University Hospital Aintree Research Articles

Impact of the opening of a ward-based noninvasive ventilation unit on critical care

Noninvasive ventilation (NIV) is now the accepted first-line treatment for acidotic exacerbations of chronic obstructive pulmonary disease (COPD). Many hospitals perform NIV in a ward-based unit outside the ICU. Patients are still admitted to the ICU when failure of NIV may lead to mechanical ventilation, or for bed resource reasons. The impact of the opening of a ward-based NIV unit at University Hospital Aintree in July 2004 is described.

Evaluation of in-house and commercial immunoassays for the sero-diagnosis of brucellosis in a non-endemic low prevalence population

The Brucella Reference Unit (BRU) at the University Hospital Aintree offers a national Brucella sero-diagnosis service for England, Wales, Eire and Northern Ireland. The United Kingdom is a non-endemic area with a very low prevalence of infection. The objective of this study was to evaluate new CE marked assays, Brucellacapt (Vircell) and Brucella IgG and IgM ELISAs (Vircell), against the standard set of in-house serological assays used at BRU. These include a micro-agglutination (MAG) assay, in-house IgG and IgM assays and a complement fixation test (CFT). One hundred and forty-three archived serum samples were re-tested by both the commercial and in-house assays. Samples were divided into four distinct groups based on the most common clinical patterns of serological profiles seen (negative, clinically significant and two forms of clinical indeterminate results). The kappa test was calculated to determine the level of agreement between the commercial and in-house results. The kappa coefficient for Brucellacapt and MAG assays was 0.90 (95% CI 0.85, 0.95) giving a very good level of agreement. Discrepancies between positive MAG and Brucellacapt assay results (5.7%) occurred only in sera with weakly reactive MAG titres of <1:160. Similarly the kappa coefficient calculated for the IgG assays was 0.81 (95% CI 0.75, 0.87) also indicating good agreement. However, the kappa coefficient for the commercial and in-house IgM assays was poor at 0.38 (95% CI, 0.30, 0.46). The weak IgM correlation was associated in some instances, with a lack of use of IgG sorbent in the in-house assay resulting in false-negative results. In a low prevalence population, the combination of in-house and commercial immunoassays offers improvements in the sero-diagnosis of brucellosis.

Factors associated with restricted mouth opening and its relationship to health-related quality of life in patients attending a Maxillofacial Oncology clinic

Trismus can be a problematic consequence of treatment for oral and oropharyngeal cancer. The aim of this study was to investigate the relationship between trismus, subjective function and health-related quality of life, in order to postulate a clinically relevant cut-off that might be useful as an indicator of patients who might benefit from intervention. One hundred consecutive patients attending the Maxillofacial Oncology clinic at the University Hospital Aintree were assessed during a period of four months. Mouth opening was recorded in millimetres. Subjective outcomes were evaluated using UW-QOL questionnaire for chewing, saliva, mood, anxiety and overall quality of life. The median age of patients was 63 (IQR 56-69) years. The median time since treatment was 16 (IQR 6-34) months. The median mouth opening (32 mm; range 6-53, IQR 24-40) was associated strongly with clinical T stage (Tis/T1-2 35 mm, T3-4 24 mm), radiotherapy (no 38 mm, yes 27 mm) and type of primary surgery (primary closure 38 mm, soft-tissue flaps 30 mm, composite flaps 24 mm). The amount of mouth opening and of the single question (about how much less mouth opening since treatment) was significantly associated with patients perception of chewing deficit, less than full diet and less than good overall quality of life. This study supports a 35 mm cut-off for trismus. There is merit including the two elements together (opening in mm and the single item question on mouth opening since treatment) as outcome parameters.

