying collaboration is very, very important, I suppose 2008 H S S and you can see on the timeline I have published 18 papers together with Andrew people. But over the years, I didn't stop the contact. So keep focusing on your collaboration. This is very important is because said already we are offering our fellowships at Endo Clinic. And I will show also our fellows later on on the next slides. Then I did my uh residency program in the trauma center and the University Hospital, Batman side boom. This is Germany's most important trauma center. And uh I was there, I did my residency program and I did my phd Deasy's. I published only I say only 45 papers at this time because I was not really experienced. Uh Then during this time, I did a rotation because Germany is a residency program, orthopedic and trauma. So I'd have to do one year ought to be residency at Endo Clinic was 2012. And this one year I published 23 papers together with this team. So I recognize this is a specialized hospital. They have a lot of data. So, but no one is interested in really in research. That's, that's most important you will see on the next slide. So that's the reason I went back to Endo Clinic, November 15, 2016, like uh 5.5, almost six years ago in November this year. And I had a new mission on the one hand, consult orthopedic surgeons. On the other hand, the director of the research department, Endo Clinic for just a short summary, Endo Clinic was founded in 1976 by Professor Buchholz. And uh this is Europe's largest arthroplasty center and we are doing around 8 to 9000 arthroplasty cases a year. And our specific is the one state Septic Exchange. Uh And uh it's a world famous hospital. It was uh the building was like this before and changed. It's it's growing. But if you'll see on the timeline on permit, you see what the whole year is. 1918 1987 from 2, 2016, they have published 158 papers. But if you see uh the last year's 86 papers in five years, so what has been changed because I arrived at this time, how can we further improve research productivity? This is important. I think if you start with research, you have to think about how can we improve the research? What has been changed? How can be uh Mexican? And I recognize that this time I arrived as a director of the research department. We are doing 8000 years a year uh per year, 8000 cases. But the research team two month, two men show. So there's a mismatch. So what what I'm thinking about? OK, if I work alone, of course, I can write all the papers, but I can write maybe 10 papers a year. So we need a team, but it's not easy to create a team if you come to the hospital. And this is not specialized in research. You have to teach the patient, the colleagues. So I I introduced our fellows, our residents to uh to have a similarity between the research team and the data because uh because was already talking about the data, we have data but no one can use it. So I tried to create research teams. Be with the senior resident as weak as I said, already sent, senior resident is for the ideas and the junior resident is the supporting guy. So I divided different teams. So what, what is our specific gi said at one stage? So who was interested in one stage? So I put the teams together, which we had ideas and we talked about together, how can we find a result for this question, for this research question? So what we did, we did research meetings, we did journal clubs every month. The group was still increasing, increasing, increasing. And uh we had a team at the end, we had a team working all together with residents international fellows and we had a bigger success because it's easier if you work with the team instead of working alone. So then we had uh pandemic, what we did, we did online courses for residents because some residents uh I don't know how to use permit. And if you have to work with those guys, you have to teach them, you cannot tell this is the idea. Please write the paper, you have to be, you have to teach them, you have to answer the questions. And this is important also for the senior guys, how to teach the junior guys and how to motivate the guys uh for, for doing research. So we had a study, uh nurses. We I activated two more at the beginning. I had only one. So I said, okay, I don't need a big team. It's better if you have an organized team than working 10 people, but no one knows who's doing anything. So it's better a group of three people, but everyone is organized and every, everyone is doing different jobs. As we catch said, already, I became the fellowship director in 2018. So I said, okay, we have fellows but uh usually the fellows are not doing research. So I said, if you are interested, you can join our research meetings and you can see we have fellows from all over the world. We have uh I will show you later on the map our connections through our social media platform. And this is just one month or two months ago, the group of research or international fellows is increasing the picture on the left hand side was supposed during the surgery, they can scrub in, in the surgeries, they can learn our techniques and afterwards they join the library. I uh we had at the beginning, we had the library from the beginning on but no one was using the library. So uh the international fellows going after the uh surgeries, they went to the library doing research. And every 22 weeks or one month, we are doing uh dinner together with the international fellows to not to talk about research just to bake a better team spirit. So still the the colleagues left our hospital already, but we are doing routinely our Zoom meetings, talking about um current standings of the projects. As you can see, we have fellows from New Zealand. We have saint fellows from Saudi Arabia, uh Spain, Italy and Portugal. And of course, Turkey. So I also introduced our research fellowship sponsored by link. Uh six months, usually can also apply for this. I think the next will start in January next year. So they, they have an apartment because uh in Hamburg, the apartment is very, very expensive so you can stay in the apartment and uh you can, you can use this fellowship to do to do to do our research. Here's an example, Doctor A Kaya from Ankara. He was the second international research fellow from sponsored by link. And uh I think right now, he has published 10 articles, I think five or five or eight are still coming. So it will publish in six months, around 15 to 20 articles. This is quite a good number. Um Ignacio told already I was part of the International Consensus Meeting and this is one of my important steps of my career. I was first uh liaison in 2013 in the first international consensus meeting. Here's the picture from 2018 from the second. Uh and uh I had a knee injury but I flew to Philadelphia because for me, it was important to be, to be present at this meeting. And uh through this international consensus meeting, I had more contact to colleagues from all over the world. And I visited uh the Roman Research Department last year in November. Uh I stayed for a week there and to see how the research department of Jape are busy is working and uh he had, he has a very good structure. Uh He has a lot of people uh working for him with him and everyone is really motivated and it's inspiring. I can recommend to, to to do a fellowship also in his department. So I'm a university teacher also from uh university in Boho. My included also to increase our research productivity, our medical student. And right now we have, I have 50 American students working on research projects. So that's the reason why I could increase the number of the uh the publications at Endo Clinic. One more time. Collaboration is important. Here's a picture with no it Bhandari. I met him first time face to face in Oman 2019 before I know him only for er Instagram for social media. We met together and we had a nice uh talk. Uh It was really nice to meet him in person. And we have a lot of collaboration and I say one more time, collaboration is important to increase your attention, build wide and to increase your um research productivity. Another important thing is follow your ideas. So this is an example. I just published my own classification last year. It's a seat, a classification. I just want to show you how it happens. So the first idea was because we are doing the rotating hinge implants and we are seeing of course, a septic loosening. So we did a case control study comparing the uh septic loosening cases where it was uh not loosening cases. And we identified in the first uh the first results that 85% had an isolated um loosening of the femoral component. And the fellow said to me, okay, it's a very good result. I said yes, but it's, it's because we didn't expect us, we expect that we have a higher rate of loosening from the tibial component component. So I said, okay, maybe we should look on the x rays. There has to be something and we identified really uh additional risk factor. If you have a wider canal of the femur, you have a higher risk of the cemented prosthesis. So we brought those papers has, has been published in JBs American. And I said to the fellow, hey, we have to make a classification because I'm not sure if the guy from Germany, the tour guys are similar to the small guys maybe from Turkey. So they said we have to divide, we have to define an index. Then we defined an index. We found three different types. And what I want to show you follow your ideas from one idea. You have to find another idea. Don't stop with the first paper, I'm sure in every paper you can create the next paper. So right now we have future plans. We are trying databank, We were talking about data. Uh We do not have a data bank, but we are working on it right now. We are start, we have started with a further fellowship program with the I C M fellowship. Here's a picture on his first day from Doctor Mean JD from Sydney. And uh further collaboration is also important and you can see now the apartment hits uh from uh Endo Clinic. Last year, we had 43 papers for Endo Clinic, which is a quite good number because we are not the university hospital. And if you put Endo Clinic, Hamburg and see tax since I'm there, I have published together with Endo Clinic, 41% of all publications from Endo Clinic. And this is I think in five years or six years. If you include my rotation time, it's six years, 41% it's not a good uh it's a good number I think, but it's not only my work, my work was only to create a team. And if you have a great team. You can publish more. I'm sure we, we started now we will increase this number. We will, we have already this year 23 papers. If we publish further, we will have this year more papers than last year. But you just need a system, you just need a team, then you can increase your permitted. I want to show you why influencing because we are talking about influencing one state septic exchange. They are doing a dental clinic since 1970 but they of course, it's only one surgery but the people are doing not doing it worldwide because why, what is the reason there are no results? So I started to work on this topic with the one state Septic exchange. We have increased our publication numbers and uh 58% of all one stage articles. I was part of it. And the good thing is right now worldwide. Even in North America, the attention and the use of one state septic exchange has received more attention in recent years. I think it will be the golden standard in the future and we are working for it because it's only one surgery. And if you compare the results, we have similar results in functional and eradication rate. Why we should do the two states Septic Exchange? Of course, you cannot do it in every patient. But I'm sure that this attention will increase worldwide. We have a lot of fellows also senior for us they are just coming for one week to see this procedure. But this is only related to our articles by, by, by the people can see it because they can use much more easy social media before like 50 years, 20 years ago, it was not so easy. Like, like now we have different platforms. You can see the the part methods and it's getting more attention and attention. So here's my social media account. I have 835 followers. So I'm not a research influencer, but I started this account last year in December and I tried to do it more professional. I would, I wouldn't say it's professional, but I tried to be a professional. So what I'm posting is usually of my articles and I'm using the same layout. I think it's important. It makes more attractive because if you just put the title page, it's not attractive if you do it like this. I for personally, this is for me, if I see this, it's more attractive than a normal title page. I'm doing it always like the same system just cutting the title with the names on it, with the journal, just uh short summary or the the abstract with two images. Uh And then below I right, uh the abstract, the most important findings. And I think I used, I try, I use both Instagram and Facebook. And for me personally, that's the reason why I said it differs from different country to country Instagram, I have more likes if I put the same post on Instagram compared to Facebook. Because most of the Facebook colleagues of my are not really doctors', I think because the doctors are using in Germany or worldwide, I think more Instagram. So why is social media important? We have a lot of collaboration with colleagues I mentioned already