University Hospital Birmingham NHS Trust Research Articles

Global evaluation and outcomes of cholecystectomy: protocol for a multicentre, international, prospective cohort study (GlobalSurg 4)

IntroductionCholecystectomy is one of the most common operations performed worldwide. Although laparoscopic surgery has been the ‘gold-standard’ approach for this operation, there is a paucity of global evidence around the...

Does a Healthy Weight Body Mass Index at Onset of Idiopathic Intracranial Hypertension Change the Outcomes? A United Kingdom Prospective Cohort Study

ABSTRACT Idiopathic intracranial hypertension (IIH) predominantly affects reproductive-aged females with obesity. However, the prevalence and impact of a healthy weight body mass index (BMI) at disease presentation is not known. This study aimed to evaluate the visual and headache outcomes stratified by the presenting BMI. This was a longitudinal prospective cohort study (IIH Life) based on a tertiary neuro-ophthalmology IIH service, University Hospitals Birmingham NHS Trust, United Kingdom, recruiting consecutive patients living with IIH between 2012 and 2021. Those with a presenting BMI were included. The outcome measures included visual outcomes of LogMAR visual acuity, Humphrey visual field perimetric mean deviation (PMD), optical coherence tomography (OCT) measurements, and headache outcomes of frequency, severity, and Headache Impact Test-6 score. Three hundred seventy-five people with IIH and a documented baseline BMI. About 3.7% of the entire cohort had a healthy weight BMI at IIH presentation and 15.5% BMI < 30 kg/m2. The baseline PMD was worse in patients without obesity; however, OCT papilloedema measures were similar. The presence of obesity was associated with a small but significant greater worsening in visual acuity but slower macular ganglion cell layer loss. There was no impact on PMD or papilloedema prognosis related to baseline obesity. The headache outcomes showed heterogeneity, with worse baseline headache frequency in patients with obesity. No BMI group was associated with worse headache outcomes. Patients with a healthy weight BMI or those without obesity at baseline make up a small proportion of IIH patients. BMI at presentation does not appear to influence long-term visual or headache outcomes.

Ultrahypofractionated breast radiotherapy during SARS-CoV-2 virus pandemic, beyond fast-forward trial: a local experience

Abstract Background: During the SARS-CoV-2 virus pandemic, University Hospital Birmingham NHS Trust Oncology Department incorporated the ultrahypofractionated regime of 26Gy/5 fractions alongside the moderate hypofractionated regime of 40Gy/15 fractions as part of local adjuvant breast radiotherapy treatment (RT) for eligible patients. We conducted a local study to assess the real-life experience of patients undergoing ultrahypofractionated schedule to compare feasibility and toxicity to the fast-forward trial during the COVID − 19 pandemic. Methods: A single institution, retrospective, qualitative study. Patients included had early-stage breast cancer and received adjuvant radiotherapy between 23 March 2020 and 31 May 2020, a total of 211 patients. Inclusion was irrespective of any other neoadjuvant/adjuvant treatments. Data were collected retrospectively for treatment dose, boost dose and toxicity. Results: Of the total 211 patients, 85 were treated with 26Gy in 5# and 19 patients received a boost as per the fast-forward protocol. Of these 85 patients, 15·9% did not report any skin toxicity post-treatment. 63·5% of patients reported RTOG Grade 1, 15·9% had RTOG Grade 2, and 1·6% reported RTOG Grade 3 skin toxicity. 3·2% of the patients could not be contacted for follow-up. Of the 19 patients who received a breast boost, 10·53% reported no skin changes. 78·9% reported Grade 1 skin toxicity. Both Grades 2a and 2b skin toxicity were reported by 5·26% each. The patient demographics and tumour characteristics in our study cohort were comparable to those within the fast-forward trial. In terms of post-RT skin toxicity, fewer patients reported any toxicity in the UHB patient cohort versus those in the trial, and the number of Grade 2/3 toxicities reported was also low. A delay in toxicity reporting from 2 weeks for 40Gy/15 to 3 weeks for 26Gy/5 was observed. Conclusion: Our study concluded that offering ultrahypofractionation was convenient for patients; reducing the number of hospital visits during the SARS-CoV-2 virus pandemic appeared safe in terms of acute post-RT-related skin toxicity. The reduced hospital visits limited exposure of patients and staff to the SARS-CoV-2 virus while also ensuring efficient use of Radiotherapy Department resources. Local follow-up protocols have been amended to ensure review at 3 weeks for the 26Gy/5 schedule to acknowledge the delay in acute toxicity development. To date, there is only 5-year toxicity and relapse data available from the fast-forward trial; therefore, hypofractionation schedules should be offered to patients as long as they fulfil the criteria and understand the limitations of the study as well as accelerated peer review processes in the face of the pandemic.