Radiation Retinopathy After Fractionated Stereotactic Conformal Radiotherapy for Primary Intraorbital Optic Nerve Sheath Meningioma

There are just two reported cases of radiation retinopathy after fractionated stereotactic radiotherapy (SFRT) for optic nerve sheath meningioma (ONSM) (1,2). We report a further case of radiation retinopathy secondary to fractionated stereotactic conformal radiotherapy (SCRT) for biopsy-proven ONSM. A 42-year-old woman developed increasing proptosis of the right eye. Visual acuity was 20/16 in both eyes. Color vision was normal and there was no relative afferent pupillary defect. Visual fields were normal. Hertel exophthalmometry disclosed 9 mm of right axial proptosis. Ophthalmoscopy was normal. MRI showed a well-demarcated round intraconal orbital mass that abutted the globe and exhibited contrast enhancement (Fig. 1). A biopsy of the tumor disclosed an epithelial membrane antigen (EMA)-positive meningothelial meningioma (Fig. 2).FIG. 1: Postcontrast TI axial MRI shows an enhancing mass in the intraconal space of the right orbit that abuts the globe.FIG. 2: Tumor biopsy specimen (hematoxylin and eosin) shows a syncytial growth pattern and no mitotic figures, consistent with a meningothelial meningioma, World Health Organization Grade 1.The patient underwent fractionated SCRT to a total dose of 54 Gy in 30 divided fractions of 1.8 Gy. The maximum dose to the posterior retina was 54 Gy. The anterior half of the retina received a dose of <16.2 Gy. Two years after completion of radiotherapy, several cotton wool spots were noted in the right posterior pole (Fig. 3). Visual acuity remained 20/16 in each eye. Blood glucose level and antinuclear antibody were normal.FIG. 3: A. Right fundus photograph taken 2 years after completion of radiotherapy shows multiple cotton wool spots and a retinal hemorrhage inferior to the fovea, findings consistent with radiation retinopathy. B. Right fundus fluorescein angiogram shows late perivenous staining.A retinal fluorescein angiogram showed areas of capillary closure, microaneurysms, and venous staining in the right fundus (Fig. 3). Visual acuity dropped over the next 6 months to 20/40, and new blot hemorrhages were noted, but no edema or proliferative changes were seen. In the first reported case of radiation retinopathy after SFRT for ONSM (1), the patient received the same treatment as did our patient: 30 fractions of 1.8 Gy for a total dose of 54 Gy. The posterior retina received 27-48 Gy. Fluorescein angiography showed findings similar to those of our patient. These changes worsened over the next few months despite laser photocoagulation. The second report consisted of a letter by Levi (2) about a 57-year-old man diagnosed with optic nerve sheath meningioma who underwent SFRT with the same tumor dose (2). Five years after treatment, visual acuity dropped, and fluorescein angiography showed findings similar to those of our patient. Our case differs from the two previously reported cases in that the diagnosis was biopsy-proven and that 3D conformal methods were used to minimize collateral radiation damage. Many patients have now received radiotherapy for ONSM, and this is only the third reported case of radiation retinopathy. Our patient may have been relatively more vulnerable to radiation retinopathy because of the biopsy and the fact that the treatment field included the posterior retina, as in the case reported by Subramanian et al (1). In the case reported by Levi (2), the radiation dose to the posterior retina and the proximity of the tumor to the globe were not mentioned. Whether ONSM would respond to doses lower than 54 Gy in 30 fractions (the standard dose) is not known. It may be prudent to examine the possibility of treatment using a lower radiation dose, particularly for ONSMs that abut the globe. Radhika Krishnan, MA (Cantab), MRCOphth Indu Kumar, MRCOphth Graham Kyle, FRSCEd, FRCOphth Ophthalmology Department Walton Daycase and Outpatient Centre University Hospital Aintree Liverpool, UK [email protected] David John Husband, MRCP (UK), FRCR Clatterbridge Centre for Oncology Bebington, Cheshire, UK

Initiating tumor banking for translational research: MD Anderson and Liverpool experience

The ultimate progress in the cancer diagnosis and therapy has only been possible with the ongoing translational research that is likely to play a very important role in future as well. Hence the importance of such translation from bedside to bench and vis versa cannot be over-emphasized. Accordingly it has become more important to collect tumor samples along with the clinical information in a systematic manner to perform a good basic science research in future. With a population of over a billion and a heavy burden of cancer, India has the 'biggest' potential to establish the 'largest' tumor bank across the globe. Establishing a tumor bank involves money and manpower that may not be feasible across most of the centers in India. Taking into the considering the model of tumor banking of the two leading institutions of the world (MD Anderson Cancer Center, USA and University Hospital Aintree, Liverpool UK), this article presents the salient tips for a center in India to get started with tumor banking with minimal investment. Furthermore a simplified form of ethical consent is presented for the centers to adapt unanimously.

