Research

I have been involved in research at every stage of my career, recognising its importance for improving both education and clinical care. I predominantly worked in the areas of medical education, global health, and cardiology.

Medical Education

My work in medical education has predominantly centred around empowering students and junior doctors to contribute to developing educational resources. We have found that this highly motivated group not only offer something very valuable to medical education, but also have a huge amount to gain in terms of professional development from contributing to the process.

Flipped Publishing: A New Paradigm for Medical Textbooks

Shahab Shahid, Mark Rodrigues, Simon Maxwell, Katrina Mason, Madelaine Gimzewska, Zeshan Qureshi

Medical textbooks remain an integral component of the undergraduate education pathway. These texts are traditionally prepared by senior clinicians or academics, based on their long experience of the subject matter. Medical students and junior doctors are commonly asked to review these books, but often have little role in influencing the content. This article will discuss the opening of a new paradigm in medical publishing, whereby students and junior doctors (juniors) take the lead in planning and producing the content of their textbooks with senior clinicians taking the role of reviewer.

Back to the bedside: the role of bedside teaching in the modern era

Zeshan Qureshi

Fifty years ago, three-quarters of clinical teaching was at the bedside. Today’s estimates are 8–19 %. This reduced exposure in undergraduate years to a critical aspect of training may be responsible, in part, for the declining clinical skills of junior doctors. Peters and ten Cate have reviewed the literature on bedside teaching, assessing its strengths, the causes of its decline, and its potential role in medical education.

Perceived tutor benefits of teaching near peers: insights from two near peer teaching programmes in South East Scotland

ZU Qureshi, KR Gibson, MT Ross and S Maxwell

There is little evidence about the benefits to junior doctors of participating in teaching, or how to train doctors as teachers. We explore (through South East Scotland based teaching programmes):

  1. How prepared do junior doctors feel to teach?
  2. What junior doctors consider to be the main challenges of teaching?
  3. What motivates the junior doctors to continue teaching, and what is the perceived impact of teaching on their professional development?
Zeshan Qureshi - Deakin Presentation

Developing junior doctor-delivered teaching

Zeshan Qureshi, Michael Ross, Simon Maxwell, Mark Rodrigues, Constantinos Parisinos, H. Nikki Hall

Medical textbooks remain an integral component of the undergraduate education pathway. These texts are traditionally prepared by senior clinicians or academics, based on their long experience of the subject matter. Medical students and junior doctors are commonly asked to review these books, but often have little role in influencing the content. This article will discuss the opening of a new paradigm in medical publishing, whereby students and junior doctors (juniors) take the lead in planning and producing the content of their textbooks with senior clinicians taking the role of reviewer.

Zeshan Qureshi - Monash

Perceived tutor benefits of teaching near peers: Insights from two near peer teaching programmes in South East Scotland

Zeshan U. Qureshi, Kyle R. Gibson, Michael Ross, Simon Maxwell

Increasing emphasis is being placed on training to teach and teaching opportunities for doctors at all career stages. A number of junior doctor-led teaching programmes have been described in the literature, with some evidence suggesting that students perceived such programmes of similar quality to teaching from senior faculty. Two such programmes in South East Scotland are ‘Bedside Teachers’ (teaching clinical examination on real patients) and ‘Year 5 Prescribing’ (teaching practical prescribing). We evaluated the benefits of participating in these programmes.

University of Melbourne

Centrally organised bedside teaching led by junior doctors

Zeshan Qureshi, Matthew Seah, Michael Ross, Simon Maxwell

Clinical bedside teaching is arguably the most favoured form of teaching by medical students, but has been on the decline in recent years. Junior doctors are often underused as teachers and, with adequate training, may help to solve this problem. Bedside Teachers is a junior doctor-led teaching programme that is delivered throughout South-East Scotland, and is now in its third year. This study aimed to investigate the perceptions of final-year medical students participating in the Bedside Teachers programme, and how they compared this with teaching from senior staff.

Zeshan Qureshi - Unofficial Guide to Medicine selling

Has bedside teaching had its day?

Zeshan Qureshi, Simon Maxwell

Though a diverse array of teaching methods is now available, bedside teaching is arguably the most favoured. Students like it because it is patient-centred, and it includes a high proportion of relevant skills. It is on the decline, coinciding with declining clinical skills of junior doctors. Several factors might account for this: busier hospitals, broader roles of clinicians, competing teaching modalities, and the limited training of clinicians as medical educators.

However, bedside teaching offers unique benefits. Students gain firsthand experience of the doctor patient relationship. They see the process of interacting with patients, investigative yet sensitive, demystified. Certain clinical skills, like the recognition of the tactile sensation of hepatosplenomegaly cannot be simulated elsewhere.

Bedside Teaching

Zeshan Qureshi, Simon Maxwell

Students like bedside teaching because it is patient-centred, contextualises knowledge and provides direct contact with experienced practitioners. Fifty years ago, three quarters of clinical teaching was at the bedside, but by 1978 one estimate suggested it had already decreased to less than a fifth, and a glance at many current student timetables indicates that it has declined even further since. This reduced exposure in undergraduate years may be partly responsible for declining clinical skills.