A fast, accurate, and generalisable heuristic-based negation detection algorithm for clinical text

Negation detection is an important task in biomedical text mining. Particularly in clinical settings, it is of critical importance to determine whether findings mentioned in text are present or absent. Rule-based negation detection algorithms are a common approach to the task, and more recent investigations have resulted in the development of rule-based systems utilising the rich grammatical information afforded by typed dependency graphs. However, interacting with these complex representations inevitably necessitates complex rules, which are time-consuming to develop and do not generalise well. We hypothesise that a heuristic approach to determining negation via dependency graphs could offer a powerful alternative. We describe and implement an algorithm for negation detection based on grammatical distance from a negatory construct in a typed dependency graph. To evaluate the algorithm, we develop two testing corpora comprised of sentences of clinical text extracted from the MIMIC-III database and documents related to hypertrophic cardiomyopathy patients routinely collected at University Hospitals Birmingham NHS trust. Gold-standard validation datasets were built by a combination of human annotation and examination of algorithm error. Finally, we compare the performance of our approach with four other rule-based algorithms on both gold-standard corpora. The presented algorithm exhibits the best performance by f-measure over the MIMIC-III dataset, and a similar performance to the syntactic negation detection systems over the HCM dataset. It is also the fastest of the dependency-based negation systems explored in this study. Our results show that while a single heuristic approach to dependency-based negation detection is ignorant to certain advanced cases, it nevertheless forms a powerful and stable method, requiring minimal training and adaptation between datasets. As such, it could present a drop-in replacement or augmentation for many-rule negation approaches in clinical text-mining pipelines, particularly for cases where adaptation and rule development is not required or possible.

Positive vein groove margin does not affect survival in patients undergoing pancreatoduodenectomy for early stages of pancreatic ductal adenocarcinoma

Presenter: Manish Ahuja MBBS, DNB | University Hospitals Birmingham NHS Trust Background: The prognostic significance of portal/superior mesenteric vein (PV/SMV) groove involvement after pancreaticoduodenectomy (PPPD) for pancreatic ductal adenocarcinoma (PDAC) is controversial. Following adoption of the reporting guidelines by the Royal College of Pathologists (R1: tumour margin < 1mm), R1 reporting rates have increased which are considered to impact the overall survival. The aim of this study was to investigate the significance of R1 vein groove margin on overall (OS) and disease-free survival (DFS) after pancreaticoduodenectomy (PD) for early stage pancreatic ductal adenocarcinoma (PDAC). Methods: This is a single centre retrospective study including all resections performed for resectable and borderline with venous only involvement (BR-V) PDAC of the head and uncinate process over a 10-year period (2011-2020). Statistical investigation was performed with descriptive statistics and Kaplan Meier and univariate and multivariate Cox regression survival analysis. Results: Two hundred patients underwent PD for resectable (n = 117, 59%) or BR-V (n = 83, 41%) tumours. Vein resection was performed in 102 (51%) cases. Pathological staging of the tumours was pT1 11 (6%), pT2 122 (61%) and pT3 67 (33%) cases; and pN0 18 (9%) pN1 101 (51%) pN2 81 (40%) cases. Clear surgical margins were observed in 35 (17%) cases. In 34 (17%) cases the vein groove margin was the only positive margin reported (VG+). Median follow-up was 14 months (range: 1-83). OS was significantly better in cases with clear margins (p = 0.006) (Picture 1a). No difference in OS was identified between VG+ only patients and those with negative margins (p = 0.129) or those with multiple sites of margin positivity (p = 0.172). Cox regression analysis did not identify VG+ only margin as an independent predictor of OS (Table 1). In a multivariate model investigating the surgical margins separately, the posterior, SMA and pancreas transection margins, as well as perineural invasion and adjuvant chemotherapy were identified as independent predictors of OS. DFS was significantly better if surgical margins were clear (p = 0.014) (Picture 1b). A trend to worse DFS was identified in patients with VG+ margin only compared to those with negative margins (p = 0.058). No difference in DSF was observed between VG+ only patients and those with multiple sites of margin positivity (p = 0.608). Cox regression analysis did not identify VG+ only margin as an independent predictor of DFS (Table 1). In a multivariate model investigating the surgical margins separately, the SMA margin was the only margin along with adjuvant chemotherapy that independently predicted DFS. Conclusion: Vein groove margin positivity doesn’t affect OS but may affect DFS after PD in patients with resectable and BR-V PDAC. In contrast, the posterior and pancreas transection margins along with PNI were identified as independent risk factors for OS. The SMA margin and adjuvant chemotherapy were independent factors for both OS and DFS.

