26 January 2016

Part 3: The ‘four seasons’ of a clinical academic without borders

Franco Cappuccio, Professor of Cardiovascular Medicine & Epidemiology, continues his journey through the ‘four seasons’ of his career to date as a clinical academic which we hope will inspire and delight you and hopefully encourage some of you to follow suit in this challenging but fulfilling medical career path.

Part 3. The Season of Ripening (2000-2005)

The opportunity to apply for a suitable Chair came at St George’s in 2000 where I became Professor of Clinical Epidemiology, and my confidence in being able to pursue independent ideas strengthened. I secured funding for two large epidemiological studies, IMMIDIET and the Kumasi Study, and established a research group around these two studies, whilst continuing exploiting the results of the WHSS.

The IMMIDIET study was a European-funded consortium whose aim was to look at gene-environment interactions of risk factors for coronary heart disease to explain the geographic gradient in heart disease across Europe. We studied three population samples in Surrey (England), the Flanders (Belgium) and Abruzzi (Italy), all with the same standardised protocol.
IMMIDIET in Surrey
The Consortium was a mix of clinical researchers, epidemiologists, statisticians, biochemists, geneticists, IT experts, nutritionists and health promotion and communication specialists. The memories of those three intense years offset the feeling of hard work and tight deadlines. We met regularly rotating each participating Partners as host. We enjoyed hand-made pasta in Abruzzi, the pre-Christmas atmosphere of a traditional pub in Surrey (see picture), ate fondue (cheese as well as chocolate) on the hills of Lyon and drank good Belgian beer in Leuven. The study had a successful completion and created a repository that is still producing data now.

High blood pressure is very common in sub-Saharan Africa alongside stroke and kidney failure. Due to the scarce resources to detect and treat these problems in rural areas I developed the idea of applying the knowledge accumulated in studying hypertension and salt in my patients to the people leaving in Africa. The underlying hypothesis was that they were at a greater risk of salt-dependent rise in blood pressure and stroke and kidney failure, and that a reduction in salt intake would be cheap, feasible and beneficial in those settings. It took me a few years to convince the Wellcome Trust that it was a good idea to set a population study in sub-Saharan Africa and to carry out a randomised clinical trial of salt reduction.

The Kumasi Study Team
No one had ever managed to complete one, and most reviewers deemed it impossible to do. It took resilience, beliefs, determination and teamwork to produce pilot data that would eventually convince the funding body to grant us the money to go ahead with it. The Kumasi Study became the first ever population based study of hypertension and salt that performed a longer-term (six months) controlled intervention trial (key publications 1 2 3 4 5). The results are still highly quoted. They have also influenced more recent global recommendations on population salt reduction (more on this in Part 4 next week).

I reached a personal milestone when Her Majesty The Queen visited the modern St George’s premises in Tooting in December 2002 to unveil a sculpture donated by Sir Joseph Hotung to celebrate the 250th Anniversary of St George’s Hospital (established at Hyde Park Corner in 1752).  
Her Majesty at the Queen at
St George's

During Her visit, Her Majesty met selected groups and key areas of research were highlighted to Her in a mini-symposium with short eight-minute presentations.  The Kumasi Study was one of them. Never in my professional life did I experience such level of adrenaline flowing during a presentation. If asked ten years earlier, I wouldn’t have predicted such a level of exposure of my work!

Whilst on the home front my work was recognised and showcased, internationally it received unexpected accolade. In 2003, I received the International Society of Hypertension in Blacks (I.S.H.I.B.) Distinguished Researcher Award. The motivation was “…in recognition of significant research contributions in the control of hypertension and cardiovascular risk factors in ethnic minority populations around the world.”  The award was undoubtedly flattering but, more importantly, indicated to me the importance and outreach of my research findings. 

Next time: The Harvest Season (2005-2015). If you have any questions or comments for Professor Cappuccio please post below. 

Career learning points:

  • Achievements are hard to get, but possible...
  • Be resilient in your work.
  • Believe in yourself but do not underestimate the value of working with others.

What did my research show about salt?

  • Reductions in salt intake can be achieved in difficult low-resource settings to help control high blood pressure and its complications. 
  • Population salt reduction should be a global strategy to tackle the epidemic of cardiovascular disease. 

20 January 2016

Part 2: The ‘four seasons’ of a clinical academic without borders

Franco Cappuccio, Professor of Cardiovascular Medicine & Epidemiology, continues his journey through the ‘four seasons’ of his career to date as a clinical academic which we hope will inspire and delight you and hopefully encourage some of you to follow suit in this challenging but fulfilling medical career path.

