The Lister Hospital in Chelsea is a private hospital in Chelsea Bridge Road, London. It is owned by the Hospital Corporation of America, the largest private operator of health care facilities in the world, and so is not part of the National Health Service (NHS).
INTRODUCTION:Mucosal melanoma (MM) is a rare disease, accounting for approximately 1.4% of all melanomas and only 0.03% of all new cancer diagnoses. Traditionally, it has been associated with a poor prognosis, with an overall 5-year survival rate of <25%. Progress in treatment has been hindered by its rarity and lack of evidence. However, studies on the treatment of subcutaneous melanoma with immunotherapy have demonstrated significant improvement in survival rates and have become a core part of oncological strategies. This paper discusses the revision of the evidence for the use of immunotherapy in the head and neck.METHODS:This systematic review was conducted on January 19, 2019. The Medline and Embase databases were searched. In total, 509 articles were collated and screened. Inclusion criteria for the study included treatment-naive cohorts, cohorts with recurrent disease, primary outcomes with overall survival and disease-free survival at 5 years and at the longest follow-up, and studies of adults with MM in whom immunotherapy was reported as a treatment strategy. The exclusion criteria included duplicate papers, anatomical sites other than the head and neck, case reports, and those not published in English.RESULTS:Fifty-two papers out of the 509 collated papers met the inclusion criteria. The results are shown as a comparison of yearly survival rates following different treatment modalities (immunotherapy vs nonimmunotherapy) at 2, 3, and 5 years. It was found that, with immunotherapy, survival rates at all intervals were higher than those without immunotherapy.DISCUSSION:Immunotherapy outcomes in small studies have shown good data for increasing survival rates at yearly intervals in MM of the head and neck. Larger clinical trials are needed to accurately distinguish the efficacy and survival outcomes of immunotherapy when compared with treatment modalities, excluding immunotherapy. However, the ability to perform larger trials is limited by the rarity of MM of the head and neck.
Mitochondrial disorders are a clinically heterogeneous group of disorders that are caused by defects in the respiratory chain, the metabolic pathway of the adenosine tri-phosphate (ATP) production system. Epilepsy is a common and important feature of these disorders and its management can be challenging. Epileptic seizures in the context of mitochondrial disease are usually treated with conventional anti-epileptic medication, apart from valproic acid. However, in accordance with the treatment of intractable epilepsy where there are limited treatment options, the ketogenic diet (KD) has been considered as an alternative therapy. The use of the KD and its more palatable formulations has shown promising results. It is especially indicated and effective in the treatment of mitochondrial disorders due to complex I deficiency. Further research into the mechanism of action and the neuroprotective properties of the KD will allow more targeted therapeutic strategies and thus optimize the treatment of both epilepsy in the context of mitochondrial disorders but also in other neurodegenerative disorders.
Background & Objectives: The deformation of spinal needles during clinical use can affect the safe and timely conduct of anaesthesia. The strength profile of needles is measured by industry standard tests, which do not necessarily reflect clinical use (1). Testing is done by individual manufacturers and there are few objective, comparative studies of different needle brands (2). We aimed to compare the resistance to deformation in commonly used brands of spinal needles of a set length and gauge (27G 90mm) using both industry standard approaches and our own. Materials & Methods: We designed a testing rig incorporating a force transducer which measured the registered force during calibrated deflection of a sensor tip. A horizontal three-point bend test (A) was performed as a common industry standard test and a separate vertical test was designed by the group (B). During horizontal testing the sensor was pushed onto the needle shaft and in the vertical test the sensor was pushed onto the needle tip. Final needle deformation was measured (C). 27G 90mm luer spinal needles were tested from 4 popular, global brands. Each needle brand was tested 8 times in random order. Results: Only the vertical testing showed a significant difference in the deformation of the needles where Brand C showed significantly greater deformation than the other brands (p<0.05).Conclusion: Currently employed manufacturer tests may not identify differences in needle strength that could be clinically relevant. Our study identified differences between manufacturers in our specially designed test of axial strength but not in the standard industrial test. An awareness of such differences is important for clinicians when using or purchasing needles from different manufacturers. References: 1. Howatson AG, Moppett IG, French J. ‘They just feel different’ An objective assessment and comparison of luer and non luer spinal needles. Anaesthesia 2013;68 (supplement 3); 4-5. 2. Mercer D. An examination of needle and syringe force testing. February 2016. Retrieved from: http://www.mecmesin.com/an-examination-of-needle-and-syringe-force-testing Disclosure of Interest: A. Pillai Conflict with: Needles were obtained free of charge from company B and C, R. Monteiro Research grant/funding from: Obstetric Anaesthetists’ Association Small Project Grant, S.-W. Choi: None declared, S. Yentis: None declared, D. Bogod: None declared
To the Editors: W e read with interest the recent article by Tothy et al on the outcome of pediatric left-without-being-seen (LWBS) patients. This subject draws particular attention because children are often unable to advocate for themselves with the decision to leave not their own. The article quotes an LWBS rate of 5.4%, which is compared with the UK clinical target of <5%, a figure derived from adult studies. It is a natural tendency to compare LWBS rates between different pediatric emergency departments, but how useful are such comparisons, especially with respect to safety? We performed a review of children LWBS for a 1-month period. Forty-four (1.3% of total presentations) patients were identified with 31 (70%) contactable by phone. As expected, a large proportion (45%) identified the reason for LWBS as a long waiting time although 38% stated that they left because their children were well or had improved. Approximately half (53%) sought alternativemedical assessment, which is a similar rate to that experienced by Tothy et al, and only 1 (3.2%) patientwas rereferred to the emergency department although not admitted (Fig. 1). While it is reassuring that there was consistency in our findings compared with Tothy et al, an unacceptably low follow-up