Impact of the eye clinic liaison officer at an NHS foundation trust: a retrospective study

ObjectiveVision loss has a significant impact on physical, mental and social well-being. Eye clinic liaison officers (ECLOs) have a crucial role in providing holistic care for patients with visual impairment....

Endonasal surgery in the coronavirus era - Birmingham experience.

The World Health Organization declared coronavirus disease 2019 a pandemic on 11th March 2020. There is concern regarding performing endonasal surgical procedures because of a high viral load in the nasopharynx. This paper describes our experience in conducting emergency and urgent endonasal operations during the peak of the coronavirus disease 2019 pandemic in the UK. To show the outcome of endonasal surgery during the peak of the coronavirus disease 2019 pandemic and to assess the post-operative rate of nosocomial coronavirus disease 2019 infection. A retrospective cohort study was conducted of all patients who underwent high priority endoscopic nasal surgery or anterior skull base surgery between 23rd March and 15th June 2020 at University Hospitals Birmingham NHS Trust. Twenty-four patients underwent endonasal surgery during the study period, 12 were males and 12 were females. There was no coronavirus-related morbidity in any patient. This observational study found that it is possible to safely undertake urgent endonasal surgery; the nosocomial risk of coronavirus disease 2019 can be mitigated with appropriate peri-operative precautions.

Age and Frailty Are Independently Associated with Increased Mortality in COVID-19: Results of an International Multi-Centre Study

Introduction: Increased mortality has been demonstrated in older adults with COVID-19, but the effect of frailty has been unclear. Methods: This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty, and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation, and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS), and delirium on risk of increased care requirements on discharge, adjusting for the same variables. Results: Data from 5711 patients from 55 hospitals in 12 countries were included (median age 74, IQR 54 – 83; 55.2% male). The risk of death increased independently with increasing age (>80 vs 18-49: HR 3.57, CI 2.54 – 5.02), frailty (CFS 8 vs 1-3: HR 3.03, CI 2.29 – 4.00) inflammation, renal disease, cardiovascular disease, and cancer, but not delirium. Age, frailty (CFS 7 vs 1-3: OR 7.00, CI 5.27 – 9.32), delirium, dementia, and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. Conclusions: Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age.Funding Statement: The Geriatric Medicine Research Collaborative has previously received funding from the British Geriatrics Society for administrative and running costs. No project specific funding was obtained for this research. MW and SR acknowledge support from the NIHR Newcastle Biomedical Research Centre.Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: Local, regional, and national approvals were obtained from all participating sites. In the UK, this study was registered as clinical audit or service evaluation, with approval granted in line with local information governance policies, in line with assessment and guidance by the Health Research Authority. At the lead site (University Hospitals Birmingham NHS Trust) this study was registered as clinical audit (CARMS-15986). In other countries, local principal investigators were responsible for obtaining approvals in line with their local, regional, and national guidelines and recommendations. Only routinely collected data was collected and patient care was not altered by this study. Anonymised data was securely transferred to the Birmingham Centre for Prospective and Observational Studies (BiCOPS), University of Birmingham via REDCap. All sites were required to confirm that approvals were in place prior to being provided with logins; written data sharing agreements were arranged where requested by individual sites.