uh I met Mohit Bhandari, we have together to papers right now. We have uh we are working on trials right now. I met uh Mister send the forties from New Zealand. He was actually also here in UK. We have published 12 papers together. I have uh through social media connections to Iran to diverse other colleagues from Turkey, Spain, Italy, Argentina. So and here's the map, almost world wife we have through social media collaboration with research. So I mentioned at the beginning, what is the old metric attention score? Uh Now everyone knows here uh what is the metric attention score? I just compared my publications from 2009. Uh At this time that metric score is was zero. Of course, there was uh metric attention scores I think through since 2012, uh I have another example, I published 2015 paper at B J J which is quite good journal has a high impact but only impact metrics score of one then uh through the years 2017, 2019, I could also increase my metric attention score. And uh the paper from 2019 is a top cited research uh for me for personally. Uh and we could also increase uh still increasing the number of metric attention score. The last paper from 2022 has a metric attention score of 260 which is quite good. So as one more time, if you have a higher metric attention score, you have also higher citation rates. I think we have to mix both. As I mentioned, you have, we need a social media account, maybe professional and doing good research because not every good you have to publish first in a good journal to increase your metric attention because this is also important topic. Um I'm uh founder also from research anchor publishing. It's um uh we try to help younger colleagues uh to teach them how to do research. We have our own website. If you put research ankle publishing, you can find it. We have also our um youtube channel and also our Instagram account. And I did already um uh podcast together with Mohit Bhandari uh presenting our company. We want to try, we want to help remote, to motivate young colleagues how to do research and support them. And my take home message is the social media use in orthopedics is increasing. And uh the thing is what I showed at the beginning. If you are self promoting, it doesn't mean you have a high quality research. So you should do both. Uh So the best thing is the mix of social media presence and to try to change, change in clinical practice through your research work and important collaboration, collaboration, collaboration, follow your ideas and have a vision. And uh I think those guys are the sexiest researchers alive. Thank you so much. That's great. Any questions from the floor? Yeah, thanks very much. And I'm one of the twenties uh locally and my biggest problem so far has been trying to actually get things published. Say, for example, the last thing I actually submitted the feedback that I got said English is quite clearly not the authors first language because that's the English together. Mhm Yes, I'm not publicly, you know, private school educated but I didn't speak. I think it's a very, very good question. I think uh I'm also ready of very high impact journals and uh the high impact journals are really blinded, but uh some journals are not really blinded. And if you see the topic you can see from which part of the hospital from which uh institution the work is coming. And I think there's some bias to be honest. And uh we have the same. We have uh we have also like a native speaker, I'm not a native speaker, but we have a lot of colleagues, fellows uh proof reading our articles that we are receiving sometimes also the same like the uh you need a native speaker but it has done, it has been done already. But I think it's for the, for the rivers, it's the most easiest thing to if they cannot find anything, they just say, yeah, they don't like it. But the best thing what you can do is if you get a rejection, sometimes they are really good comments. Sometimes they are really good how to, how you can improve your research. You should implement those um recommendations, but you should submit to another journal. And we have the same way. I have not a 100% acceptance rate, JVS American for me, for example, it's not like it's maybe 60% which is quite good. But I know which journal, this is the most important thing. You have to select the adequate journal because this is what you what you can learn over the years with your experience. Sometimes the colleagues, I mean, the colleagues are always asking me which journal should I submit it? I said, OK, should I submit it to journal part of North journal? But we have no chance. But if you have time, you can try, but I'm sure they will reject it. So you have to define the correct journal. I think this is very important and you can learn this over time because um JBs American, I know which journals they like because for example, I published our new um clinical like with with risk factors, the risk factor, they like those studies like clinical relevant studies. But of course, every journal like this but the other journalists just want to publish, I'm never publishing in open access journals. Uh I don't like it because uh I think uh I have, I have open access journals but maybe the number is 5% maximum. Uh I do not use it because open excess because you have to pay money. And if you have a lot of open access journals, it makes maybe a different, you know, if the people would say, oh, this guy is only publishing an open access journals. So if you have rejection, implement your psa the suggestions, good suggestions and tried another journal, you have no other chance unfortunately, but you obviously want impact factor five plus journals, right? The fact of the matter is that their acceptance rate is anything between 9 to 16% most of these impact factor five plus journals. So you start there get the best review of comments apart from the English one obviously uh and then submitted to a three plus impact factor journals. And then if they reject it, then there is a 1.5 impact factor journal and that's how you start. All of us have done it that way. If you chart out on pub med are impact factors when we started off and where, where we are now, it's slowly improves over time and and then you know what journal will accept which article and then you pitch it appropriately. Mark. You've got a point that uh language is not English say construction of the arguments that are made and it is critical to have proper supervisory. So it's so making awful. I need to just like a doughnut. Okay. That is not the way to do research. You actually have, you have to get your um your senior office to be properly engaged. So they understand what's involved for you uh to put the article through to submission and without proper senior input, I think it becomes much more challenging. So my advice is to if you get rejection, get onto the soup, get onto this need authors and, and say, can we go through this? These are the points, these are the specific issues that were raised. What are the issues in the arguments that we're not making clearly enough and then have another go once you're on with that. And of course, the review of comments, which is critical because, you know, it's very common to submit to, you know, to shoot high as it were in the hope that although they rejected, you actually get some goods kind of scientific points and some good obvious um critiques out there so that you can address them. And the other point about getting people who you work with but aren't directly involved in the project to read it to say. So you get a second sense check on it. It was also very important. A quick question from our online audience. Omar one of our registrars, he's asked how much time is provided for residents for research, work within their working work, working week. That's a good question. I mean, you have to do a research uh in your private time, not during working time. That's important. You cannot most important if you work in the hospital, it's patient care. This is the most important step is mine. You cannot say I'm doing research. I'm not looking at patient's, you have to finish your work first. And if you work longer, you can reach your goals earlier. But if you work only like half an hour a day after your normal work, you need, of course more. I mean, I remember my time once I was a resident, I worked, I think every day also at weekend, at least half an hour, but I worked every day since 2005. I'm doing it also on vacation. Um Maybe I'm not the best example. I think that era of, of uh doing research and burning the midnight oil for all of us who are clinicians is probably gone. You cannot, I know, I know with this young generation, I know that's what I'm saying. But that's, that's a bad example. That's, yeah, that's what I'm saying. But I mean, but if you work, I mean, for, for us, for example, our endo clinic, we do not have like a research day. So you have to do your work and then you have to do your research work afterwards. Of course, you can do it at midnight. But as Vica said, the young generation, they live at 3 34 o'clock and that's it. But that's a good, an important question and important point. But again, patient care is the most important thing. If you work in a hospital, you cannot leave the patient and do your research. That's not a good way and you shouldn't do it. Thank you. Okay. Any more questions? Thank you very much. Thank you on that note. Um I think we need an orthopedic surgeon to be on tiktok or Love Island for international speakers, international audience. If you don't know what tiktok, tiktok or violinist, uh don't um our next two speakers uh they represent uh British Orthopaedic Association. So I just have to do a shameless um advertising. If you haven't signed up, we want to promote sustainability. So nothing today is printed. Everything's online, all the certificates, feedback forms, all online. Thanks to Medal and Balta is doing sustainability and orthopedic surgery. Next Friday as a virtual conference together with Southwest London Elective orthopedic Conference Center. So join us. Uh next up, a dear friend of mine, Mr Abin Acing. He's currently a phd student at Oxford. He's got dedicated time to do research to do that. And he's also the Boater academic rep who's going to talk about collaboration. So it's flows seamlessly. So as professor Xavier Griffin. Uh Most of which from the UK will know him from Queen Mary. He's unable to join his face to face. Uh He's currently presenting from Zoom. So, hello. Hey, can you hear me guys? Yes, great. So I was fantastic. I'll let them take over. Great. Yeah, so bear with us. Um So thank you very much for your kind invitation to Iggy Mr Khadija and east of England Beanery. Um So as you've heard, Professor Griffin's, obviously the professor at Queen Mary's, he is the chief investigator for a number of very impactful trials such as White Wax Fame a lot more. Um And me, I'm one of the registrars and the Imperial rotation um currently doing my phd at Oxford and also look after Boater. So, what we'll do is um we will, we've sort of engineered this talk around four key things about collaborative research and it's things that I wish I had known as a junior uh when I was starting out. Um And we will take questions at the end of each of the sections. So the first bit is Professor Griffin. Then we'll take some questions on that than me, than him, than me again. And then I'll just hopefully showcase uh some of the voter things right towards the end uh and finishing at 10 30. So uh prof you ready? Yeah, I'm good. Can you see the first side? Yeah, I can see the first slide. Thanks so much. Abby and it's wonderful to be here with everyone. I'm really sorry, I can't join you. I, I like our previous speaker do have to occasionally reduced in clinical research. Uh Sorry, some clinical work as well as my clinical research. So, um I've got a list today. Just, just getting going. Um So I thought I'd just kick off with a little brief about what we're trying to get over to you today. Um And that's really too big take home. Message is uh first is a co production with patient's, which I think is absolutely crucial if you're gonna be serious about doing research that really lands. And uh the second is working in big collaborative teams, which is something that we're trying to do down here in bars and I think speaks well to, to the organization that are in the audience there, but also online. Um And we're going to try and explain how you can get involved and uh he's going to speak to that little bit as well and a little bit around what we're up to bone joint health down at Bart's. So perhaps if the A B team could share my, share my zoo feed and I'll take you through a couple of those points. So the first thing I really want to speak about is why, why are we interested in doing this? Why is collaboration and patient coproduction really that important? Well, it's because of these factors really. And I'm just going to blow that up so you can all see it uh in the audience. Um I really, really think that the kind of work that we're doing in trauma orthopedics in the UK is exceptional and world leading. Um There were other groups particularly the Canadians that stole the march on us in the late 20th century. But in the last 20 years, I think they've all been eclipsed and that really goes down to all the giants on whose shoulders all of us talking today and listening today are standing and these are the aspects on