Salivary duct carcinoma (SDC) is an extremely rare and aggressive subtype of salivary gland cancer with high morbidity and mortality and poor response to treatment. The current options of treatment include radical surgery followed by radiotherapy (RT) with or without chemotherapy. The aim of this study was to analyse the patterns of recurrences, possible predictors of outcome and role of RT in a cohort of patients with non-metastatic SDC.

A retrospective review of patients treated between 2010 and 2019 with histologically proven non-metastatic SDC was conducted.

Sixteen patients were included in the series. Median follow-up was 25 months. Progression-free survival (PFS) and overall survival (OS) at 12 months were 61% and 80%, respectively. Seven out of the 16 patients had disease progression, distant metastases being most frequent. Four patients died due to disease progression. PFS was significantly worse for patients with pathological neck node positivity (p = 0·036) and peri-parotid nodes (p = 0·007). Local control was significantly associated with RT (p = 0·011). Addition of any chemotherapy, regardless of either concurrent or adjuvant, had no impact on the PFS or OS. Pathological neck node positivity with nodal stage of N2 or higher correlated significantly with worse OS (p = 0·031).

Salivary ductal carcinoma is an aggressive malignancy with high metastatic potential. Inferior prognosis was observed among patients who had metastatic deposits in either cervical nodes or peri-parotid nodes on histopathology. As systemic failures are more predominant among these patients, larger prospective trials are needed to formulate an optimum strategy for choice and sequencing of first-line systemic therapy.

This study sought to assess the impact of simulation training in influencing trainees’ initial surgical participation as perceived by experienced surgeon trainers.

Twenty ENT surgeons assessed how much of a given procedure they would expect to allow a trainee to perform for their first time. Responses were provided for trainees who had undergone a relevant simulation course and those who had not, and scored according to the eLogbook levels of involvement in surgery. This was completed for simulated procedures with validated models, across four grades of junior doctors.

A total of 1120 judgements on the trainees’ intended level of involvement were made. The median involvement score was higher in the simulation group versus the non-simulation group (Mann–Whitney U, p = 0.0001), corresponding to a translation in surgical opportunity from a primarily assisting role to an active role.

Trainer perception of a relevant ENT simulation course appears to positively impact on the initial surgical opportunities afforded to the trainee.

To determine the radiological prevalence of frontal cells according to the International Frontal Sinus Anatomy Classification in patients undergoing computed tomography of the paranasal sinuses for clinical symptoms of chronic rhinosinusitis, and to examine the association between cell classification and frontal sinusitis development.

A total of 180 (left and right) sides of 90 patients were analysed. The prevalence of each International Frontal Sinus Anatomy Classification cell was assessed. Logistic regression analysis was used to compare the distribution of various cells in patients with and without frontal sinusitis.

The agger nasi cell was the most commonly occurring cell, seen in 95.5 per cent of patients. The prevalence rates for supra agger cells, supra agger frontal cells, supra bullar frontal cells, supra bullar cells, supra-orbital ethmoid cells and frontal septal cells were 33.3 per cent, 22.2 per cent, 21.1 per cent, 36.1 per cent, 39.4 per cent and 21.1 per cent, respectively. There was no significant difference in the occurrence of any of the cell types in patients with frontal sinusitis compared to those without (p > 0.05).

The presence of any of the International Frontal Sinus Anatomy Classification cells was not significantly associated with frontal sinusitis.

Electroconvulsive therapy (ECT) is recommended in treatment guidelines as an efficacious therapy for treatment-resistant depression. However, it has been associated with loss of autobiographical memory and short-term reduction in new learning.

To provide clinically useful guidelines to aid clinicians in informing patients regarding the cognitive side-effects of ECT and in monitoring these during a course of ECT, using complex data.

A Committee of clinical and academic experts from Australia and New Zealand met to the discuss the key issues pertaining to ECT and cognitive side-effects. Evidence regarding cognitive side-effects was reviewed, as was the limited evidence regarding how to monitor them. Both issues were supplemented by the clinical experience of the authors.

Meta-analyses suggest that new learning is impaired immediately following ECT but that group mean scores return at least to baseline by 14 days after ECT. Other cognitive functions are generally unaffected. However, the finding of a mean score that is not reduced from baseline cannot be taken to indicate that impairment, particularly of new learning, cannot occur in individuals, particularly those who are at greater risk. Therefore, monitoring is still important. Evidence suggests that ECT does cause deficits in autobiographical memory. The evidence for schedules of testing to monitor cognitive side-effects is currently limited. We therefore make practical recommendations based on clinical experience.