Bedside teaching opens the mind to the reality of clinical medicine that perhaps cannot be mimicked with an actor. The balance of being efficient with time, yet establishing a rapport with patients can be learned. Although some clinical signs and experiences can be simulated, many cannot (e.g. the tactile experience of hepatosplenomegaly or joint effusions). The progressive decline of bedside teaching is the consequence of several factors. In increasingly busy hospitals, the availability of teachers is reduced as well as the availability of patients, who spend less time in hospital and have a generally ‘busier’ in-patient stay. Teachers, despite an interest in bedside teaching, now find themselves with broader roles in the hospital. There may also be a perception that the bedside teaching, as it was formerly practiced, is intruding or demeaning to patients.

Global Health

My work in global health is focused on maternal and child health. Stillbirth prevention is a key issue, particularly knowing that the majority of the 2.6 million stillbirths each year are entirely preventable.

Ending preventable stillbirths 2 : Stillbirths: rates, risk factors, and acceleration towards 2030

Joy E Lawn, Hannah Blencowe, Peter Waiswa, Agbessi Amouzou, Colin Mathers, Dan Hogan, Vicki Flenady, J Frederik Frøen, Zeshan U Qureshi, Claire Calderwood, Suhail Shiekh, Fiorella Bianchi Jassir, Danzhen You, Elizabeth M McClure, Matthews Mathai, Simon Cousens, for The Lancet Ending Preventable Stillbirths Series study group* with The Lancet Stillbirth Epidemiology investigator group*

An estimated 2·6 million third trimester stillbirths occurred in 2015 (uncertainty range 2·4–3·0 million). The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030. 94 mainly high-income countries and upper middle-income countries have already met this target, although with noticeable disparities. At least 56 countries, particularly in Africa and in areas aff cted by conflict, will have to more than double present progress to reach this target.

Zeshan Qureshi - RCPCH 2016

Stillbirth should be given greater priority on the global health agenda

Zeshan U Qureshi, Joseph Millum, Hannah Blencowe, Maureen Kelley, Edward Fottrell, Joy E Lawn, Anthony Costello, Tim Colbourn.

The global rate of stillbirths was estimated to be 18.9 per 1000 births in 2009, equating to a total of 2.64 million stillbirths, 1.2 million of which were during labour. The burden is heaviest for women in low and middle income countries and the poorest women in high income countries. Given its scale, stillbirth prevention should be high on the global health agenda. However, in the current draft of the United Nations sustainable development goals, which sets global targets for 2015-30, stillbirth is not mentioned, even though neonatal and under 5 mortality rates are included.

National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis

Hannah Blencowe, Simon Cousens, Fiorella Bianchi Jassir, Lale Say, Doris Chou, Colin Mathers, Dan Hogan, Suhail Shiekh, Zeshan U Qureshi, Danhzen You, Joy E Lawn, for the Lancet Stillbirth Epidemiology Investigator Group*

Previous estimates have highlighted a large global burden of stillbirths, with an absence of reliable data from regions where most occur. The Every Newborn Action Plan (ENAP) targets national stillbirth rates (SBRs) of 12 or fewer stillbirths per 1000 births by 2030. We estimate SBRs and numbers for 195 countries, including trends from 2000 to 2015.

We collated SBR data meeting prespecified inclusion criteria from national routine or registration systems, nationally representative surveys, and other data sources identified through a systematic review web-based searches, and an investigator group.

Zeshan Qureshi - Perth presentation

The case for launch of an international DNAbased birth cohort study

Igor Rudan, Mickey Chopra, Yurii Aulchenko, Abdullah H. Baqui, Zulfiqar A. Bhutta, Karen Edmond, Bernardo L. Horta, Keith P. Klugman, Claudio F. Lanata, Shabir A. Madhi, Harish Nair, Zeshan Qureshi, Craig Rubens, Evropi Theodoratou, Cesar G. Victora, Wei Wang, Martin W. Weber, James F. Wilson, Lina ZgagaHarry Campbell

The global health agenda beyond 2015 will inevitably need to broaden its focus from mortality reduction to the social determinants of deaths, growing inequities among children and mothers, and ensuring the sustainability of the progress made against the infectious diseases. New research tools, including technologies that enable high-throughput genetic and ‘-omics’ research, could be deployed for better understanding of the aetiology of maternal and child health problems.

Cardiology

As an undergraduate, I worked closely with Professor Nick Curzen at Southampton University exploring personalised medicine in cardiology. This has helped lead to a shift from patients suffering heart attacks being treated with a ‘one size fits all’ approach, to patients getting tailored therapy to their individual needs, their individual disease, and their individual bodies.

Clopidogrel %22Resistance%22 : Where are We Now?

Zeshan Qureshi & Alex R. Hobson

Antiplatelet therapy with aspirin and clopidogrel in PCI patients, though effective, is still associated with thrombotic complications. These are multifactorial in origin, but partially attributable to “clopidogrel resistance.” However, how best to identify and manage “clopidogrel resistance” remains unclear. Targeting therapeutic changes specifically at those individuals with poor response to clopidogrel is likely to be a solution. A “one size fits all” approach to clopidogrel dosing is probably flawed.