the slide here that you can see and read that mean that what we're doing in the UK eclipses anything else in the world. And that is why we're hitting the big four journals routinely and why orthopedics is year on year improving in terms of its ability to influence worldwide clinical practice through research. Now, I know Vikas has already spoken a little bit to say, how do we get this done? And the reality is we get it done by working in big teams. Um No one is doing research nowadays in small single institution teams that is yielding the kind of impact that we're seeking to achieve. So these are some of the teams that I've been involved in. You can see the logos there. That's my personal experience. But the important thing that I want to get across to everyone out there today is don't think that you're going to be successful or change anyone's care, which ultimately is why we're doing research unless you're participating in a big team. Now, you already, you know, you're the converted because here you are in the, in the orca audience. Um But you need to work with that collaborative and you need to work with mentors in and around your environment to get access to these teams. So became a university, obviously other universities in East Anglia uh Specialist Societies, botha and we're gonna try and highlight some of those things today, but, but, but please try and work in big collaborative teams because you're yield a much better product. And part of that team sat alongside, you should be the patient's that you are going to try and improve the care of for their future patient's in time. And my experience is that in fact, you can really only do top quality research and get the question, just write if you involve patient's in all of the phases, right? From the word go in the initial design and application for funding. So we've broken the area to four talks. Um And the first sort of particular thing that I want to talk about now is research questions. Now, this is the sort of basics, but I'm aware that lots of people in the audience will be at different stages. So we're just going to talk through this in a little bit more detail. Um This is a research question. It's really research question where we're interested in comparing two treatments, you might have a slightly different research question structure. If you're interested in risk factor analysis, you know what factors about patient's and their environment predict whether or not they develop arthritis. For example, is a different type of research question. This one is really focused on comparing two different treatments which is often interesting for us as orthopedic surgeon. So participants, what do we mean by the participants? That is essentially a definition of all the factors that are important about the people that you want to enter into your study is so called description of the sample or the population, the broader group of people whom your study is representing, and this is often expressed as a list of eligibility criteria. You may have come across that in the, in the journals. And typically we break it down into factors that you need to have to be included inclusion criteria and factors that you can't have and for which you would be excluded. So you have inclusion criteria, exclusion criteria and taken together, they describe the population of patient's. Now, one of the things I just pick up on there is this research question is what we're doing at the beginning of our study. And it is how we are determining who is eligible. But if we're doing a prospective study, there is the additional layer of who consents to enter the study and which patient's are approached by the surgeons. So the eligibility criteria in the study report are of less interest arguably then actually who did get included. And that is best found in the descriptive table of the participants often called table one in most of the big journals and and in J B G S B J J etcetera. Table one characteristics of the participants um more helpful when you're interpreting the study and to the degree to which it can be generalized. The second or obvious interventions and controls, those are description of the two groups. Um And typically in orthopedics, we've usually got a control arm which is the standard of care, but that's not always the case. And and there is a whole kind of research area around how you specify controls, particularly placebo trials, which is quite interesting in, in uh in the orthopedic and other surgical literature where we have special challenges uh compared to the drug literature. Now, the intervention and control groups need to be specified well enough that you believe that the treatment that those patients are receiving is something a little bit like the treatment that you might give in practice. And I think thankfully gone to the days where we think that orthopedic surgeons are magicians that work in isolations with no support from other allied health professionals and nurses. So the reality is you need to be describing everything about that treatment pathway from pre operative assessment through the treatment. The anesthesia, the perioperative care and the rehabilitation. And unless you describe that fully, I don't think that you can properly generalize it. And so this should be quite a bulky description. Um And it's very important for people when they read the paper, which is essentially a statement of research, question the methods that they can interpret it in light of their practice. And then finally, outcomes and I'm going to talk a little bit more in detail about the outcomes. But to my mind, this is one of the crucial areas where patient's really have to have their voice heard loud and clearly. And there's one or two different strategies that we'll talk about later on about how we bring the patient voice into selecting the outcome. If you select the wrong outcome and you find there's no difference, but it wasn't an outcome that was really relevant to, to the patient's that we're trying to treat to what extent has that research really yielded any useful information? So the selection of the outcome is absolutely crucial in determining whether your question yields a result that is meaningful to clinical practice and the patient's that we care for. And that is where I would really invest the effort in PPI initiatives and in work, other work to bring in patient voices. Okay. So that brings me to the end of our sort of 1st 1st slot. And I think we're going to try and take some questions to break it up a little bit. So perhaps I can go to Abby who will just have a little uh feeling of the questions either for himself or for me. If there's anything from the audience or online, any questions at all. Yeah, sure. Go ahead. Uh Oh, sorry, it's going to come to you. Thank you. Hi, thanks very much. Uh My question is, do you have any tips to selecting patient's for involvement? Said the risk of getting people who've got a specific acts to grind might be particularly keen to be involved with some studies. For example, people who have had specific problems have got a particular interest and that could skew your outcomes that you generate from your involvement with patient's. So I think that's a great question. Um So thank you for that. The I would say two things. First of all, we, we are, we're going to speak a little bit about NIH are and kind of configuring our relationship as researchers with key funders and NIH are have quite clear advice about involving patient's. And so there is the involved advice which is really about bringing patient's into a sort of co production environment. And then there's a include advice and I think it's gonna, speaking of that, so I won't steal his thunder. But the include advice is about how we include appropriately generalize a ble populations in our research. So I think this speaks mostly to the involved advice and the involved advice is both around patient's and members of the public. So you need not exclusively involve just people have experienced your condition of interest because I hear you're, I hear your concern that if somebody develops an infection after an arthroplasty, then they're gonna be extremely concerned about infection. Um And your question may not be configured around that. However, there's a valid experience that needs to be taken into the mix. And so I think what we, what I try and do is I try and get a broad uh consensus view from a relatively large group of patient's and their carers, relatives, you know, parents, depending upon what age group you're working with and focus that down to one or two uh co applicants who are patient's themselves. And that way you can, you can legitimately argue that you have brought in multiple voices and that therefore, the experience that you're reporting is reflective of wider patient experience. If you just involve one or two people, you do run the risk that the project is, is not reflective of the wider experience. Uh That's excellent first session just for our international audience and for some of our trainees who are just getting into research. Could you take us through a PICO example uh that you've done for one of your studies? Uh So that we've got all those four Asthams or I can, I can give you a scenario. Okay. You want, do you want me to give you, you tell me you're gonna, you're gonna hit me up with a scenario or shall I tell you one that I've done before? Let's, let's hit you with a scenario, right? Put me on the spot. Do it. Exactly. So, so hip arthroscopy clinic on a Friday morning, you face with 30% of the patient's who've got mental health issues and we really want to do a study on how does mental health affect outcomes in operative intervention in these patient's? How, how do I go about it with the speaker? Ok, great question. Um So that's, that's a really nice example of how there are different study designs and different types of research question depending upon are kind of lay summary of the problem, which, which because presented very nicely. So my understanding there because is we're not asking a question about two different treatments. What we're trying to understand is how we best select patient's that are going to do well or identify patients are gonna do poorly with an intervention that we might offer. Um So that is really a prognostic problem or a observation I'll study typically. So they're, what we're interested in is again participants and outcomes. But instead of interventions were interested in something that the uh the epidemiologists were called exposures and by exposures, what we're saying is something about the patient or something about the environment or some combination of all those factors taken together that predicts the outcome. So they're, what I say is um in Vikas Clinic. So, Vikas, do you treat adults and Children? Uh adolescents and adults? No Children? Okay. So let's say let's say in adolescents and Children, people over the age of 14. Yeah. Yeah. Um attending secondary care for a consultation with a highly expert, young adult hits surgeon. I like that. I like that. Do you like that bit? Uh Now the question is, do we want to refine this down? So here's, here's a nice problem. Do you want to say everyone in the clinic with hip pain or do we want to say everyone in the clinic with hip pain and a specific diagnosis? What you're feeling? Because what's the clinical truth on that? I think the clinical truth would be narrow down the diagnosis because it'll become easier for outcomes. So let's say patient's in that age group with fe Okay, great. So people over the age of 14, they've got femoroacetabular impingement proven on say a CT or let's say cross sexual imaging, right? Because most people have some sort of cross sexual imaging that shows their pincer or their bump and they're in the clinic for consideration of arthroscopy. Um So that's quite tight definition. Now, we, I think we're all clear the kind of patient we're talking about and then the exposures of interest might be factors about the patient, which is generic ones like these things should be known, predictors of outcome. So I'm not going to pretend to know, but I'm gonna guess age is pretty predictive of outcome, arthur arthur arthroscopy, maybe sex. That's a very common predictor, baseline functional status. So something like an Oxford hip school or a Womack um and then on top of that, you add your exposures that we're particularly interested in. So we add in some kind of characterization of their mental health uh concerns so that can be done with very super score ing systems or you might just say something like a very specific diagnosis or range of diagnosis. What do you think? Because what would be the important predictors of outcome, independent of everything else that we should include? And what would be be a good way of bringing together the patient's that you see with these mental health issues that you're concerned by? Yeah, so I think the known predictors which have been published widely would be the grade of articular cartilage injury at arthroscopy. Obviously a pre operative article cartilage injury status at MRI age. You correctly pointed out any evidence of rotational abnormalities, hyper laxity, all these unknown predictors that you'll have in that algorithm anyway, and then independently you would want to assess mental health. And like you said, there's there's a few schools actually because we're doing a little bit of work around mental health in trauma. There are