Despite modern ECT techniques, cognitive side-effects remain an important issue, although their nature and degree remains to be clarified fully. In these circumstances it is useful for clinicians to have guidance regarding what to tell patients and how to monitor these side-effects clinically.

Depression and mortality have been studied separately in patients with coronary heart disease (CHD) and in populations healthy at study inception. This does not allow comparisons across risk-factor groups based on the cross-classification of depression and CHD status. We prospectively examined the effects of depressive symptoms, assessed in 2002-2004, on all-cause and cardiovascular -mortality in a large sample of 5936 middle-aged participants, with and without established CHD, followed over 5.6 years

We created 4-risk-factor groups based on the cross classification of depressive symptoms and CHD status. The age-and-sex-adjusted hazard ratios for all causes death were 1.67-fold (p< 0.05) higher for participants with only CHD, 2.10-fold (p< 0.001) higher for those with only depressive symptoms and 4.99-fold (p< 0.001) higher for those with both CHD and depressive symptoms when compared to participants without either condition. The two latter risk-factor groups remained at increased risk after adjustments for relevant confounders. Further comparisons indicated that the risks of all-cause death were also higher, but to a lesser extent, for participants with both depressive-symptoms and CHD when compared to those with only one of these conditions. These associations were also observed for cardiovascular mortality

This study provides evidence that depressive symptoms are associated with an increased risk of all-cause and CVD death and that this risk is particularly marked in depressive participants with co-morbid CHD. Several clinical guidelines have recommended screening, referral, and treatment of depression in primary and cardiovascular care units. These findings suggest that these recommendations need further consideration.

To compare the current standards of clinical practice with the recommendations of NICE guidelines (CG 45).

NICE guidelines (CG 45) on Antenatal and Postnatal Mental health suggest that Healthcare professionals should discuss contraception and the risks of pregnancy including relapse, risk to the foetus and risks associated with the stopping or changing medication with all women of child-bearing potential who have an existing mental disorder and or who are taking Psychotropic medication.

A standardised questionnaire was answered by 50 female patients out of 60, attending New bridge unit in Birmingham for the Outpatient appointment in the month of November -2007. The age group was between 18 and 50. The questionnaire was handed out at the reception and Doctors encouraged patients to fill out the questionnaire. Confidentiality was not compromised.

12 (24%) patients were aware of contraception. 17 (34%) knew about the risks of relapse during pregnancy. 15 (30%) women recognised the risks of stopping or changing the medication and 13 (26%) agreed that the risks to foetus were informed to them. This indicated there was room for improvement.

To improve the standards of practice

1. · The Audit report that highlighted standards, was disseminated to all the clinicians through formal power point Audit presentation and through emails.

2. · The importance of passing on the relevant information to the patients was incorporated in Doctors Handbook for Junior Doctors.

Prospective data on depressive symptoms and blood pressure (BP) are scarce, and the impact of age on this association is poorly understood.

The present study examines longitudinal trajectories of depressive episodes and the probability of hypertension associated with these trajectories over time.

Participants were 6,889 men and 3,413 women London based civil servants followed for 24 years between 1985 and 2009. The age of participants over the follow-up ranged from 35 to 80 years. Depressive episode (defined as scoring 4 or more on the General Health Questionnaire-Depression subscale or using prescribed antidepressant medication) and hypertension (systolic/diastolic blood pressure ≥ 140/90 mm Hg or use of antihypertensive medication) were assessed concurrently at five medical examinations.

In longitudinal logistic regression analyses based on Generalized-Estimating-Equation using age as the time scale, participants with depression trajectory characterised by increasing depressive episodes overtime had a greater increase in the likelihood for hypertension with advancing age; an adjusted-excess increase of 7% (95% CI 3-12, p < 0.001) for each five-year increase in age compared to those with a low/stable depression trajectory. In a model adjusted for relevant confounders, a higher risk of hypertension in the first group of participants did not become evident before age 55. A similar pattern of association was observed in men and women although the association was stronger in men.

This study suggests that the risk of hypertension increases with repeated experience of depressive episodes over time and materializes in later adulthood.