This review will explore (1) the definition and mechanisms of clopidogrel resistance, (2) assessment of clopidogrel resistance, by (i) platelet function testing and (ii) genetic testing, (3) the management of “clopidogrel resistance,” and (4) newer antiplatelet agents, and evolving stent technology. A pubmed literature review was performed using the keywords “clopidogrel”, “resistance”, “poor response”, “adverse events”, “platelet function tests”, and “genetic tests”. In looking at new
agents, keywords “prasugrel”, “cangrelor”, “ticagrelor”, “Elinogrel”, and “P2Y12 receptor antagonists” were used. Third, a search was performed looking at “stent design”, “”IVUS”, “bioabsorbable stents”, and “stent apposition”. Whilst new P2Y12 receptor antagonists and improved stent technology may reduce thrombotic events in the future, there is still a need for clopidogrel.

The Potential Value of Near Patient Platelet Function Testing in PCI: Randomised Comparison of 600 mg versus 900 mg Clopidogrel Loading Doses

Alex R. Hobson, Zeshan Qureshi, Phil Banks and Nicholas Curzen

The clinical value of dual antiplatelet therapy with aspirin and clopidogrel to reduce platelet-mediated cardiovascular events is now well established in patients with acute coronary syndromes and those receiving intracoronary stents. In the field of PCI, in particular, a large and expanding body of evidence indicates that periprocedural complication rates can be reduced by loading doses of clopidogrel given at least 6 hours before planned stenting. The superiority of 600 mg loading doses of clopidogrel over 300 mg is now widely accepted.

Effects of clopidogrel on ‘%22aspirin specific%22 pathways of platelet inhibition

Alex R. Hobson, Zeshan Qureshi, Phil Banks, & Nick P. Curzen

The most widely accepted methods of assessing response to clopidogrel involve isolated ADP-induced platelet aggregation. Whilst poor response determined by these assays correlates with adverse clinical events, the number of “poor responders” is far higher than the number of events attributed to treatment failure. Clopidogrel may have effects that cannot be assessed using isolated ADP-induced aggregation. We have investigated the effect of clopidogrel on Arachidonic Acid (AA) induced platelet activation – an “aspirin specific” pathway using a novel near patient assay.

Gender and Responses to Aspirin and Clopidogrel: Insights Using Short Thrombelastography

Alex R. Hobson, Zeshan Qureshi, Phil Banks & Nick Curzen.

There is significant variability in both baseline clotting tendency and response to antiplatelet therapy. Responses are associated with outcome. We have investigated whether differences could explain the increased risk observed in women presenting with coronary artery disease. We have utilized short thrombelastography to assess (i) baseline clotting responses, (ii) response to aspirin and clopidogrel, and (iii) post-treatment platelet reactivity in 48 young volunteers, 22 older patients and 18 patients with previous stent thrombosis.

Baseline responses were significantly higher in young women than in men. While there was no difference in response to aspirin, platelet reactivity on aspirin remained higher in women (area under curve at 15 min [AUC15] of arachidonic acid channel 332 ± 122 vs. 172 ± 80, P = 0.04). Young women had less response to clopidogrel (% reduction in AUC15 with adenosine diphosphate [ADP] 36.4 ± 12.4 vs. 64.0 ± 13.2, P < 0.01) in addition to higher post-treatment reactivity (AUC15 of ADP 714 ± 161 vs. 311 ± 146, P < 0.01) compared to men.

There were no such differences between male and female patients over 50. However, young women with previous stent thrombosis had among the highest platelet reactivity observed. Compared to men, young women have greater baseline clotting tendency, reduced response to clopidogrel, and greater post-treatment reactivity while on both aspirin and clopidogrel.

Miscellaneous

Adverse effects of activated charcoal used for the treatment of poisoning

Zeshan Qureshi & Michael Eddleston

The incidence of adverse effects of activated charcoal in poisoned patients is unclear. We performed a search of PubMed, EMBASE, and Ovid to identify large cohorts, and both randomized and pseudorandomized controlled trials, finding nine articles. The most commonly described adverse events were vomiting, aspiration, and intubation. Activated charcoal did not increase the incidence of vomiting [25 of 166 patients receiving charcoal vs. 23 of 161 not receiving charcoal, relative risk (RR) 1.05, 95% confidence interval (CI) 0.63–1.77, P¼0.84], aspiration (1 of 166 patients receiving charcoal vs. 1 of 161 not receiving charcoal, RR 0.97, 95% CI 0.10–9.37, P¼0.98), or intubation (154 of 3087 patients receiving charcoal vs. 79 of 1636 not receiving charcoal, RR 1.03, 95% CI 0.79–1.34, P¼0.82 AQ6).

Other adverse events such as bowel obstruction, corneal abrasions, electrolyte disturbances, and seizures were rarely reported in the trials. Activated charcoal was associated with few clinically significant adverse events in the treatment of poisoned patients.

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