quite a few scores that can be used in primary secondary settings which are not specific to experts. So neither of us are a, an expert about mental health, but we see actually doing, doing a musculoskeletal clinic, a lot of people coming through your clinic do have recognize mental health disease, one type or another. So, uh there are scores that you can use to, to identify as a screening tool which we could then incorporate into our practice and, and do this study. Okay. So that's the all the exposures and then the outcome are interested in. What do you mean? Just explain to us what do you mean? Because by poor outcome, so core out what that looks like to me. Yeah. So court outcome and young adult hip surgery would probably be defined uh the primary outcome measure we use. So most things would be the whole 12, which is the specific hip outcome score for young adults, which is what we use for our registry as well. So that will be the court outcome measure and then you'll have secondary outcome measures. So, but primary outcome measure would be the 12 and, and just tell us. Um, so this is a field that I'm not familiar with. Just tell us how you went about selecting that measure. Why, why is that in the non arthroplasty hit register? And why would, why do you have such an affinity with that measure? What, what process have you come to get their? Yeah. So very good question again. So when we were deciding on this, obviously, they've been validated uh studies which have actually validated this measure as probably the best outcome measure that exists. So it used to be the hot 36 evolved into the hot 12. Uh most responsive and best validated measure for this patient cohort. That's why we went ahead with this. And then we've got a generic one which is the E Q five D. So these are the two that we use on the registry. Yeah. And did the patient's tell you have the patient's had a look at the the schools? Yes. Yes. Yeah. So I think uh we're talking about a little bit later on. So I won't still marrying thunder and Abby thunder. But to my mind, this is a great place where clinicians and patient's can really work together to improve the quality of the study in selecting the outcome. Because for example, if you chose E Q five D and you didn't have this disease, specific patient's specific score, you're probably not gonna see any effect, right? But there might be something important that you're missing because the U five D is insensitive to. And so, so introducing mythological rigor in terms of validity of the score, it's statistical behavior and kind of patient face validity. It's measuring something that means important stuff to me after my hip arthroscopy, that's a great synthesis in a co production approach to improving the study. Brilliant. So that's that's an example of how it probably work out that PICO works very nicely for this. Obviously, there are no, no specific interventions here, but that's what you're trying to study the effect of. I'll let you all continue. Great. So I'm going to hand over unless there's any more questions, I'm going to hand over to you. Great. Okay. So thanks Ralph. Will that continue? So, just gonna talk a little bit to you all about patient and public involvement, also known as PPI um so not payment protection insurance, which is what I thought it was when I was an F two, when people were talking about PPI and research. So PPI is super important. I'll try and give you some examples of why that's the case. And then from my own grant applications, I can give you some examples of how that sort of uh measures in. So why is it crucial that uh why is this crucial in conducting um impact or research? Well, it stands to reason that you're doing the research for patient benefit. So the patient's themselves should be important stakeholders in the process of designing that research. That's a fairly logical way of looking at it. OK. Go on other days of just paternalistic uh you know, models of care where you just say no, this is what is best. Um So we've moved away from that and that's why I think this is an important facet. So Prob Griffin touched briefly apart the involved and they include guidelines. So the involved guidelines uh basically an NIH are funded scheme started in 96. It's probably one of its kind in the world in terms of getting patient's to actively get involved in coming out with research questions. So the process actually starts a little bit before that. Has anyone heard of priority setting partnerships? Some nods in the audience. So priority setting partnerships are things like the James Linda Lions. They do uh these partnerships where they come up with the questions that need answering. Okay. So you could go away and spend lots and lots of money looking at a question that is very um dear to your heart. But actually, if it's not something that's on a priority list for patient's in the public, it's unlikely that it's going to get funded for starters and that it's unlikely to be very impactful. So patient's are involved in this uh phase very early. So for example, in pediatric orthopedics, uh my phd is looking at hip dysplasia and now we know that the screening system in hip dysplasia um can be improved. And the public and patient's have also said the same thing. So now when you're creating a research question, you're going towards something that everyone is invested in. So the involved guidelines are a guideline which can just type in NIH are involved and it will just tell you how uh patient's can, can get involved. The next stage from involved was the include guidelines which were financed by the clinical research network, the crn off NIH are so essentially that is looking at. So you're getting the keen patient. So you're, you had a question where you said, you know, the patient who's been affected by something maybe keen to be involved. But how do you make the process? Pragmatic? Well, they include guidelines are talking about people who generally don't tend to get involved in research uh points. So, you know, um ethnic minorities, for example, young young people may not want to. I mean COVID vaccination was an example of how certain parts of society were not involved or did not want to be involved uh in the research process. So the include guidelines is looking at how do you best incorporate uh those patient's uh and that uh facet of society into your research, questions, patient advocacy groups and charity partners. So these are something um that are really important. So what you so for pediatric orthopedic research, for example, Mum's Net is a great way of disseminating things that you want the public to read about. Okay. Now that is an idea that was given to us by a patient. They said, okay, if you wanted to talk about BGH research and you want people to read about it, why do you talk about it on moms net? Okay. So you put you put some stuff on there and you'll get lots of replies, people really engaging. And now that is not a traditional platform that we would have thought of off the bat of creating a design in the question. So for our research, for example, steps, charity, which looks after, you know, problems with Children walking. So they're involved and they're involved in disseminating your research. So it's all well and good doing good quality research, but you need to disseminate it. So writing things like the lay summary, so not using overly complex terms, which are not going to be, you know, possible for everyone. So what we tend to do is, you know, PPI groups will be involved in your research and they will write your lay summary for you. They will write things which the public would be able to understand. Um and they go get involved and present this at conferences. So that's a very important facet of, of uh of creating good research. And then I'll just give you a couple of examples here and you'll be surprised. I hope with how important it is to, to have these partners in actively shaping research. Is anyone aware of the force trial which is a currently trial which is looking at Tourist fractures in uh pediatrics? So I'm obviously going on about pediatrics. You can tell I'm a bit interested. Um So uh Tourist Fractures, the trial looks at between current immobilization protocols versus soft tissue, just, just a crepe bandage. Okay. Now, Professor Dan Perri, who is the C I for that project, he tells the anecdote where basically they were going to design the study and say, do nothing versus current immobilization. And in one of the PPI meetings, it was abundantly obvious that people didn't want to do nothing. So the patient's were like, we'll know if we've gone all the way to the hospital, you're not going to recruit in this study. If you say we're not going to do anything, we confirm a tourist fracture and we do nothing was not acceptable to patient's. So, if that process had not been done that point about putting a soft create bandage would not have been included in the trial, which would have then led to people not recruiting to the trial. Do you see what I mean? So it's like a, it's a very subtle point. Um Similarly for fame, which was looking at close contact casting, which Professor Griffin's A C I on patient's are very much in favor of having the close contact casting being done in theater. Okay. Um If that wasn't specified, it's very likely that the recruitment for that trial would have not been good. Okay. So hopefully that gives you an idea of how and why PPI is important within, within trials. Uh Do you have any questions at all on that topic? So you involve patient's in this, both these examples, they tell you that you have to do something and you have bent your trial protocol to agree to what patients' want, but that may not be the right thing actually doing nothing. Maybe the right thing, not putting advantage may be the right thing. Giving them a general anesthetic to take them to theater, to do a total contact cost cast, maybe the wrong thing. But to include patient's in the trial, you've gone by PPI and you've actually included that as one of the arms. How do you circumvent that issue? So that's a really interesting question. And that's, that's a question that's brought up in that the point about bending the trial protocol. The important thing here is that it's not done in isolations. You have a whole trial steering committee and a trial management committee that looks at these things. So if, for example, patient's were suggesting potentially something that is not possible, then that is a conversation that has had before you start, you know, applying for grants for millions of pounds to get the study off the ground. It's generally a judgment of harm versus benefits. So it was felt for the fourth trial, for example, that's actually putting a bandage on, wouldn't be, you know, it was, it's acceptable to the patient's, it's also acceptable to clinicians. So there's, I think, you know, that was why that was allowed to happen. Um But I think the important point was that you can't obviously go so far away from the question that you're no longer informing clinical practice. But if you don't have the insight of the patient's, then you will not recruit. So I think that's, it's, it's a balancing act. And I think, I don't know if Griffin has any um any further thoughts, you know how he got around the close contacting, close contact casting thing prof so I um I take your point because I guess my, my thinking on this is we're trying to test interventions which we could then subsequently rollout. And if patient's feel that this is not an intervention that they sign up to in a trial, why would they then go on and sign up to them and give consent within the environment of clinical practice? Um You know, uh the patient's were absolutely clear. They said we, we understand the close contact casting doesn't require an open operation, but we anticipate it's going to hurt. And for those of you casted a displaced ankle, yes, it does hurt. And they said quite clearly, well, if we're involved in designing the intervention, we don't want it done under a devious bit of gas and air, we'd actually like it done under G A which which in fact has then gone on to inform, inform my practice more widely that, you know, I very rarely do something outside of the theater now, partly because it's difficult, but also because you can have a properly prepared patient who's anesthetized and doesn't experience a lot of pain. I personally haven't come across a scenario where a patient told me something that, uh you know, I don't think or that I think will fundamentally change the research question. It's always been an improvement. My only, only concern with that Damien is that, I'm sorry, Xavier is that we, we spend a lot of money, millions of pounds on this, uh were involving probably 5 to 10 patient's who are a subset of a population there who will actually uh inform your trial as to how you want to go and then general applique a bility of that trial globally, you have the same fracture in Africa, you have the same fracture in India. You, you, you may not be able to get that done there. That's the issue. I take your point and, and, and that's where you have to make a balance, right. So just because a group of people, I mean, these, these teams are made up of probably best part of 30 people overall, put, put in contributions and then they're judged by a very large group of reviewers. And so you have to, you have to come to a view and that view won't necessarily be concordant with every single