Issues of human rabies immunoglobulin and vaccine: policy versus practice

A retrospective audit was conducted of all issues of rabies vaccine or human rabies immunoglobulin (HRIG) from the Clinical Microbiology Department at University Hospital Aintree for post-exposure prophylaxis. The appropriateness of management was reviewed by a blinded panel, which used guidelines issued by the Health Protection Agency (HPA) as a standard. Thirty-six enquiries, on average 9 days following exposure, led to issues of HRIG, rabies vaccine or both. Dog bites accounted for the majority of incidents. In no cases was the biting animal recorded as having been observed for signs of rabies. Management was judged to have been inappropriate in 9 cases, and documentation was judged to have been unsatisfactory in 13 cases. This study has highlighted several areas of ambiguity in the current guidelines, and a number of deficiencies in the information prompted by the standardized proformas used to deal with post-exposure queries.

Response to Hannan and Kotecha

Clinical OtolaryngologyVolume 31, Issue 4 p. 342-342 Response to Hannan and Kotecha T.M. Jones, T.M. Jones The Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK, E-mail: [email protected]Search for more papers by this authorJ.E. Earis, J.E. Earis The Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK, E-mail: [email protected]Search for more papers by this authorA.C. Swift, A.C. Swift The Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK, E-mail: [email protected]Search for more papers by this authorP. Charters, P. Charters The Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK, E-mail: [email protected]Search for more papers by this author T.M. Jones, T.M. Jones The Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK, E-mail: [email protected]Search for more papers by this authorJ.E. Earis, J.E. Earis The Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK, E-mail: [email protected]Search for more papers by this authorA.C. Swift, A.C. Swift The Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK, E-mail: [email protected]Search for more papers by this authorP. Charters, P. Charters The Department of Otolaryngology/Head and Neck Surgery, University Hospital Aintree, Liverpool, UK, E-mail: [email protected]Search for more papers by this author First published: 26 July 2006 https://doi.org/10.1111/j.1749-4486.2006.01253.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume31, Issue4August 2006Pages 342-342 RelatedInformation

Successful cardiovascular risk reduction in Type 2 diabetes by nurse‐led care using an open clinical algorithm

To implement a protocol-driven, nurse-led cardiovascular risk reduction clinic using an open clinical algorithm. The primary aim of the clinic was to optimize blood pressure (BP) control; secondary aims were to reduce modifiable cardiovascular risk factors. We studied 110 people with Type 2 diabetes attending a diabetes out-patient centre at University Hospital Aintree, Liverpool. Patients taking one or more antihypertensive drugs were selected for referral to the nurse-led clinic if BP was > 140/85 mmHg; there was no age threshold. An open clinical algorithm was designed to direct the nurse on the use of antihypertensive, statin and aspirin therapy plus lifestyle advice and concordance. Thirty-one percent of patients attending for a first visit to the nurse-led clinic had BP within target when measured to British Hypertension Society standards out of the consultant clinic. Mean BP was 150/76 mmHg compared with 178/88 mmHg (P < 0.001). Subsequently, BP was reduced to 130/68 mmHg (P < 0.001), this reduction being sustained at review 9 months later (mean BP 133/67 mmHg), with 87 (79%) achieving BP <or= 140/85 mmHg. Treatment modalities were adjusted to reduce cardiovascular risk, including antihypertensive medication, lipid-lowering therapy and antiplatelet therapy. High-density lipoprotein-cholesterol improved from 1.2 +/- 0.5 mmol/l to 1.4 +/- 0.5 mmol/l (P = 0.004). The number of patients with microalbuminuria decreased from 41 (47%) to 25 (28%) (P = 0.02), with a fall in urinary albumin:creatinine ratio from 3.0 (1.3-7.9) to 1.8 (1.0-5.0) mg/mmol (P = 0.01). The number of smokers decreased from 22 (20%) to 14 (13%) (P = 0.01). Although not included as an intervention in the protocol, HbA1c improved to 8.1 +/- 1.6% from 8.7 +/- 1.6% (P < 0.001). A protocol-driven, nurse-led clinic using an open clinical algorithm can be used effectively to manage cardiovascular risk reduction in Type 2 diabetes.