P222 Vitamin D in early rheumatoid arthritis

Abstract Background Rheumatoid arthritis (RA) is the commonest chronic inflammatory arthritis, predominantly affecting small/medium joints and associated with extra-articular features. Previous studies have linked RA risk and disease activity with vitamin D-deficiency, but a causal role for vitamin D in RA is still unclear, partly due to heterogeneous study methods and sample populations. Moreover, no studies have focused specifically on vitamin D status (serum levels of 25-hydroxyvitamin D, 25OHD) in early RA, or whether low 25OHD is linked to progression from undifferentiated inflammatory arthritis to RA. Our objectives were therefore (1) to analyse serum 25OHD in early inflammatory arthritis, (2) to compare 25OHD levels with disease activity and fatigue in early RA and (3) to determine whether low serum 25OHD is associated with progression to RA. Methods We analysed 791 patients enrolled in the Birmingham Early Arthritis Cohort from 2013-19 at Sandwell and West Birmingham Hospitals NHS Trust and University Hospitals Birmingham NHS Trust. We collect baseline demographic data, serum 25OHD (ng/ml), and clinical variables including: duration of symptoms, duration of early morning stiffness (EMS), CRP, ESR, anti-CCP antibody status, Rheumatoid factor status, tender and swollen joint counts, DAS28-ESR, DAS28-CRP, Visual Analogue Scale (VAS) pain/fatigue and FACIT scores. Diagnosis was recorded at 0 and 12 months onwards as either RA, psoriatic arthritis (PsA), Undifferentiated Inflammatory Arthritis (UIA; synovitis not meeting other classification/diagnostic criteria), Clinical Suspect Arthralgia (CSA; arthralgia of an inflammatory type without synovitis), or Other. Data were analysed using SPSSv25. Full ethical approval was given for the study (REC12/WM/0258). Results Baseline demographic data were similar between all groups, with a median symptom duration of 16.8-34.0 days. Baseline 25OHD was not significantly different between groups [median, interquartile range (IQR): RA 46.7, 30.0-73.3; PsA 41.2, 30.0-65.0; UIA 51.4, 30.0-72.3; CSA 47.7, 30.3-73.0; Other 37.0, 24.9-55.3]. In the RA group (n = 335), there were no significant differences between 25OHD and any measures of disease activity/fatigue. Finally, we found no association between 25OHD and progression from UIA (n = 121) or CSA (n = 150) to RA (p = 0.554 and p = 0.741 respectively). Conclusion Overall we found no clear association between serum 25OHD and baseline diagnosis, RA disease activity, or progression from UIA/CSA to RA in this large cohort of early RA patients. Limitations of the study include that we were unable to report on levels of vitamin D metabolites which may be more important than total vitamin D. In addition, we were unable to adjust for supplement use/ time of year the sample was taken due to missing data. Future studies into the role of different metabolites of vitamin D in aetiopathogenesis of inflammatory arthritis would provide invaluable insight into the role of vitamin D in inflammatory arthritis better defining the complex role of vitamin D in RA. Disclosures S.R. Harrison: None. G. Jutley: None. D. Li: None. I. Sahbudin: None. A. Filer: None. M. Hewison: None. K. Raza: None.

Macroeconomics and Cardiovascular Risk Factors

The major risk factors for cardiovascular diseases (CVDs) have been known for at least half a century from both observational and clinical trial study designs.1–6 Despite advances in many countries, progress in prevention has been slow from a global perspective. The INTERHEART study and many epidemiological studies have shown that the vast majority of CVD can be explained by common risk factors, including hypercholesterolemia, hypertension, diabetes mellitus, and smoking.7 The Global Burden of Disease (GBD) study has led to a seismic shift in conceptualizing the burden of diseases and risk factors across countries and regions and has shown that the Western affluence model may be flawed when considering CVDs in low-income settings, where a dual burden of communicable and noncommunicable diseases exists.8,9 Data exist at many levels in many forms, and the message of growing burden of risk factors and resultant disease is undeniable. Researchers and clinicians alike strive for better data, better study designs, and better analytic methods to improve our knowledge of the causation and prevention of CVD, which will, in turn, allow us to plan the most effective strategies. However, readers are forgiven for concluding that sufficient data already exist and that it is time for action. Article see p 1493 In reality, science alone rarely changes hearts and minds; such change requires multisectoral action with buy in from multiple stakeholders, including …