Part 2. The Season of Growth (1989-1999)

With Donald Singer and Graham MacGregor
at St. George's 
After a short spell of work back in Italy, in 1989 I accepted a five-year fixed term contract as a Clinical Lecturer in Medicine at St George’s Hospital Medical School in South London, where Graham MacGregor had moved as a Professor. I returned to my previous research group. I completed the training in General Internal Medicine (MRCP then FRCP), resumed clinical research, secured grant income, consolidated my publication record, and pursued my previous interests in epidemiology.

During the first part of this period, I published relentlessly and got myself involved in numerous clinical trials studying the mechanisms by which different drugs lower blood pressure in people with hypertension. I was rapidly absorbing a level of expertise in hypertension that later in  
my career would constitute an asset.

The passage to epidemiology and public health

Geoffrey Rose’s work on the principles of prevention has inspired generations of epidemiologists and clinicians worldwide, including me. His clear paradigm of Sick individuals and sick populations opened the vision of a physician like me (who had great expectations to make a difference) not to neglect the bigger picture of prevention: to amalgamate the dichotomy between ‘high-risk’ and ‘population’ strategies.

If we wish to find the causes of common diseases, we ought to study the determinants of the ‘normal’ levels of the risk factors as “the population mean predicts the number of deviant individuals. If we wish to find the causes of hypertension, obesity, alcoholism … then we need to study the determinants of average blood pressure, weight and alcohol intake …” (Br Med J 1990). When referring to the strategy of secondary prevention of cardiovascular disease, Jeremiah Stamler, another great cardiovascular epidemiologist of our time I had the pleasure to meet recurrently, used to say: “The strategy [of secondary prevention] is late, defensive, reactive, time consuming, associated with side effects, costly, only partially successful, and endless”.  These thoughts represented the most powerful encouragement of chronic disease prevention, through actions directed at avoiding the occurrence of the disease in the first place rather than focusing exclusively on the clinical approach of disease management.

Working at the LSHTM

I set off to pursue epidemiology by enrolling into a Master programme in Epidemiology and Public Health at the London School of Hygiene & Tropical Medicine where I completed an MSc and worked for a further three years. My training peaked with the MFPH (then FFPH) and the participation at the Advanced Ten-Day Seminar in Cardiovascular Epidemiology held in Singapore in 1993.

The winning team with the officers of the RCGP

established a personal line of research by succeeding in fully funding a research programme known as The Wandsworth Heart & Stroke Study (WHSS). I returned to practice cardiovascular medicine at St George’s as a Senior Lecturer (then Reader), in a highly ethnically mixed area of South London. I began to question whether and why some risk factors appeared more often in some groups than others. I established a population-based survey of three ethnic groups in South London, and studied them in all possible aspects, including the establishment of a biological and genetic databank for future exploitation. The study was published widely and in high impact journals, its results influenced future directions in the diagnosis and management of CVD risk factors in ethnic minority groups and led to the 2002 RCGP and Boots The Chemists Research Paper of the Year Award (Royal College of General Practitioners). The Research Paper of the Year Award had been running since 1996. Its purpose was to raise the profile of research in general practice and to give recognition to an individual, or group of researchers, who had undertaken and published an exceptional piece of research relating to general practice. The paper demonstrated the difficulties of applying the Framingham risk assessment for ten-year coronary risk across different ethnic populations and indicated the need for further inclusions of estimates of risk based on ethnic background (precursor of the QRISK-2 Score).

Next time: The Season of Ripening. If you have any questions or comments for Professor Cappuccio please post below. 

Career learning points:

  • Pursue your ideas, if you believe in them. 
  • Work hard and value other people, colleagues, your team. 

What did my research show about salt?

  • Salt intake is a determinant of the rise in blood pressure with age. 
  • Reducing salt intake reduces blood pressure in a dose-dependent manner in everyone. 
  • Salt intake is too high in populations, and a reduction across the entire population would reduce high blood pressure and cardiovascular events. 

12 January 2016

The ‘four seasons’ of a clinical academic without borders

Welcome to the first medical education blog of 2016. This month we are pleased that we have a series of four weekly blogs from Warwick Medical School’s own Franco Cappuccio, Professor of Cardiovascular Medicine & Epidemiology who will take us on a journey through the ‘four seasons’ of his career to date as a clinical academic which we hope will inspire and delight you and hopefully encourage some of you to follow suit in this challenging but fulfilling medical career path.