person in the team. And that's one of the great pleasures of being chief investigator. And you get to make the choice and you get to take the blame uh when it doesn't get funded or it doesn't recruit. Um And so you have to weigh up all these things. Number one, you've got to get funded to do the research which means you got to understand your funders bias in what they're interested in. So for example, NIH are wants studies that can change UK practice. So if we were to make an argument that this won't be applicable in lower middle income countries, they would, they would not accept that as an argument that makes sense to them. Uh And secondly, um you need to, you need to be alive to the clinicians who will drive local uh collection of participants and their data and recruit into the study. And if you design a study in such a way as to make it too difficult for clinicians to perform both the treatments that is bound to fail. So it is a huge balancing act and that's why we try and bring in lots of opinions. But in the end, you know, as with all things involved in orthopedics, you have five people in the room, you have 10 opinions and someone has to make a decision because you only get to do one operation. So uh it's, it's challenging but uh that, that I guess is the collaborative approach, one of the, one of the advantages and disadvantages of collaboration. Cool, thanks. Okay. So we'll move on to the third part. Prof okay, great. How are you? Thanks so, so much. So, I'm going to talk a little bit about uh how do we influence and get success are getting funded by a group of people or an organization. Which I hope you've heard of, which is an eye chart. She's now got a new name, the National Institute of Health and Care Research. I managed to update my, my slides. So I'm sure they'll be pleased. Uh, listen, why, why are we so obsessed? And when you go to these sorts of presentations, we're always talking about. NIH, are, think my gosh, there's lots of other, there's lots of other organizations out their funding research. Well, the reality is that for clinical research. So for research involving patient's, um NIH are essentially the big show in, in the UK. And if you want to get work funded, that's going to be able to influence practice, then you are at some stage in the cycle that we've heard about of, of developing an idea which tends to occur over years. You are going to need to convince an eye chart to fund uh after the last part of that research. So you, I think that we are short sighted if we don't at the outset, think about how we can figure our search to land it well with an H R. And so what I wanted to talk a little bit about was the two ways that NIH are or two of the important ways that NIH are um prioritize. I've just got a message from me is that a problem could be a problem. Excuse me. Um We are trying to influence NIH are in terms of their research priority setting. And the first is James Lind Alliance and they are a patient partnership with clinicians to prioritize uh clinical questions for later subsequent research. And it's one of the great ways of avoiding waste because actually behind the scenes, there's a big systematic view process taking place and they are ensuring that we're not proposing research uncertainties which have already been answered adequately. Now, that's the James Lind Alliance and many of the specialist societies are running those. And if you are, have got an area where you think that you have got some questions that you want to develop over the next few years, I would advocate very strongly that you get involved with your specialist society or with voter at running a James and Alliance. It's absolutely doable. It doesn't cost an awful lot of money and it will set you up over the next few years. The second is you could spend some time delving into the nice website and this is a little picture of the amount of work that goes into a clinical guideline. This is the clinical guideline for vte prophylaxis uh with all of the clinical recommendations and the systematic reviews behind them that have already been conducted too high rigorous level. And what I would say is the key thing you need to go looking for is the research recommendations. If you go onto the web and you look up clinical guideline of an air of interest, this one for osteoarthritis just produced, look at the research recommendations. If there's a research recommendation from nice, then it will be prioritized or it will be considered for prioritization by uh an eye char and not NHL have recently formalized the way they do this prioritization. And they now have specific calls looking at James and alliance research priorities and nice research priorities. And so rather than spending a lot of time working up your own single brained idea, climb into those big collaborative networks which are already up and running and express through these two different pathways and you'll have a much more responsive uh time when you go to the big funders. And that's not just on our charts. In fact, all the big funders are responsive to that, but our hr particularly explicit about that. Now, I can see you a little bit short for time. So what I'm gonna do is maybe pause the questions now and I'm gonna go revert over to Abby on the stage and we're gonna do our fourth section and then we'll take questions for our, for the whole sectional session together if that's all right. Great. Um So I'll go through the last part here. This is much more relevant to, to the trainees um here in the room in terms of how to get research questions off the, off the ground. So you need to be aware that there are regional design services funded by and our child, which are in your sceneries. Um Again, something I wasn't aware of. So if you have a research question, you want to write a grant application, you can go to these guys for, for advice uh and also statistic support in terms of regional collaborative. So this is very much a boater thing that we've tried to increase the profile off. So every region has it's collaborative. Obviously, you guys are extremely active in East Anglia, which is fantastic. Um But the thing I wanted to show you is the both a decision tree. So this is our website, please have a play around on it. It's very good, Iggy runs it. So um ad invested interest. So if you go on the voter website, you click under research, this is what you'll see. So I just want to draw your attention to one section here, which is pitch an idea. So if you have a question that you come up with and you want to sort of go around the collaborative model of how you go about. So this year both have instituted this um since we've been in, in, in office where you can suggest that question to us. Okay. Uh We will take it through a process of SWAT analysis. So looking at the weaknesses and the strength of your often work and our point is that we're looking at um trying to make sure that the research helps the trainees who are going to be your collaborators. So that's where the bota is comes in. Okay. So for example, if every project that says, does everyone have their lunch, it's probably not going to get endorsed by Botha. Okay, because that's not going to be material benefit to all the UK trainees who are taking part in it. But if you have projects that could potentially go the extra mile in terms of looking at infections, there's a couple of active projects at the moment, then we will go through the process and essentially you get a free advice from people who know a lot about how to conduct good quality research. So um we'll undertake the analysis, give you free feedback and then you can decide to do your project with or without voter endorsement. That's not a problem. But this is just a way of getting, giving you the ability to get more sort of projects, more collaborators on board. These are some of the projects that we have supported. Um The bottom two are currently running, so go on the website, you can join up and collaborate. Um That's running from Yorkshire Deco elbows is writing to an F F P O M and open have now closed and they're being uh sent for publication. So these are all botha projects that have been endorsed in last year. All right. So that's it. Sorry, what soft or towards the end there. If you have any questions about section three, section four, anything specifically on section four, I'm around all day. So you can come and ask me about section four. But if you have anything else, please ask, um, just in the interest of time and because our next speaker just has clinical commitments, is it possible, Prob Griffin if we take questions later on at about 11 or if we, if they place on chat box, we can always point sign point. Sure. Sure. Okay. Sure. Yes. So there's no questions on the chat box. Any questions from the floor? Thank you very much, really practical, really good advice or anybody who's embarking on research or in the midst of it. So really, really fantastic. Thank you. Just, just one quick question. How, how much is it to pay for James Lin alliance? Just from a practical perspective. How much does it cost to pay? How much does it cost to pay? Pay for what? So it doesn't cost anything? The James labor lions. Oh, the James, the alliance. So you don't have to pay James Limbs. There's no charge, but you do need a little bit of money because you have to pay your patient participants. So I think you can get, depending upon how you do it. You can get one done online now for about 10,000 lbs. But the specialist societies, so that's, you know, I get it 10,000 lbs, a lot of money to raise. You're not going to get that at your department. But the specialist societies are all hugely engaged with doing this because it generates an enormous amount of research opportunity coming down the line. And so I think that the specialist societies and the B O A are highly responsive to people applying for money to do a James and Alliance. In fact, the be always just had three applications and that funded two of them. And I know trauma, the Speed Trauma Society funded several and both fast had just completed one. I'm not sure because maybe you can speak to whether the BHS has got one recently completed or in the pipeline. So yeah, BHS has got the revision uh hip arthroplasty. What are the important questions that, that running at the moment? And then the young adult hip one is coming on next. So those two, the BHS is running with fantastic. So I think, I think it's one area where the amount of money that you have to spend generates an enormous research activity and research income downstream. And it's a small enough part that most special societies can absorb it and get it over the line. Thank you very much. Great. Thanks very much. Thank you. Thank you. See everybody. Thanks Prof Griffin. It's with great pleasure to invite our next speaker who's come all the way from Sheffield and I really appreciate his time is Professor Mark Wilkinson from the National Joint. Um So most of you will have known what N J R s if you, if you don't know, look it up, but it's one of the biggest institutions in the UK and he runs the research committee. So without further a do prof Wilkinson. Yeah, sure. Thanks very much. Uh Thank you for inviting me to. Thank you the uh the opposite. Um So I'm going to talk to you a little bit about the, what the N G R does, what it's the opportunities are for research and how you might engage with, with us to develop research projects and get them through to completion. So I'm going to talk a little bit about what we have available in the N J are the overall framework for how we do things in terms of uh research and then a little bit about the nuts and bolts of actually making an application. And then finally, I'll just go outline that there are some other opportunities in house that we offer as well in the form of the research fellowships. So I think everybody is familiar with you. Is there anybody here who hasn't heard of the NJ are well? Uh Yeah, indeed. So we now we've been running since 2003 and we now have over 3.5 million patient care episodes. Now, notwithstanding COVID attempts to diminish elective practice in the UK. Um we cover all of the surgeons who cover do surgery in England, Wales, Northern Ireland, uh the isle of man and the states of urgency as well. Uh all surgeries that are done in Arthur plastic, hip, knee, shoulder and ankle uh should be in the N J R, whether they're in the private sector or in the public sector. Uh And we uh have key outputs that we measure which are revision problems and death. The revisions, we measure directly problems and death. We get through our linkage to other data sets. And so this is just a sort of overview of the scope and expansion of the N J R. And it is through these linkages also that we're able to uh create a uniquely powerful resource for uh researchers to use. So we think a little bit about the patient journey. You let me just check and see if I can make this thing work. If I hold it the right way around, it will work. Yeah. OK. So on the patient journey from first presenting first having symptoms through to uh late post operative care, there are points along this journey, the where data goes into the NJ are. So all of this stuff kind of occurs mainly in, in firstly out in the community and then into interactions with secondary care. And then there are a bunch of elements in in uh the pre op process. But we start getting involved with where of of capturing data with the pre op problems. And