Copy
Thu 7 Dec 2017
View this email in your browser
Share
Tweet
Forward to Friend
NIHR CLAHRC West Midlands News Blog header
This work is funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health
National Institute for Health Research logo
Download PDF
Welcome to the latest issue of your NIHR CLAHRC West Midlands News Blog.
Richard Lilford as a gingerbread man
Welcome to the latest issue of our News Blog, where we look back on the first human heart transplant that was conducted 50 years ago this week. We also look at recent research on the harm caused by intensive care in elderly patients; association between lipoproteins and triglycerides and coronary risk using a Mendelian randomisation study; more evidence against alcohol; sudden death in sport; the effectiveness of taking antioxidant supplements to prevent AMD; and a method to reduce radiation risk from hospital scans.

We also have a press release following a Bellagio Conference on slum populations; the latest news (including a summary of a recent cross-CLAHRC research event) and upcoming events; funding opportunities; our latest quiz question; profile Simon Smithand showcase some of our latest publications. We also have a number of replies to our recent blogs.

We hope that you find these posts of interest, and we welcome any comments. You can find previous issues of our News Blog here.
Please note that due to the Christmas break our next issue will be sent out on
12 January 2018. We hope you have a Merry Christmas and a Happy New Year!
 depending on your email, adding us may ensure that pictures load automatically.
 Director's Blog

50 Year Anniversary of the First Human Heart Transplant: Lessons for Today

On 3 December we commemorated the 50 year anniversary of the world’s first heart transplant. The operation took place in the early hours of a Saturday morning at the Groote Schuur hospital in Cape Town, South Africa. Christiaan Barnard sutured Denise Darvall’s donated heart into the chest of the recipient, Louis Washkansky. Barnard restarted the new heart with an electric shock and then tried to wean the recipient off the heart and lung machine. But the new heart could not take the strain and Washkansky had to go back on the machine. The second attempt also failed, but when the heart and lung machine was turned off for the third time the recipient’s blood pressure started to climb. It kept on climbing, and soon Denise Darvall’s small heart had taken over the perfusion of Louis Washkansky’s large frame. Later that morning the world woke to the news of the world’s first heart transplant. Looking back over fifty years what should we make of Barnard’s achievement?

The transplant in an historical perspective
The two decades preceding the heart transplant have sometimes been referred to as the golden age of medical discovery.[1] The transplant can be ‘fitted’ retrospectively as the culmination of this golden age just as Neil Armstrong’s moon walk, two years later, can be seen as the crowning achievement of the space race. They belong to a number of technical achievements, including the first “test tube” baby and the first man in space, which are emblematic of human progress. They generate great public interest and media attention, but differ from more fundamental intellectual discoveries, such as the double helix in DNA or Higgs boson, that are rewarded with Nobel prizes.

The heart transplant in the ‘heroic’ medical age
In his book ‘One Life’ Barnard provides an interesting cameo of the power and autonomy of the medical profession in his time.[2] He recalls writing up the routine operation note that must follow any surgical procedure. The anaesthetist, ‘Oz’, suggested that Dr Jacobus Burger, the hospital superintendent, should be informed. Barnard asked whether he should wake him so early in the morning, but Oz replied that the night’s events warranted such an intrusion.  At first the befuddled Dr Burger, aware if work in the animal lab, thought that he was being informed about another heart transplant in dogs. However, even when he learned that the transplant involved a human heart, he cryptically thanked the surgeon and replaced the receiver. Nowadays, the idea of carrying out a procedure of such novelty, cost and risk without formal sanction would be unfathomable. The vignette from the doctor’s tearoom vividly illustrates how the relationship between the medical profession and the broader society has changed over one generation. Rene Amalberti argues [3] that many professions progressed through a heroic age in the twentieth century before gradually becoming more formalised and regulated – aviation followed a similar trajectory following Charles Lindbergh’s dramatic flight across the Atlantic in 1927.

Gradually changing ethical norms
The ethics of heart transplants relate mainly to organ donation. In ‘One Life’ Barnard describes the tense atmosphere in the operating room as the team waited for the donor heart to stop after turning off Darvall’s ventilator. In fact, they did not wait, and Barnard’s brother Marius has stated he persuaded Christiaan to stop the donor heart by injecting a concentrated dose of potassium in order to give Washkansky the best chance of survival. Today two different doctors need to independently carry out tests to confirm the donor is brain stem dead before the heart can be removed, as opposed to waiting for death by the whole-body standard, i.e. when there is brain death and the heart has stopped beating.