Immunohistochemical expression of p53 and MDM2 within head and neck squamous cell carcinoma

Objectives. To determine the presence, location and degree of expression of p53 and MDM2, by use of immunohistochemistry, in squamous cell carcinoma of the head and neck (HNSCC). Design. Laboratory based observational study. Setting. University Hospital Aintree, Liverpool and The University of Liverpool. Participants. Twenty‐three consecutive patients with HNSCC were studied. Ethics approval and informed patient consent were gained. Paraffin sections of carcinoma were stained for p53 and MDM2. Sections were assessed by stratified random sampling of the periphery and centre of the tumour for nuclear staining. Main outcomes measures. (i) Number of positive cases for p53 and MDM2; (ii) percentage of cells positive for p53 and MDM2; (iii) variation of positive cells within the tumour. Results. The range of p53 positivity was 0–100%; 10 cases were negative for p53, five cases were intermediate for p53, seven cases were highly positive for p53. The range of MDM2 positivity was 0–16%; 10 cases were negative for MDM2, four cases were intermediate for MDM2, nine cases were highly positive for MDM2. 10 cases were predominantly p53 positive, eight cases were predominantly MDM2 positive and five cases were negative for both p53 and MDM2. There was no consistent difference between the edge and the centre for either antibody, however for MDM2, there is increased expression in peri‐necrotic areas. Conclusions. (i) HNSCC shows different patterns of p53 and MDM2 co‐expression, which has potential biological and clinical significance; (ii) peri‐necrotic expression of MDM2 may be explained by a response to hypoxia.

Acoustic parameters of snoring sound to compare natural snores with snores during ‘steady‐state’ propofol sedation

To investigate the acoustic similarity between natural and sedation-induced snores. Prospective observational study. University Hospital Aintree, Liverpool, UK. Twenty-one patients, who had already had overnight snore recordings, completed a pre-operative sleep nasendoscopic examination. Endoscopic examination of the upper aero-digestive tract was performed at sequentially increasing, steady-state sedation levels, using intravenous propofol administered according to a weight/time-based algorithm to predict blood and effect site (tissue) concentrations. At each sedation level at which snoring occurred, snoring sound was recorded. From these samples, snore files, comprising the inspiratory sound of each snore were created. Similarly, from natural snores recorded pre-operatively, snore files, comprising the inspiratory sounds of the first 100 snores with the patient sleeping in a supine position, were also created. Snore duration (s), loudness (dBA), periodicity (%) and energy ratios for the frequency sub-bands 0-200, 0-250 and 0-400 Hz. Snore loudness increased significantly (P < 0.0001), whilst energy ratios for frequency bands 0-200, 0-250 and 0-400 Hz all decreased significantly as sedation level increased (P < 0.001). A significant difference between natural snoring and snoring induced at the lowest sedation level was shown (P < 0.0001). Endoscopic examination was not tolerated at this sedation level. The acoustic characteristics of sedation-induced and natural snores are sufficiently different to recommend the need for further research to determine whether the technique of sleep nasendoscopy is, in fact, a valid predictor of outcome of snoring surgery.

Neodymium:YAG Laser Peripheral Iridotomy: Cause of a Visually Incapacitating Cataract?