RISE OF MULTI‐RESISTANT URINARY TRACT INFECTIONS

BJU InternationalVolume 110, Issue 3 p. 300-301 RISE OF MULTI-RESISTANT URINARY TRACT INFECTIONS Thomas King, Thomas King Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UKSearch for more papers by this authorAsad Abedin, Asad Abedin Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UKSearch for more papers by this authorMohammed Belal, Corresponding Author Mohammed Belal Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UKMohammed Belal, Department of Urology, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK. e-mail: mohammed.belal@uhb.nhs.ukSearch for more papers by this author Thomas King, Thomas King Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UKSearch for more papers by this authorAsad Abedin, Asad Abedin Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UKSearch for more papers by this authorMohammed Belal, Corresponding Author Mohammed Belal Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UKMohammed Belal, Department of Urology, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK. e-mail: mohammed.belal@uhb.nhs.ukSearch for more papers by this author First published: 13 April 2012 https://doi.org/10.1111/j.1464-410X.2012.11142.xCitations: 2Read 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 onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume110, Issue3August 2012Pages 300-301 RelatedInformation

Type-2 diabetes mellitus in schizophrenia: Increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up

Objective Physical co-morbidity including type 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is little consistent evidence that co-morbidity with diabetes mellitus and/or other diseases leads to excess mortality in schizophrenia. Thus, we investigated whether co-morbidity with diabetes and other somatic diseases is increased in schizophrenics, and if these are equally or more relevant predictors of mortality in schizophrenia than in age- and gender-matched hospitalised controls. Methods During 2000–2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust. Co-morbidities were compared with 88,778 age- and gender group-matched hospital controls. Predictors of mortality were identified using forward Cox regression models. Results The prevalence of type 2 diabetes mellitus was increased in schizophrenia compared to hospitalised controls (11.3% versus 6.3%). The initial prevalence of type 2 diabetes mellitus was significantly higher in the 100 later deceased schizophrenic patients (24.0%) than in those 579 surviving over 7 years (9.2%). Predictors of mortality in schizophrenia were found to be age (relative risk [RR] = 1.1/year), type 2 diabetes mellitus (RR = 2.2), pneumonia (RR = 2.7), heart failure (RR = 2.9) and chronic renal failure (RR = 3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR = 2.2 versus RR = 1.1). In agreement, deceased schizophrenics had significantly suffered more diabetes mellitus than deceased controls (24.0 versus 10.5%). The relative risks of mortality for other disorders and their prevalence in later deceased subjects did not significantly differ between schizophrenia and controls. Conclusion Schizophrenics have more and additionally suffer more from diabetes: co-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; type 2 diabetes mellitus causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in hospitalised patients with schizophrenia.

PW01-180 - Type 2 diabetes mellitus is a predictor of excess mortality in schizophrenia: a naturalistic 7 year follow-up

ObjectivesType 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is a lack of evidence that co-morbidity with this and/or other physical diseases lead to excess mortality in schizophrenia. We investigated whether diabetes and other diseases are increased and are predictors of mortality in schizophrenia.MethodsDuring 2000-2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust, co-morbidities were compared with 88778 age- and gender group-matched hospital controls. Predictors of mortality were identified using logistic regression.ResultsType 2 diabetes mellitus was increased in schizophrenia compared to hospital controls (11.3 versus 6.3%). The prevalence of diabetes mellitus at first admission was higher in later deceased patients with schizophrenia (n=100, 24.0%) than those surviving (n=579, 9.2%). Predictors of mortality in schizophrenia were age (relative risk RR=1.1/year), type 2 diabetes mellitus (RR=2.2), pneumonia (RR=2.7), heart failure (RR=2.9) and chronic renal failure (RR=3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR=2.2 versus RR=1.1), deceased schizophrenics had more often suffered diabetes mellitus than deceased controls (10.5%).ConclusionsCo-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; it also causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in schizophrenia.