Public views of heart transplants, then and now
Following the operation the exhausted Barnard went home for a sleep. In the afternoon he returned to the hospital where he was surprised to find his route obstructed by a large crowd of reporters. He had unleashed a tide of publicity and acclaim that resonated for many decades, but dissenting voices were also heard. Some, notably Malcolm Muggeridge, the editor of Punch magazine, attacked the operation on the basis of a near mystical reverence for the human heart and to this Barnard had a succinct response: “it’s merely a pump.” Others worried about the allocation of scarce resources to such a high-tech solution when people were dying from malnutrition and malaria. Defence of the procedure came, albeit years later, from the economics profession when it was shown that the operation has a highly favourable cost-to-benefit ratio (at least in a high-income country).[4] The procedure not only extends life by many years on average, but greatly improves the quality of that life. In fact, patients feel much better from the moment they regain consciousness after the operation despite pain from the sternotomy.  The operation is now uncontroversial and is performed routinely in high-income countries. It was long predicted that a mechanical pump would supplant the need for transplantation. Mechanical hearts have improved,[5] but they are largely seen as a bridge to transplantation, rather than a better alternative.

If Christiaan Barnard had not performed his operation, heart transplants would have developed anyway (the second transplant was carried out independently by Adrian Kantrowitz in the USA on 6 December). I was a school boy with hopes of getting into medical school when Washkansky received his new heart. I was among the many millions who were swept up in the wonder of the event and it still stirs my imagination half a century later. And my family knows that I wish to donate my own heart if the circumstances arise.
 
-- Richard Lilford, CLAHRC WM Director

Leave a comment

References
Question
CLAHRC WM Quiz

Which Nigerian physician curbed the spread of ebola through Nigeria by placing the Patient zero in quarantine despite pressure from the Liberian government?

Email CLAHRC WM your answer.
Answer to our previous quiz: The Kofi Annan Foundation is an organisation that works to promote better global governance and strengthen the capacities of people and countries to achieve a fairer, more peaceful world.

Congratulations to Lisa Chilton who was first to answer correctly.
 Director's Choice - From the Journals

Intensive Care Harmful in Elderly Patients

An intervention to promote use of intensive care in elderly patients (over age 75) was evaluated in a cluster RCT of 20 French hospitals.[1] The intervention worked in the narrow sense that it did increase the rate of admission to the intensive care unit (ICU) (by nearly 70%). But did this result in improved survival? Not at all – in fact there was a statistically significant increase in death rates in the hospitals randomised to have lower thresholds for ICU care; both in hospital (18% increase) and at 6 months (16% increase). So a conservative policy dominates – it is both less expensive and more effective in old people. But this paper should make one think – how effective is ICU for other groups of patients? Apart from looking after people who need a breathing machine, is ICU really an effective treatment at all? It is highly invasive and intrusive. I am not a therapeutic nihilist, but one does have to wonder. Perhaps we should design a less intensive form of intensive care? Such an approach could be evaluated in RCTs before advocating global use of the current standard ICU model in high-income countries. Let me annoy my colleagues by proposing a hypothesis. ICU types think that it is the monitoring and fiddling with vital signs that saves lives. I think the main effect is better diagnosis – because patients are scrutinised carefully by highly trained people, conditions are spotted that would otherwise be missed. Just a thought!

I would like to thank News Blog reader Gus Hamilton for drawing my attention to this article.
 