then our core activity really is around the inpatient episode and capturing all the the patient, the surgeon and the implant uh details. And then of course, in follow up any subsequent events that happen to the patient, we then capture through the same metrics. And at six months POSTOP which is determined by uh NHS digital. Currently, at least uh patient's get a POSTOP prom which will be one joint specific problem and one general problem. So if it was a hip, for example, they will get uh Oxford hip score and then they also get an E Q five D as a as a general problem. And then we uh follow patient's out through the arm and ation uh to either death or revision. So we find out what happens for the lifetime of the implant and the lifetime of the patient, I guess uh at least until such point as they have no implants left in them, if they have some kind of revision procedure that ends in a disarticulation of some sort. So the research element uh of the N G R is obviously built upon this huge data set and we have a mandate really to maximally use the data that were given for patient benefit. But at the same time, we're under a very significant burden of both common law duty of confidentiality. And uh more recent legislation handed down from the eu in terms of governance of this. So we have to be very careful about the data security. Uh We have a fairly streamlined application process which all comes in through a sing, it doesn't matter what you can, you can interact with the NGL at various different points. But ultimately, if you won't want to ask a research question, it gets funneled down the research committee through a standard application process. And while some people start off thinking they want a data request for some stuff about a particular hospital or activity, if it actually is deemed as being a research question rather than something that is purely about the running of the the service as it were it come, it gets redirected through the research committee and I'll talk to you. We've got a clear framework around which we align research uh internally. And so we have a series of in depth questions that we generate each year through the research committee and then they get, they get addressed. But then we also invite external research. Well, there's an open invitation for external researchers to apply to use the data for their purposes. And we're obviously interested in promoting the N G R brand uh as part of that. And if you look at the range of topics that we're interested in pretty can fill it pretty much fit anything you want to ask into that into these different categories. But the key points are really if you want to have an application that's going to be successful. The key thing is you've got to ask a feasible question and you may, it may be obviously feasible or you may have to talk chat to us to, to explore its feasibility. It's got to be something that's kind of, uh, of interest to the, to the healthcare providers, to the patient's themselves, to commissioners. It's got to be, it's got to be of, of actually of interest for it to be worthwhile doing. Uh, and it doesn't have to be novel, but it has to ask a question that is still open rather than one that has been addressed as severe was pointing out before about involving patient's uh in uh in your grant applications to NIH are the same thing is really true. Uh Absolutely. For the N G R and we have quite a large and strong uh patient panel which are, we have two patient panel members actually involved in our research committee that and we scrutinize all aspects of the application, including the that the lay summaries and they all go through our patient panel to check that they're appropriate and understandable. So, and the next thing is, it's clearly it's got to be, it's got to have the appropriate information governance around it. The question you want to ask, is it, is it ethical and relevant? So here's a little scenario. Say I'm sat there with a question as a researcher sat in the audience. Perhaps it would be very nice if I could just formulate my question, think about how I might want to ask for it. Go to the N J R get access to the data and then do the project. That would be very nice and tidy sort of for everybody, but the world doesn't work like that. And as I mentioned before, there's a large amount of regulation that we need to work within uh commonwealth confidentiality I mentioned. But also G D P R as from 2018, this place is a number of um requirements upon us uh for share ing data. And when we want to share data, there are different people involved. There's the regulators obviously who decide what we can share. And that includes a confidentiality advisory group in the H R A. And also N residents clearly falls under a patient identified research element. We have to interact with data controllers. So the N G R itself, whilst we're a data, we're a sort of data controller in partnership with H gripped the health quality improvement partnership. But ultimately, we have to go to them to say, can this day to be released. So the your question may get through our committee and it gets approved by us, but it still has to be approved by the overall data controller within the NGR which is H equip. And if you want to have linked data sets, say from NHS digital on death, data or problems, they have to approve it as well. So all the relevant data controllers have to have to give their formal backing for a uh for data to be released. And then once all of that is sorted out, we then interact with the data manager, which is N E C used to be called Northgate, but they got taken over by, by any see, but they still serve the same function and you may or may not want to interact with our lot to providers who do a lot of our core at work, which is the University of Bristol. So how do we negotiate all of this? Well, think of data as a kind of risk pyramid and at the very top or the bottom, depending on your perspective, we have aggregate data or summary data, the sort of stuff that goes into the annual report. So you can pop pick out, you know, in, in 2006, there were 92,000 hip replacements that were done in the N J R in England. You know that that's a summary data that that's, that's what we call completely safe. And then we have this uh mildly risky data, which is this is patient level information or, or individual level information, but it's anonymized and it's not linked with anything else. And the more you start adding linkages, an additional data fields, the more you can get into the point of being able to identify a discreet individual. And with that increasingly get increases the value of the data that you're looking at. But it also substantially increases the risk because re identification is a, is uh illegal and we can be, we can be uh sanctioned because of data releases, identify individuals and the fines are not insubstantial. So how do we manage these? Then if it's low intensity safe data, it's already in the public domain, you don't need down our approval to do anything. You can just get on with it uh if it's individual level data, but it is, it's completely anonymized and, or as anonymized as it can be or pseudo anonymized and it's not linked to anything else. It's just within the N Jr's gift to uh make that data available to you um subject to our usual sort of criteria. And then if you want to access data that is either it's, it's, it's, it's anonymized, but it's patient level, but you're actually gonna want to link it to lots of other data sets which make it very easy to triangulate individual patient's or you want to add surgeons to that where you want to add hospitals to that or any other geographic things, it really starts becoming quite sensitive and those types of projects, particularly if you actually want to re contact patient's become quite complex to actually manage, but they can, it can be done and we do do it. So just to go through what the application process is, our first step is to take a look at the website because it's very clearly stated in the website, how you go about applying for uh access to data, to do research within the N J R. And the website will point you to a little sort of XL form that you fill in, which is the expression of interest you feel. And if you feel saying who you are, what you want to do, why you want to do it, why I think it's important. And the, it's important to mention at that point, if you want to submit a successful research application, you really need a backer to do it. So you need, you need somebody who's in a permanent post in your institution uh to act as the sort of the permanent contact point because you may come and go around different hospitals. And if the N G R wants to contact you about your research work that you've been doing that was approved by us, it if you're moving around, we can't get a hold of you. So we actually need to have you linked to somebody who's in a permanent post that will act as the, the sort of the formal guarantor if you like of the work. So that's a key thing to remember. Um So when you make your application, you put in the EU I and then either you tell us, you think it's an external because it doesn't involve any other data apart from the NJ are or you think it's internal because you want to get national problems, data or involved some other data set. Uh For example, we've been doing something recently with the uh with the intensive care data set, the national intensive care data set, those are partnership projects because you're linking up and it's not just the N J R that's responsible for the data you're using, it's actually a completely separate registry is, is involved as well. And so we have to think about the governance, all of that it goes through, you put in your full application, it goes through the research committee and then it's either it's either accepted and approved by us and then it goes to quit dog to be validated. And then the data is made available or you go through a cycle of it. We don't think it's quite right. We tell you and then you have the opportunity to revise and resubmit. So, so those are the different steps. But h quick dog always is a, is a great limiting step. It's not necessarily us. But the h quick dog process, I think they meet once every week or two. So they're usually quite quick and then provided that everything everybody's happy, then the data gets made available to you through the data access portal. And so the reason that we do everything through the data access portal and we have done for several years now is it means that the data still stays with NJ are, but you get access to it from a remote uh from a remote terminal, you have your own um log in and the project itself has got its own code so that you get access to the data that you need to do your project that you requested on the form. And that we, there's a big sort of tick box thing of, of exactly what data you want and then we make that available. Um This means that we do it this in a safe way and that since we've been doing this, uh NHS digital have gone this way and actually even, even UK Bio Bank have gone this way now. Uh But this is really since uh chronologically since we did it were not the reason that they just did it. It's all recognizing a common challenge and we've all come to a common solution and this reduces the delivery burden and it allows us to service more, more requests because when you make a date, a request, somebody has to go away, dig out that data, compile it and then make it available. Historically, they'd have to stick it on the C D, post it to you, etcetera, etcetera. This, this setting this system up cost quite a lot of money. And although the NGR gets in income, it doesn't get income, it gets remunerated for hospitals, uploading data onto the system. Um We don't really have a, there's not, there isn't a like a top slice for doing research. So research is extra. So it's done within the NJ. Our core business because they're called business. But supplying a portal to allow you to access data costs quite a lot of money. And we do charge an excess fee which differs if you're, if you're a commercial entity or a versus a non commercial entity. So there is a charge of a couple of 1000 lbs or so to access all the data. But that's not an awful lot Cheetah cheaper than NHS digital will charge you to exact access exactly the same data. They charge about 20 grand uh for a single project. We charge about two uh unless you're a commercial entity, uh which case, the figure goes up somewhat. Uh And lastly, just to, to finish off my time, I'm going to tell you a little bit about the research fellowships with the N J are. So we have a continuous cycle of, of research fellows running through the NJ are, we did have a break in 2020 because of, because of 2020 2020 I think because of COVID 19. So we had a little hiatus because people were obviously fixated on, on other issues at that time. Um It's two year fellowship. Uh It's a shared between the N J R and the Royal College of Surgeons, although we put the funding into it and they administer it for us. Uh So every year there's a new fellow post comes up, we've just appointed uh the next one to an elbow fellow who's going to be based in Manchester. Uh and then the next one will come up in September, the next round and that will be a new initiative between orthopedic research UK, the N J R and the, and the RCs. So our next one will be uh an N G R O R U K R C s uh fellowship, but it's based along the