Neodymium:YAG (Nd:YAG) laser peripheral iridotomy is the procedure of choice to treat and avoid further episodes of angle-closure glaucoma. A patient who developed a visually incapacitating posterior subcapsular lens opacity shortly after Nd:YAG laser peripheral iridotomy is described. The patient underwent cataract surgery and achieved a good level of visual acuity postoperatively. The intraocular pressure remained under control with no medical treatment. This case suggests a possible, albeit rare, potential complication of Nd:YAG laser peripheral iridotomy.

Neoadjuvant Chemotherapy for Metastatic Colon Cancer: A Cautionary Note

Anton J. Bilchik, John Wayne Cancer Institute at St John’s Health Center, Santa Monica, CA Graeme Poston, Royal Liverpool and Aintree University Hospitals, Liverpool, UK Steven A. Curley, The University of Texas M.D. Anderson Cancer Center, Houston, TX Steven Strasberg, Siteman Cancer Center at Washington University in St Louis, St Louis, MO Leonard Saltz, Memorial Sloan Kettering Cancer Center, New York, NY Rene Adam, Paul Brousse Hospital, Paris, France Bernard Nordlinger and Philippe Rougier, Paul Brousse Hospital, Paris, France Lee S. Rosen, John Wayne Cancer Institute at St John’s Health Center, Santa Monica, CA

Snoring Surgery: A Retrospective Review

To undertake a retrospective, questionnaire review of surgery for heavy snoring, to ascertain patients' perception of the procedure and its effect on their snoring. A specifically designed postal questionnaire was sent to 261 patients who underwent snoring surgery at University Hospital Aintree, Liverpool, UK, between April 1993 and March 2000. One hundred ninety-three patients responded (73.9%), including 151 men and 42 women. Mean age was 49.0 years (range, 24-74 yrs). Twenty-two patients had a uvulopalatopharyngoplasty, 53 a traditional laser palatoplasty and uvulectomy, and 118 an uvulopalatal elevation palatoplasty. There was a 26% patient-reported postoperative infection rate. Morbidity regarding postoperative swallowing, pharyngeal sensation or voice change appeared minimal. Seventy-six percent scored postoperative pain as "moderate" or "severe," irrespective of the operation performed (P = 0.989). Thirty-seven percent of patients perceived an improvement in postoperative sleep quality. Twenty-four percent of patients reported no improvement in snoring after surgery. Forty-three percent reported an initial improvement that was not sustained for 2 years, whereas 34% of patients benefited from an improvement sustained for longer than 2 years, irrespective of the operation performed (P = 0.143). Only 47%, with hindsight, would have undergone surgery. These data highlight that snoring surgery has a high postoperative morbidity rate and a high failure rate. Research endeavors should be directed to the development of a strategy which enables reliable preoperative identification of patients' who enjoy sustained benefit postoperatively.

Reply

Diabetic MedicineVolume 22, Issue 5 p. 667-667 Reply S. M. A. Bennett, S. M. A. Bennett Department of Diabetes and Metabolism, University of Newcastle, Newcastle-upon-Tyne, UK, Search for more papers by this authorM. Heise, M. Heise GlaxoSmithKline, Collegeville, PA, USA, Search for more papers by this authorN. P. Jones, N. P. Jones GlaxoSmithKline, Harlow and Search for more papers by this authorM. Walker, M. Walker Department of Diabetes and Metabolism, University of Newcastle, Newcastle-upon-Tyne, UK, Search for more papers by this authorJ. P. H. Wilding, J. P. H. Wilding University Hospital Aintree, Liverpool, UKSearch for more papers by this author S. M. A. Bennett, S. M. A. Bennett Department of Diabetes and Metabolism, University of Newcastle, Newcastle-upon-Tyne, UK, Search for more papers by this authorM. Heise, M. Heise GlaxoSmithKline, Collegeville, PA, USA, Search for more papers by this authorN. P. Jones, N. P. Jones GlaxoSmithKline, Harlow and Search for more papers by this authorM. Walker, M. Walker Department of Diabetes and Metabolism, University of Newcastle, Newcastle-upon-Tyne, UK, Search for more papers by this authorJ. P. H. Wilding, J. P. H. Wilding University Hospital Aintree, Liverpool, UKSearch for more papers by this author First published: 18 April 2005 https://doi.org/10.1111/j.1464-5491.2005.01472b.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Volume22, Issue5May 2005Pages 667-667 RelatedInformation