-- Richard Lilford, CLAHRC WM Director

Leave a comment

Reference

More on Mendelian Randomisation

News Blog readers know that the CLAHRC WM Director loves Mendelian randomisation studies, originally proposed by his erstwhile colleagues, Gray and Whitley.[1] The method has been used to crack open the story regarding lipids and coronary artery disease.[2] Everyone knows that low density lipoproteins are bad news – these fats clog up arteries. The association is confirmed by Mendelian studies. But what about those two old chestnuts, high density lipoproteins (HDLs) and triglycerides? In observational studies HDLs are consistently associated with reduced risk of coronary disease.[3] While triglyceride levels are associated with increased coronary risk, this effect disappears once confounders have been controlled in multi-variable analysis.[3] However, Mendelian randomisation tells a completely different story – HDLs are not associated with coronary risk, while triglycerides are.[4] [5] What is going on here? That is to say, why do the observational studies and the Mendelian studies give such different answers with respect to HDLs and triglycerides? More curious still, why does the association between triglyceride and coronary artery disease confirmed by Mendelian randomisation disappear after controlling for confounders? This is not entirely clear, but as HDL levels drop, so triglycerides tend to rise. Hence controlling for triglyceride levels when examining HDLs, and vice-versa, will give the wrong result. This may be yet another example of ‘over controlling’ by including in a multi-variable analysis / logistic regression variables that have a causal interaction with the explanatory variable of interest.[6]
 
-- Richard Lilford, CLAHRC WM Director

Leave a comment

References
 

Oh Dear – Evidence Against Alcohol Accumulates

Wine bottle with cigarette-style warning labelYes, more research [1] [2] on alcohol – increases in cancers of mouth, throat and oesophagus. Not good places to have cancer. Direct contact of C2-H5-OH with the membrane is the likely causal mechanism. So here is an hypothesis – the more dilute a given amount of alcohol, the better. So I think beer > wine > spirits, ceteris paribus. I guess this has been tested? But next week I may have some more reassuring news for us oenophiles.

Might we one day see cigarette-style warning labels on bottles of alcohol?

(Medical image from Wikimedia Commons.)

-- Richard Lilford, CLAHRC WM Director

Leave a comment

References

Sudden Death in Sport is Rare

People with established health issues have an increased risk of sudden death during vigorous exercise. But the general population has a very low risk of death with strenuous exercise (any activity that increases metabolic rate by at least 6 times [i.e. >6 METs]) [1] – less than one death per 100,000 athlete years according to a recent study of deaths in people between the ages of 25 and 45, ascertained through an ambulance service.[2] But what about people older than 45, among whom I am numbered?!
 
-- Richard Lilford, CLAHRC WM Director

Leave a comment

References

Antioxidants and Age-Related Macular Degeneration

It is estimated that around 5% of the general population suffer from age-related macular degeneration (AMD),[1] where extracellular material known as drusen accumulate under the retina at the back of the eye and which can eventually lead to blurred or a loss of vision. It has been suggested that antioxidants may help prevent or delay development of AMD in people who do not suffer the condition by protecting the retina against oxidative stress, but it is unclear as to whether this is the case.

A systematic review in the Cochrane Database by Evans and Lawrenson looked at the effectiveness of antioxidant supplements as treatment in people who already had AMD,[2] and found that taking a multivitamin antioxidant vitamin may delay the progression of AMD when compared to a placebo or no treatment (odds ratio 0.72, 95% CI 0.58-0.90). The authors also conducted a systematic review looking at whether there was an association between taking antioxidant vitamins (carotenoids, vitamin C, vitamin E) or minerals (selenium, zinc) and the development of AMD in people without AMD.[3] Five RCTs were included, with a total of 76,756 individuals without AMD. These studies all looked at the use of various supplements against placebo. Generally, the various studies found that there was no effect of supplements on development of AMD, while in some cases there was evidence of an increased risk (see table below).

 
 Comparison  No. of
 studies
 Disease  Risk Ratio
 (95% Confidence Interval)
 Vitamin E vs. placebo  4  AMD  0.97 (0.90-1.06)
 Late-stage AMD  1.22 (0.89-1.67)
 Beta-carotene vs. placebo  2  AMD  1.00 (0.88-1.14)
 Late-stage AMD  0.90 (0.65-1.24)
 Vitamin C vs. placebo  1  AMD  0.96 (0.79-1.18)
 Late-stage AMD  0.94 (0.61-1.46)
 Multivitamin vs. placebo  1  AMD  1.21 (1.02-1.43)
 Late-stage AMD  1.22 (0.88-1.69)

-- Peter Chilton, Research Fellow

Leave a comment

References

Reducing Radiation Risk from Hospital Scans

Even though it is something carried out in hospitals hundreds of times a day, X-rays and CT (computed topography) scans are procedures that expose the patient to radiation. Yes, the radiation dosage for the majority of scans carried out is very little when compared to every day exposure; for example an X-ray of the arm is 0.001 mSv (millisievert), a dental X-ray is 0.005 mSv, a chest X-ray is 0.020 mSv – in comparison the average background radiation received over one day is 0.010 mSV, while someone flying across the continental USA would receive 0.040 mSV.  However, other scans are higher, a mammogram is 0.400 mSv (equivalent of 40 days worth of exposure in one dose), while a head CT scan gives a dose of 2 mSv (equivalent to ~7 months) and a chest CT scan 7 mSv (equivalent to ~20 months) (see the below image from Randall Munroe for more examples).
 