same uh principles that it's a two year, it's not a single year fellowship and we expect you to be registered for a higher degree phd or an MD. So just then to summarize uh with the N G R, we do have a unique resource that we make uh publicly available under uh appropriate governance regulations because we want to maximize the use of the, of the data by people who are doing research, not only in the UK but internationally. Um We are very conscious of the fact that uh patient's are at the center of this and we need to protect patients' identities and their data at the same time. But we're cognizant that we're really keen to uh to uh to help the development, the academic and clinical development of uh the trainees who put data into the N G R with their consultants. And clearly, if that works well, we get, we advanced science, patient's get a better service from the NJ are ultimately or from the UK healthcare system in general. And everybody's happy. I hope you've been happy listening to my talk, which is hopefully not gone on for too long. Happy to take any questions. Yep. Thank you. Uh The question was regarding a trainee wanting to get involved. You mentioned the cost of about 2000 lbs if you want to do a project. And you've also talked about the lot to uh this uh University of Bristol. Say if you're a junior trainees to myself, you want to get involved in an N G R project, you want to do something with N G R data. Would you always advise that you get in touch with the guys in Bristol first or just talk to your local supervisor? No, no, you don't have to get, you don't have to talk to Bristol. Bristol. Bristol are not the N J R. Bristol. Our, our uh a lot to provide us. They go through a competitive process with other academic institutions every 3 to 5 years to get the next contract. So they're a contractor. We do work very closely. Well, they work very closely with us. But if you want to do a project and say you're in based in Hartlepool or somewhere, what you really need to do is you need to be in contact with somebody who knows what they're talking about and is capable of managing big data sets because this is a big data set. When you're adding all of the other elements, you know, there are millions and millions and millions of, of individual cells within even a relatively modest IZED project. So you need, you need to have the infrastructure and the access to the infrastructure to be able to manage that and to process it because there's an uh and pre process it, in fact, so that, that there are an awful lot of stages in going through looking at a big data project and seeing it through to completion. So you actually need to be, you've got to be credible. So if you, if you're, if you're projects not credible and we can see that it's just not going to work because you haven't got the backing. You haven't got somebody senior whose a permanent member of staff on the application and you haven't got a named Statistician, which is the other thing that we need to see source, at least somebody who has a track record in managing big data and, and producing outputs from it. Uh And you also need to demonstrate, you know, that you've thought about the question and that can actually be done with NJ our data. Um So there are examples where people have had a very good idea, but you just can't do it with NGR data because we just don't collect those sort of metrics and actually you might be better just going to and they're just digital and getting the data from them from hess, you know. So, so, so we do try to point people in other directions if, if it's just not feasible, um We will say go there because we know they have the data but we don't. Um So, you know, so just a re summarize that, then you don't have to talk to Bristol, but you do have to talk to somebody who knows what they're talking about. Uh Before you, while you're in the process of think about contacting us uh with A I coming up in a big way. Now, is there a limit to the data sets that you provide or you can give us the whole data set for a million? No, we don't. You get access to the data that you need to do your project. Okay? Because of the whole information governance thing, you just, you just can't do that because then you could just, you could go back, can re identify any patient you like because actually is in legal activity. But we have constraints on us that say you just can't do that and nobody else will do that. So NHS Digital uh I mean, we follow the rules that we have to, I think NHS Digital sometimes creates rules. So that's a slightly different perspective. But, but you know, you need to have, you need to know what you're asking and have and have an idea of the cells that you want to, to answer the question that you're, you're asking, which is one of the reasons why we have the portal. So we give you the data that you need. And if you say, oh well, we just realized that we actually this data as well to answer the question. And we go, well, yeah, of course, you do, you can have that as well, you know, but it's got to be relevant to the question. And on the I I point, uh we have got a big A I program ongoing within the N J are looking at patient's individual predictive stuff. Uh not only for, for problems but for uh survivorship analysis. And that's all kind of within the NGR tent at the moment as an internal project safer for our international audience. We've got people from other countries. So if they were to want to set up a new registry, um and applicable for the UK practice on other joint registries that are not as mature as NJ are, what would you say the first step would be? That is a very good question. Uh What would I say? Clearly registries are a great thing that then they're real world data. Uh They're not clinical trials, but they are much more broadly generalize a ble uh but they're subject to the biases that that anything is and setting up registry first, I would check that there isn't one already around on that topic because often, you know that, I mean, even H quip itself deals with dozens of reg holds dozens of registries within it. So, infrastructure. So you want to make sure that it's unique and also that it's actually going to be that there's a, there's a, there's a need for it. Uh and there's sufficient volume nationally to call for a register. Um And then I think if you have identified all of those as being positive, then the key, first, key step is to speak to a register to get, you know, under get some of that corporate memory because it's a very complicated process and it depends what you want to collect and how you're going to collect it and how, what you want to do about analyzing it and what you think the audience and the outputs are going to be. So all these things you need to, to think about and the best way to do that is once you think you're on to a, a sensible winner is take advice from an established registry. And so within the N G R, we do, we get queries globally about setting up new registers. And we have given advice to various countries uh mainly in Europe about setting up registers and any see we were in North Gate, uh do a lot of this internationally as well. I think they've advised the Indians and various other places around the world on setting up national registers. Great. Thank you very much for concern. Understand pleasure. That's about. Thank you. Great. Thank you. Thank you would like me to take that off for you. Okay, great. Thank you. Thank you. Thank you. Right. So our next speaker is joining us from on Zoom. He's also from a very established institution called the NIH. Are. So if you haven't heard of it today, you will have heard of NIH. Are. So Prof uh, Glenn Jones is based at N dorms, uh, and he is the steering committee for A R U K, uh and the NIH our clinical research Network National specialty leave for M S K. So, Prof Glyn Jones, welcome on Zoom. Hello. Hi, how are you? Nice to, nice to see you. Thanks for inviting me to talk. Um And uh hopefully you can see me properly and hear me properly. So tell me if you have any connection difficulties because my apologies for not be able to be there today. But uh hopefully this will work just as well. Um So I might just share my screen if that's possible at this stage. Tell me if I can do that, uh should work. So, um I wanted to talk to you today, hopefully. Um can everyone see that? Yes, hopefully, has we can see that? So I wanted to talk to you today about the NIH, are now you've obviously heard a lot from Xavier Griffin and probably others this morning about what the N H R does and a little snippet perhaps of its functions. Um It is a vast organization. Um You've already had an introduction about me, but I'm uh an orthopedic surgeon principally. Uh but I have a uh my main contract at the University of Oxford where I do research and, but also work with the an eye chart to run one of the themes which is musculoskeletal theme. Um So I thought we'd talk a bit today about what the n eye chart is and what, what it does in terms of its function and it may be focus a bit on what the muscular skeletal theme in the clinical research network is. So, uh you know, you've had all these little bits of information about the NIH are this morning. I'm sure you all know a little better or maybe even a lot of already. But it's uh it's a research funding and delivery structure and it's pretty much the biggest research funding and delivery structure in the world. It is uh taking funding from the point of uh innovation through to clinical delivery and late phase clinical trials. Uh It also funds um specialist centers such as the biomedical research centers. Uh And you'll be aware that there's several funding streams both for early and late phase clinical research. You know, the early phase, things like I'm for either late phase would be things like the health Technology assessment program where they're looking at existing technologies and how we use them better. Um or how, how, how we look at their cost benefit analysis. Uh In addition to that, there's actually um some innovative areas. So within the N H are, there are smaller funding streams which look at med tech co operatives where there are particular talents of UK with certain universities with regard to things like stem cells or devices and they will fund individual centers to work as a cooperative sometimes with several other centers um uh to further research in these areas. In addition to that, you've got the clinical search network, which is a main component of the uh delivery structure of the NIH are. So where the there is a funding arm, there's also a delivery arm and this is a significant proportion of the 1.2 billion lbs of your budget that the NIH are receives. Um And it's really designed the clinical research network to make sure the studies that are funded and supported by the N H R delivered. Um uh where and uh that there's a structure in each hospital UK to deliver them as well as a process for looking at how studies are running and whether they recruiting to time when target and importantly, and probably relevant to this particular meeting is the fact that the N H R has uh funding for academic research pathways. And I think that's particularly well developed and actually has supported many people over the years through the academic foundation programs through all the way to NIH I'll professorships. Um And so at each stage, there's opportunities of the surgical career and the medical career to, to engage with research and, and to have type your time bought out uh and support you to become a clinical academic. So just a bit more detail on the an eye chart than a research network. And it's important to understand this. Really think if you're thinking about doing the search mainly because most people don't understand we know in surgery particularly that this resource exists. So what the N H R C R N is, is a high quality trials infrastructure. It encompasses virtually every hospital in the UK. It also encompasses a majority of, of primary care practices. Um And it, within each hospital, you will have embedded nurses, physios, radio, radiographers, ultrastenographer, try lists that are funded partly or wholly by the NIH are to deliver research from their program. And so you can engage in this structure at any stage and I'll talk about the stages of which the SERN actually supports research, but it basically covers all of England. But also there are devolved crn uh pathways in Scotland, Wales and Northern Ireland as well and they're linked to the English one. So if you have a trial in England, you can run uh satellite uh studies, uh multi center arms, uh the in other parts of the UK as well. And that is all supported. And there's no funding implications for that. We're also uh supported by the uh the surgical trials units, particularly the RCs units. And there are now three or four orthopedic team units of those around the country, all of which will help the worked up orthopedic trials and engage with the NIH are at the same time. So the N H R historically, um you know, this is a rather complex looking slide but it delivers the green, red and yellow areas. So in other words, it looks for where best to deliver a trial, it helps you set up the trial and it monitors the performance of the trial. And the key to getting that support is basically to get on what we call the portfolio, which is uh the NIH our terms saying a study that we like, we think should be adopted and the funding doesn't have to come from