Part 1. The Foundation Season (1975-1988) by Professor Franco Cappuccio

No human story is alike. We’re all different. Different in ambitions, abilities, preferences, resilience, fears, beliefs, motivations, strengths, weaknesses. Furthermore, serendipity is often around the corner to change our lives. Yet, patterns exist that may repeat themselves over years and generations, so that we can all learn from someone else’s experiences. I have been asked to write a blog about my profession for those of you who have started on the path to become a physician. I am not sure how many of you will find my reflections relevant to your own circumstances. The very fact that I am writing and that you are reading, however, fulfils the primary objective: sharing experiences.

Pietro Fabris ~1760 (Compton Verney, Warwickshire) 
A basic biography is necessary to grasp the nuances of my tale. I was born in a city that has inspired many over the centuries, struck by its beauty and its startling contrasts of wealth and poverty, affluence and despair. The typical scene of Neapolitan peasant life, painted by Pietro Fabris, includes musicians, card players and a wine seller, as seen through the mouth of a cave by the Bay of Naples with the Castel dell’Ovo and Vesuvius in the distance.  
On the left is Naples as it looked almost two centuries ago, with the beautiful sea front promenade and the Vesuvius in the background, and below, as it is now. A familiar view to those who have been there!

The reason for this long-winded preface is that the most common question I have had to answer in the past thirty years is ‘why on earth did you come to Britain?’ 

I started medical school in 1975 in Naples. The curriculum was made of three pre-clinical years followed by three clinical ones. At the beginning of year 4, I had the option to choose what type of dissertation to prepare for the finals. In those days, the dissertation was not a formality but contributed significantly to the final mark. I could have opted for a ‘descriptive’ piece on a chosen subject or for a more challenging ‘research’ piece. The latter would require practical work for the following two years, in parallel to completing the busy curriculum of subjects and exams. Whilst I had shown some early interest in orthopaedic surgery, after 6 months of frequenting orthopaedic theatres and ward rounds, I decided that I would never become a surgeon!

Instead I became fascinated with general medicine. The first act of serendipity was to apply for a research placement in the Academic Department of Medicine when they granted me a ‘research’ dissertation in the broad subject of hypertension. It was 1978! That episode steered most of my future career. I studied the effects of alpha-beta adrenergic blockade on the peripheral vasculature of patients with hypertension using strain-gauge plethysmography of the lower limbs. I completed the study on time, wrote up the dissertation and got the highest marks at finals. 

Federico II University of Naples Medical School 
Whilst enrolled in a Specialty MD I became involved in the Olivetti Heart Study, an epidemiological study of cardiovascular risk factors and hypertension in the male workforce of a local factory near Naples. The major objective of my project was to explore a possible association between blood pressure and 24h urinary sodium excretion, a biomarker of salt consumption. This project too saw a successful completion with my first international publication

Charing Cross Hospital in Fulham 

During this time, I became fascinated with the ‘salt story’ as a possible cause of high blood pressure. The opportunity to spend some time abroad with a fellowship provided by my supervisor gave me the chance of my life (so to speak!) and I joined the Charing Cross Hospital in Fulham where Hugh de Wardener and Graham MacGregor had developed a hypothesis that would dominate the next 15 years of research in the field.   

Six months into my first research job, a rare opportunity came from the Italian Ministry of Health for a research fellowship to be spent at a foreign institution. I went for it without realising that it was a national contest with over 1,200 candidates competing for only 49 awards! My colleagues considered this an utterly unrealistic and foolish attempt. However, in order to succeed - I guess - we have to have some dose of self-belief and be determined. To cut the story short, I endured a stepwise selection with two written tests and a viva and, to everyone’s disbelief, I was awarded a fellowship. This gave me enough funds to stay three years at Charing Cross and to get married as well. These were three fantastic foundation years. I learnt a great deal about what clinical research is, how it is done, how to produce good research papers, and I began travelling the world presenting research results and developing a true passion for the subject. During this time I produced my first author paper, first BMJ paper, first Lancet paper, and first international oral presentation. 

Next time: The Growth Season. If you have any questions or comments for Professor Cappuccio please post below. 

Career learning points:

  • Follow your interest and passion.
  • Keep an open mind.
  • Be positive, things will happen.

What did my research show about salt?

  • There is a significant and graded relationship between the level of salt intake and the level of blood pressure. 
  • The kidneys are central on how sodium is handled by the body.
  • The renin-angiotensin-aldosterone system is pivotal in regulating the blood pressure response to changes in salt intake. 
  • First randomized controlled evidence that reducing salt intake reduces blood pressure