Although the cells in our body are able to repair and restore DNA damage resulting from radiation, the greater the dose received in one go, and the greater received in the long-term, the more likely it is that damage won’t be repaired correctly. Thus, we should aim to reduce patients’ exposure to radiation where possible. A recent paper by Kitchen and colleagues may have an answer by using phase-contrast x-ray imaging.[1] Because soft tissue has similar X-ray absorption properties to bone, which results in poor image contrast the radiation dosage has to be increased in standard scans. This new technique combines CT scans with phase retrieval and an algorithm to define edges, densities, etc. and results in a reduction in dosage by a factor of 300 fold (with the potential for a reduction factor in the tens of thousands), while still retaining equivalent image quality. Although the study only tested this in an animal model it is an important first step.

Radiation Dose Chart by Randall Munroe
(Click to enlarge.)

-- Peter Chilton, Research Fellow

Leave a comment

Reference
 Press Release

Making People Who Live in Slums Count

Bellagio Conference Develops Framework for Inclusion of Slum Populations in National Censuses

Despite an estimated one billion people around the world living in slums, many global data collection exercises including censuses do not track populations living in places identified as slums. Consequently, most health surveys, such as the Demographic and Health Surveys and Multi-Indicator Cluster Surveys that use sampling frames taken from censuses are unable to distinguish between slum and non-slum clusters in urban areas.
 
Today, slums are often invisible in official statistics, generally hidden within urban averages. Yet the spaces people occupy are important; it is for this reason that rural and urban statistics are collected. Identifying and disaggregating urban spaces as either slum or non-slum highlights uniquely urban-related needs specific to slum residents. With Sustainable Development Goal 11 on cities and human settlements, member states acknowledged previous efforts on monitoring people living in slums or those facing inadequate housing, and pledged to continue the work for the next 15 years. This renewed mandate opens the window to improve how data on populations who live in slums/informal settlements can be collected and analysed.
 
A recently published Lancet series led by CLAHRC WM Director Prof Richard Lilford and Dr Alex Ezeh, African Population and Health Research Center shows why urban poverty is an inadequate proxy for health in slums, as it ignores the neighbourhood effects of shared physical and social environments. These articles recommended steps to change this problem, including that slum-specific data be collected in national censuses and surveys. This recommendation requires the next generation of censuses to be designed such that the lowest levels of census enumeration areas are tagged as slums or non-slums for clusters located in urban areas.
 
For this reason, a meeting was convened from November 20-24, 2017 at the Rockefeller Foundation Bellagio Centre, Italy to identify optimal ways countries can distinguish slum from non-slum urban areas in national censuses and surveys.
 
The meeting was facilitated by Prof Lilford and Dr Ezeh and a broad range of participants, including representatives of National Statistical Agencies, research institutions, non- governmental organizations (NGOs), multilateral UN Agencies, bilateral donors, professional associations, and policymakers developed a way forward to the first crucial step: identifying urban areas with the greatest levels of deprivation. This would provide all invested stakeholders with more and better granular data to use to prioritise interventions and investments to improve any study of urban health outcomes.
 
Prof Lilford said: “The Bellagio meeting was extremely important as by disaggregating the disease and deprivation burden of slum and non-slum urban residents alike, it will be easier to highlight what matters for people who live in slums and focus attention on these issues for policymakers.”

The Bellagio group identified three key actions that must be taken at both the local and global levels:
  1. An assessment of the tools currently used to identify slum populations prospectively and retrospectively;
  2. Generation of recommendations on how countries can integrate slum/non-slum urban designations in their censuses and surveys
  3. Development of a global research agenda to identify robust methods for exploring and understanding slum areas, among them innovative uses of geospatial data and machine learning.
The Bellagio group aims to take its recommendations to high-level meetings of actors over the course of 2018 in order to begin a global conversation about the need to identify and respond appropriately to the counting and hearing of slum voices in census and other national data collection mechanisms – among them the February 2018 World Urban Forum in Kuala Lumpur, Malaysia; a high-level UN political forum in July 2018 in New York; the World Data Forum in Dubai, UAE in October 2018; and the International Conference on Urban Health in Kampala, Uganda in November 2018.
 