Nice Guidelines on Preoperative Tests in Elective Ent Surgery: A Prospective AudiT

Nice Guidelines on Preoperative Tests in Elective Ent Surgery: A Prospective AudiT

Orbital Floor Fracture Repair

Archives of Facial Plastic SurgeryVol. 9, No. 4 Editor's Correspondence: Comments and OpinionsFree AccessOrbital Floor Fracture RepairRhodri Williams and Sat ParmarRhodri WilliamsCorrespondence: Dr Williams, Department of Oral and Maxillofacial Surgery, University Hospital Birmingham NHS Trust, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH England E-mail Address: rhodri.williams@uhb.nhs.ukSearch for more papers by this author and Sat ParmarSearch for more papers by this authorPublished Online:1 Jul 2007https://doi.org/10.1001/archfaci.9.4.300AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail In response to the research letter by Majmundar and Hamilton,1 we would like to highlight some limitations of their article. We agree with the authors' ideals for implantable material for reconstruction of orbital fractures and that it should be easily shaped, but we would add that the material should also have the ability to retain its molded shape. SupraFOIL material (S. Jackson Inc, Alexandria, Virginia) will not retain its new shape, unlike some other materials, such as reinforced polyethylene (MEDPOR TITAN; Porex Surgical Products Inc, Newnan, Georgia) and titanium mesh. The cost argument is valid for all health equipment and interventions, but the material must be appropriate for the purpose for which it was intended.The conclusions that the authors make with regard to the low complication rate associated with this material cannot be wholly justified given their small sample size and relatively short follow-up period. Indeed, the only other articles2,3 quoted regarding the use of this material for this purpose, reported its use in only 2 and 12 patients, respectively. This is in contrast to some of the articles in the literature reporting the use of Silastic (Dow Corning, Midland, Michigan),4 polyethylene,5 and titanium.6In addition, the computed tomographic images the authors provide show a lack of anatomical correction of the orbital floor, which is likely to result in increased orbital volume and hence measurable enophthalmos. This complication would not necessarily have been identified with a simple telephone review with the patient.Although we understand that attempts to perform and publish research in this difficult area are laudable, we do not feel that enough scientific rigor has been applied to the methods of this article and its review. It may well be true that this material is a cost-effective and safe method for treating this condition, but the evidence shown in this article does not support that conclusion. A larger, more robust study is required.

Critical illness: A view from the kidney*

Clinical Biochemistry, Selly Oak Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK Dr. Gosling has received grants from Bayer Diagnostics.

News

Drink drive: emergency care alcohol liaison nurse at Selly Oak Hospital, Birmingham, Sarah Needham has secured funding from University Hospital Birmingham NHS Trust to set up a nine-month alcohol liaison pilot project. Ms Needham, whose work won her the Tyco Healthcare UK and RCN A&E Nursing Association award in 2000, is due to speak on the topic next month at a conference in Birmingham on tackling alcohol abuse. For details of the conference on October 11, call 0121 765 4222 or email castle.comm@which.net.

Of human bondage. Dealing with vulnerable patients in theatre.

The ethical dilemmas surrounding the use of physical and chemical restraint in the acute care arena are highlighted in project work currently in progress within the University Hospital Birmingham NHS Trust. The impetus for this work has emerged from a multidisciplinary group of trust colleagues who are attempting to develop guidelines for good practice in this area. Their work relating to the theatre setting has been presented at the RCN Critical Care Conference and is outlined in this article.

Gene therapy trials: a patient pathway

This article describes ongoing gene therapy trials at University Hospital Birmingham NHS Trust for liver, head and neck and prostate cancer treatment. The authors suggest that this research programme might become an alternative option for patients who have not responded to conventional treatments.

Gene therapy trials: a patient pathway.

This article describes ongoing gene therapy trials at University Hospital Birmingham NHS Trust for liver, head and neck and prostate cancer treatment. The authors suggest that this research programme might become an alternative option for patients who have not responded to conventional treatments.