the hr it can come from commercial organizations and it mostly does to be honest with you or from other charities, but it needs to be, there's a process of adoption which typically comes through the specialty groups. But in addition to that, you've got um an opportunity because of the linkage with all the sites in the UK and different specialties to look at what we've got feasibility studies. So they can tell you whether you're gonna recruit to a particular trial where best to recruit is where the demographics you want to recruit to live, where the disease is, you want to recruit to lives. And then we can give you early feedback on the design of your trial. Is it likely to work and it's practical real world stuff that increases your likelihood of having a successful outcome to your trial. Um At the moment, each uh specialty group is divided into about 20 different specialties according to surgical medical specialties. Uh we were in the one particular cluster and that's called the muscular. And we were I lead the muscular skeletal specialty group. And on that, we've got about 30 people, mainly rheumatologists, orthopedic surgeons, HPS, but also um input from the special societies, from PPI groups, from trainees associations, botha has representation on our committee. Um And in fee indeed, there's also uh input from the funders. So the funders are interested to see how they improve their recruitment of their trials, how they spend less money and get better value. So they turn up and tell us about the trials. They're worried about each other about the trials that we're doing well at recruiting to. We'll also get input from high level as well at the Rh and what used to be called the UK Trade and Industry Board. But Central Inc changed names about four times since then. And this gives you a rough idea as to how things are managed. Well, each of the, each of the regions has a lead and each of the regions also has orthopedic champions, rheumatology, champions and other inputs according to specialty. This is a little older side, but it gives you an idea if you want to recruit in a certain region, you these are the go to people. So what about activity? That's what sort of volumes come through well over the past nine years or so. This is a, this is a live slide, you know, updates every hour or two on the recruitment. There's been 13 million participants recruited in the N H R uh through the clinical research over the past nine years or so. And they have over 25,000 studies. You can see the majority and non commercial but actually still have some commercial money pushed into them. That is through what we call investigator initiated studies. Um In M S K, we're up to over half a millions and participants in over 1700 studies. Um And all of the networks in the country or 18 actually recruit to these and we can track things, we can also look at through this. This is a live map which shows uh each region, how much they're recruiting in terms of different specialties in the North Pedic studies. Rheumatology studies. You can look at how many patient's of a particular um uh type are eligible, recruitment in different areas. And so it gives you a good idea about what's going on, how studies have been recruited on a day to day basis. But also um uh look, can help you look at feasibility studies as well. Uh We also look at what we call strategic priorities. So sometimes we'll have uh at least change year on year are usually from top down from the common health, often driven by commerce at the moment, they're trying to get commercial studies in with Brexit. Uh And with an aim to maintain our uh the Uk's Lee and well, with regard to clinical trials that the NIH are trying to bring in external funding from abroad to to run a large scale device and pharmaceutical trials. And obviously, there's been huge success in recent years with the, the COVID 19 vaccines and treatments um urgent public health uh initiative. Uh There's also a continuous desire to update our expertise and broaden our musculoskeletal themes. So we've brought in occupational health over the years, we've extended uh physiotherapy contacts so that we've got more broad base in terms of musculoskeletal conditions. We've also got initiatives and some of these uh these just a few examples really once we've done over the years. Uh One of the ones that we did a few years ago was about early phase implant evaluation and helping device companies and in the industry uh improving their time to get both beyond compliant. But more recently, medical device regulations. That's the um the our recognition and that really comes from history whereby a lot of the failures and Felix have occurred very early on in implant uh release and have not necessarily been uh stage uh salient example of this is the metal metal implants. I'll talk about that in a second, but we've already heard very elegant with the mark that the registry is huge benefits. And the gold standard for uh implant evaluation uh said there are limitations and certainly in the early phase of implant release, when particularly you have less than 500,000 devices being monitored, then this can lead to uh you know, an inability to detect early problems. Although the N jars made huge efforts to increase the granularity of data and trial still uh you know, essentially looking at this. And if you, if you look at the history behind something like the metal metal devices, you know, um small cohort studies and trial data, we're picking up problems with the devices. In 2003, the registry didn't pick it up really until about 2011. So you have a huge lag sometimes with regard to the largest cohort type data set where and, and so the, the MG are in particular and you knew UK see a regular mate, everybody looking at increasing the, the, the quality of the data early on and that's where the NIH are commit. And we've over the past few years uh set up a pathway to do this um uh advantage of course, of clinical trials that you've got a great 20 control population, you're able to look at uh issues uh and many more outcomes. And so perhaps pick up things at an earlier stage. Um This advantage, of course, as we heard earlier that sometimes you're looking at a small population and that has issues regard to external validity. But of course, this is now actually part of the regulatory process for introducing a new imparts. So we have to engage in this and this is where opportunities lie for surgical researchers uh for the NIH. Uh And one thing I'd certainly recommend you look at particularly if you're thinking of flying for research is to have a good idea and understanding of the process of evidence gathering. This is a uh there is something called the ideal collaboration which published serious papers in the lancet about um 56 years. And they, they went very carefully through the levels of surgical research and the type of trials and studies that you should do at each stage. And it's well worth looking at because, you know, several years later, the EMDR has a U K ci are adopting these ideas. And so I would recommend you read the papers they're buying mccullough in the lancet. And you know, now devices are essentially tracking the same type of uh introductory process as, as pharmaceutical. So then we're looking at phase trials moving onto registries for larger and later study. Uh This is really what we offer with the NIH are that if you have a, if your advice, pay factory, you want a new implant, then you, they often come to us through our business development office which they, this is then uh then link the same time to N D R A C I beyond compliance. And then we help them identify size, uh work on the trial and then deliver the trial. And so far, we've got 22 studies since 2018. Uh we've had far more coming online in six months with MDR coming, becoming an issue. Uh And there are various designs, majority of face market surveillance, but there are several cohort studies are CTS and many RSA studies now coming online. One of the other initiatives I thought we ought to talk about was the NIH our associate the I scheme. And this is something that I think you all need to be aware of. It is um if you don't have an academic uh foundation or clinical lecture or clinical fellow post, then this is an opportunity to get an N I H R badge, research badge through helping out with research. And the NFL has introduced this scheme over the past two or three years. It's been hugely successful in trauma and also somewhat in orthopedics, but there's capacity to improve. Um it's available to all doctors, nurses and HPS. If you're doing some research and you deliver it for more than six months and it's NIH are supported, not necessarily funded research, then um it you are eligible for a walk on A P I award. And if you do that for six months and there's a few criteria to meet, you will get this certificate and it certainly helps when it comes to doing things like grant applications later on. And it's, it doesn't require that much input but allows you to, to run and participate in a study often as a registrar um in a site where, for example, if it's studies been run from Adam Brookes, then you could help out in bury Saint Edmunds. And that would allow you to um get an A, you know, an A P I award um as a as a site lead and it also gives you some independence as well. We also heard from Xavier earlier about the prioritization and the NIH are although nice and the James Linda Lions are the main inputs historically for the N H R grants funding streams. The N H R is now taking upon itself to go back to the delivery arms. Say, look, can we do these trials of what trials are best for us to do? So, the HCA now have asked the many of the uh chemical research, number of things including Moscow's people to start working out trials in their individual disease areas such as surgery, rheumatology to, to look at uh you know, what, what are the, what are the questions that we really want to answer? And are we able to do that pract the problem with the things like the J L A is that although there greater identifying opportunities, those opportunities don't necessarily always align with an ability to deliver them in the real world. And our don't necessarily align with the, the the practicalities of uh what patients' want on the ground. And finally, I thought we ought to just talk a bit about the impact. This is always a good thing to put in the grant application or in a, in a fish R and D support is that for every patient recruited into the NIH are on the C R N front 5000, it is safe to the NHS and serves huge economic benefits. Overall, it's about 2.4 billion lb economic benefit, well researched and eight MG three years ago, that's available on the NIH our website if you put in KPMG and NIH M and then so just finally say I haven't gone on for too long, but thank you very much and uh for listening to me and happy to answer any questions. Uh So I'll come back to because I think I probably know how to do that. Um Maybe I think thank you. Um We're just any questions from the floor, we're just checking on online chats, any questions from online Sean. Thank you very much for the talk. Just a quick one. So if a trainee has got some funding and he wants uh the project to get onto the network, what's the easiest way of handling that? So, so the the way that works is you have to go for portfolio adoption and it's a bit of a you've got to be quite aware. So, um so obviously N I arch are studies that are funded in hr automatically put on the NIH our portfolio. So there's no issue with that. If you're study is not directly an R chop under 60 R U K funding or you've got commercial funding, but it's been run say through, through the University of Cambridge, you would need to request for portfolio adoption um at the ethics stage and it's been on the ethics for for a long time, but it's one of the last question to ask. So you go through about 30 pages and the last thing is a tick box. I said, do you want this to be adopted in the portfolio? If you take that box, your, your study protocol automatically will be reviewed by your local clinical research network um managers and committee. Uh So that'll be eastern for you guys. Then they will decide whether it's eligible. There are some criteria, the majority of things are to be honest with you and there's got, it's got a very high success rate in terms of adoption for most orthopedics studies. It's crucial to know that because if you don't take that box, you won't, you have to go through a retrospective process together adoption. And but if you take the box, you get automatic support for your research network team in all the hospitals you want to recruit. Brilliant. Thanks Sean. Thank you. Um So just to, uh, remind you K trainees. And I'm sure Glenn Jones will agree. The associate P I scheme for UK trainees listening. If you recruit five patient's into the associate P I scheme that counts for your completion of training. Um, so whoever, uh, just plug in for profit, Rangan the prophet to trial has been extended, you can recruit into that if you're interested in shoulders and elbows. Um, the G C P link is all on our website so you can do that. Um Yeah, so we'll take I don't think there's any more questions. We'll take a quick 15 minute break. There's coffee available. Thank you very much prof okay. Thank you very much. Enjoy the rest of your day. Thank you. Thanks for done, John. Thank you. So for online audience will be coming back at 11 45. Strict 11 45.