A formal working group will emerge from this Bellagio meeting to which invited, committed stakeholders will drive continued efforts to make every voice count. We see a globally adaptable guide as a key product from this group, to help national statistical agencies ensure they have the right tools to map and account for slum spaces and their populations in national sampling frames.

 
Attendees at the Bellagio conference
-- Jo Sartori
News & Events

Farewell and Good Luck to Luke Cheesbrough

We are saying farewell to Luke Cheesbrough, our Programme Officer, who is moving to Oxford in the new year. We would like to formally thank Luke for all of the work he has done for CLAHRC WM and wish him all the best in his future endeavours. 


NIHR Dissemination Signal

The NIHR Dissemination Centre has recently published a Signal based on research coordinated by CLAHRC WM, 'Does aerobic exercise reduce postpartum depressive symptoms? A systematic review and meta-analysis'. This research found that aerobic exercise can reduce the level of depressive symptoms experienced by women who had had a baby in the past year. The Signal is available online.


National NIHR CLAHRC Multi-Morbidity Research Event

CLAHRC East Midlands are holding a national multi-morbidity research event on Thursday 18 January 2018, 09:45-16:15 at Stamford Court, Leicester. This event will showcase the multi-morbidity work across all CLAHRCs, and stimulate further discussion and initiate cross-CLAHRC collaboration to take research forward and devise novel solutions to tackle multi-morbidity in the UK.

All CLAHRCs are asked to provide an overview of relevant multi-morbidity studies by Wednesday 20 December 2017. A number of these will be chosen for presentations and/or oral posters.

For more information, and to register, please click here. Deadline for registration is Friday 12 January 2018.


 

Job Opportunity at Warwick Evidence

A job opportunity is available at the University of Warwick under Warwick Evidence for either a Research Fellow or Senior Research Fellow in Health Technology Assessment. This is a full-time fixed-term contract until 31 March 2021. The closing date for applications are 3 January 2018. For more information please see:

Return to top

News & Events

Cross-CLAHRC Research Event Summary

On 23 November 2017 a cross-CLAHRC Care Homes research event was held in London, led by Prof Claire Goodman from CLAHRC East of England. The event built on the NIHR themed review on Advancing Care: Research with Care Homes (July 2017) and a newly developed summary of CLAHRC Care Homes research published by CLAHRC East of England (November 2017). Denise McLellan, Sarah Damery, Clare Jinks (Keele University) and Deb Smith (PPI Adviser, CLAHRC WM Theme 4, Birmingham) attended from CLAHRC West Midlands.
 
In the morning session, a number of speakers presented a range of perspectives on care homes research and the associated challenges. Presentations included an overview of an innovative and technology focused multi site provider (Somerset Care Group) and a longstanding evidence-based programme to enhance the quality of care in care homes. Attendees heard about the role of the Enhancing Research In Care Homes (ENRICH) programme in improving system capacity for research relating to care homes, and from NHS England about the Care Home Vanguards within the New models of Care programme.
 
Speakers highlighted some of the specific challenges in working with care homes, most notably those relating to data collection (no national minimum data set; low uptake of IT within care homes, especially smaller ones; variable standards of record keeping; and a lack of agreed outcome measures). Like other sectors, there is a tension inherent in co-producing research with care home owners, managers and staff – there are frequent requests to evaluate specific interventions, yet measuring the distinct outcomes of these can be challenging in a complex environment. The importance and challenges of involving people living in care homes, as well as their family and friends were also highlighted.
 
In the afternoon session, a series of parallel group discussions enabled the exploration of some topics in more depth, such as specific interventions to prevent complications, dementia, implementing evidence into practice, and living and working in care homes. A plenary session discussed whether or not there should be future national cross-CLAHRC coordination of research in this area and priority topics. Prof Louise Wallace from the NIHR Health Services and Delivery Research Programme (HS&DR) spoke about the continuing national interest in care homes research. Overall, this was an interesting and engaging day, and was a useful event to raise the profile of a wide range of issues.