Perioperative complications of intraocular lens exchange in patients with opacified Aqua-Sense lenses

To evaluate the perioperative complications of intraocular lens (IOL) exchange in 25 eyes of 22 patients with opacified Aqua-Sense IOLs (Ophthalmic Innovations International). Department of Ophthalmology, University Hospital Aintree, Liverpool, United Kingdom. The study comprised 22 patients (25 eyes) who had previous phacoemulsification and implantation of Aqua-Sense single-piece hydrophilic acrylic IOLs in the capsular bag and developed severe late opacification of the IOL. All patients reported glare and deterioration in vision. The IOLs were explanted and replaced with new lenses. The perioperative complications were evaluated. The best corrected visual acuity (BCVA) before and after surgery was compared. In 24 eyes, the opacification was complete, involving the optic, haptics, and substance of the IOLs. Uneventful IOL exchange and placement of a new IOL in the bag was achieved in 13 eyes (52%). Complications occurred in the remaining 12 eyes (48%). Ten eyes (40%) developed zonular dehiscence, 4 (16%) of which were managed with anterior chamber IOL implantation. One eye (4%) developed posterior capsule rupture and 1 eye (4%), posterior capsule rupture and zonular dehiscence. The cornea decompensated in 2 eyes (8%). One eye (4%) developed Pseudomonas keratitis. The mean BCVA (decimal scale) before and after IOL exchange was 0.57 +/- 0.24 and 0.60 +/- 0.28, respectively. There was no significant difference in visual acuity between before and after IOL exchange (P=.782, paired t test). Explantation of Aqua-Sense IOLs was challenging because of the tight adherence of the optic and haptics to the capsule. Long-term follow-up of patients with Aqua-Sense IOLs should be maintained.

Use of medical honey in patients with chronic venous leg ulcers after split-skin grafting

To assess the use of medical honey on healing times and complications in patients with venous leg ulcers after split-skin grafting. Healing time and morbidity were evaluated in six patients with chronic venous leg ulcers who underwent split-skin grafting followed by the application of medical honey at the vascular unit of University Hospital Aintree in Liverpool. Mean healing time was 22 days. There were no complications. The use of medical honey in patients who have received split-skin grafts for chronic venous leg ulcers appears to give a similar healing time to that seen without the application of honey. There were no major complications. Larger prospective randomised controlled trials are needed to confirm the findings.

In and out of Africa

Ellen Welch talks to Geoff Gill, consultant in general medicine, diabetes, and endocrinology at the University Hospital Aintree and reader at the Liverpool School of Tropical Medicine, and discovers that tropical medicine isn9t all about infectious disease

Award winner.

Junior A&E sister at University Hospital Aintree Judith McGregor is the latest winner of a nursing award worth almost £1,000.

News

Give and take: Emergency nurse practitioner Cathy Sands (left) lends a helping hand to Andrew Woods, one of four paramedics who have started a three-month programme of working alongside A&E staff at University Hospital Aintree, Liverpool. The paramedics are acting as grade D nurses to help relieve pressure on A&E staff and shorten waiting times.

The role of the nurse consultant in infection control

W ith the advent of the Controls Assurance Standards (NHS Executive, 1999), Clinical Governance (1999), The Management and Control of Hospital Acquired Infections in Acute NHS Trusts in England (Department of Health, 2000) and other circulars and directives, the role of the infection control nurse has never been so challenging, putting infection control firmly on the government and public agenda. In line with this and the Health Service Circular 1999/217 Nurse Midwife and Health Visitor Consultants (Department of Health, 1999), it enabled the appointment of a nurse consultant in infection control at University Hospital Aintree, Liverpool. This paper will review the background to the development of the role to date, how it applies to the discipline of infection control and suggest how to take the role forward in the future.