 
--Denise McLellan and Sarah Damery

Return to top

Funding

NIHR Funding Alert

A number of new funding opportunities are available from the NIHR, including the Efficacy and Mechanism Evaluation programme; the Health Technology Assessment programme; and the Public Health Research programme. A full listing of all current opportunities is available online.

Return to top

Profile

Simon Smith

Mr Simon SmithSimon Smith has recently joined the Warwick Centre for Applied Health Research and Delivery (W-CAHRD) as the Project Manager for the NIHR Global Challenges Health Research Unit on Improving Health in Slums.  Simon joined the University of Warwick in 2012 and worked briefly in Human Resources before joining Research and Impact Services, where he supported the academic population of Warwick Medical School with their grant application and contracting requirements in relation to external funding. Prior to this, Simon’s career was mostly spent in the financial sector working for both the Royal Bank of Scotland and the Lloyds Banking Group.
 
Outside of work, when he isn’t busy renovating his house, Simon enjoys attending the gym and working in the garden.

Return to top

Selected Replies

Re: Is Research Productivity on the Decline Internationally?

Excellent, thought provoking read for a Friday morning. Interesting link to article focusing on problems for present day researchers… ‪The 7 biggest problems facing science, according to 270 scientists.
-- Charlotte Connor

But Richard, how do you explain the phenomenon that almost everyone is convinced that the best developments in the world happened in their lifetime and more remarkably in their young years, rendering all past and possibly future generations superfluous?
-- Fulco van der Veen

--Author's Reply-- I like it -- Richard Lilford

In the West, hyper-regulation and managerialism sap the morale of enthusiastic researchers. The closed loop of peer review ensures that researchers have to spend more time begging for money than doing their research. The NHS has been shut down for research and the era of the “enthusiastic amateur” – which was a great strength in the UK – is over!

In China you need one ethics approval and you are in business. All patients agree to research when they enter the hospital on one form. Underdeveloped economies will outperform sclerotic, Western research efforts for the foreseeable future.

I strongly agree that 1950-1970 was a golden age. In our specialty the basis for understanding pre-eclampsia was laid down in 1953 (GJ Sophian preceded by J Trueta in KJ Franklin FRS labs). BUT we “lost” the morphology of the autonomic nerves when we started using formalin in post-1945 medical schools. Most disease results from injuries to autonomic nerves including the most of OBGYN, and now hypertension (The arteriolar injury in hypertension. See Am J Med 2018).

So we could enter a new “golden age” if we took DO Burkitt’s advice and concentrated on simple, lifestyle sources of disease, e.g. diet, bowel habit, exercise, posture, gait and childbirth rather than (epi)genomics !?!

-- MJ Quinn


Re: Towards a Unifying Theory...

This sort of stuff is so cheering! Have you seen this about Pigs for Peace – Randomised trial evidence no less. Glass, et al. BMJ Glob Health. 2017; 2(1): e000165.

-- Susan Bewley

-- Author's Reply --
I am afraid that I greatly admire the Poverty Action Lab at Harvard, and all that has flowed from it.

-- Richard Lilford

Return to top

Recent Publications

Agweyu A, Oliwa J, Gathara D, Muinga N, Allen E, Lilford RJ, English M. Comparable outcomes among trial and nontrial participants in a clinical trial of antibiotics for childhood pneumonia: a retrospective cohort study. J Clin Epidemiol. 2017; 94: 1-7.

Buckle A, Taylor C. Cost and cost-effectiveness of donor human milk to prevent necrotizing enterocolitis: Systematic review. Breastfeeding Med. 2017; 12(9): 528-36.

Combes G, Sein K, Allen K. How does pre-dialysis education need to change? Findings from a qualitative study with staff and patients. BMC Nephrol. 2017; 18: 334.

Gale NK, Kenyon S, MacArthur C, Jolly K, Hope L. Synthetic social support: Theorizing lay health worker interventions. Soc Sci Med. 2017; 196: 96-105.

Lilford RJ. Implementation science at the crossroads. BMJ Qual Saf. 2017.

Return to top

Copyright © 2017 NIHR ARC West Midlands, All rights reserved.

Disclaimer: NIHR CLAHRC West Midlands will not be held responsible for the availability or content of any external websites or material you access through our news blog.



 
Email Marketing Powered by Mailchimp