As evidenced by ongoing research and partial effectiveness of the antipsychotics on cognitive and negative symptoms, the search is on for drugs that may improve these domains of functioning for someone suffering from schizophrenia.

To do a sytematic review to find out if acetylcholinesterase inhibitors could be used for schizophrenia condisering there use in dementia for cognitive symptoms.

The aim of review was to determine the clinical effects, safety and cost effectiveness of acetylcholinesterase inhibitors for treating patients with schizophrenia.

We searched the Cochrane Schizophrenia Group’s Register and references of all identified studies were inspected. We included all clinical randomised trials comparing acetylcholinesterase inhibitors with antipsychotics or placebo either alone or in combination for schizophrenia and schizophrenia-like psychoses. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated weighted mean differences (WMD) again using random-effects model.

The acetylcholiesterase inhibitor plus antipsychotic showed benefit over antipsychotic and placebo in the mental state, cognitive domain and tolerability. No difference was noted between the two arms in other outcomes. The overall rate of participants leaving studies early was low and showed no clear difference between the two groups.

The results seem to favour the use of acetylcholiesterase inhibitors in combination with antipsychotics in different oucomes, but because of the various limitations, this review highlights the need for large, independent, well designed, conducted and reported pragmatic randomised studies.

Clozapine is the drug of choice for patients with treatment-resistant schizophrenia. However a minority of them have been unable to continue with Clozapine due to side-effects, for example rash. This report looks at the use of graded desensitization in a patient who developed cutaneous reactions to Clozapine.

This report describes the management of a patient with treatment resistant-schizophrenia, mild learning disabilities and epilepsy, following a cutaneous reaction to Clozapine. Having been maintained on Clopixol depot until 4 years ago, he required a change in antipsychotics following a relapse of psychotic symptoms. He was then treated unsuccessfully with various anti-psychotics, before starting Clozapine, to which he showed a good response. Unfortunately he developed an eczematous rash on two separate occasions when the drug was introduced. Again he was tried on other anti-psychotics, to which he also developed a rash. He was then put on a graded desensitization regimen of liquid Clozapine.

Graded desensitization, using incremental increases in drug dose, allowed maintenance treatment with therapeutic doses of Clozapine to be achieved in the absence of cutaneous hypersensitivity reactions. the patient's previously treatment-resistant psychotic symptoms were improved by this method.

We should be aware of possibilities for the management of both the common and uncommon side-effects associated with Clozapine, as the result might vastly improve the patients’ quality of life. Desensitisation regimens can be an effective means of overcoming drug hypersensitivity but should be used with great caution, especially when patients exhibit delayed-type hypersensitivity reactions.

Agitated Unipolar Depression and Bipolar mixed states combine depressive and manic symptoms, reflecting severe forms of affective disorders with an increased suicide risk. These states have not been defined with adequate consensus and hence present a diagnostic and therapeutic challenge.

We searched the records of patients with Affective Mixed States in a community Mental Health Team to identify patients with affective mixed states.

We assessed the treatments prescribed and the time it took to treat the Mixed states so that they then suffered from depression or were euthymic.

Ten out of 17 patients were suicidal when experiencing a mixed state. Of the 6 patients that were agitated, 5 were suicidal. Best results were achieved with a combination of -Reducing antidepressant -Increasing mood stabilisers (Depakote, Lithium) -Increasing/adding atypical antipsychotics. With such treatment, the average duration to resolution was 2.5 weeks. The worse results were achieved by adding antidepressants to a patient experiencing low mood with a mixed state such treatment led to resolution in 10 weeks

Agitation is a strong predictor of suicide risk. Reducing antidepressants is important thus Increasing/adding antipsychotics and mood stabilisers without changing antidepressants led to an 8.5 weeks duration of treatment.

Patients with mixed states should be reviewed regularly and risk-assessed -We suggest weekly due to increased suicide risk. With very high-risk patients, referral should be made to the Crisis Team. Care coordinators should be involved for regular contact with services.

Antidepressants are amongst the most commonly prescribed classes of drugs and their use continues to grow. Adverse outcomes are part of the landscape in prescribing medications and therefore management of safety issues need to be an integral part of practice.

We have developed consensus guidelines for safety monitoring with antidepressant treatments.

To present an overview of screening and safety considerations for pharmacotherapy of clinical depressive disorders and make recommendations for safety monitoring.

Data were sourced by a literature search using Medline and a manual search of scientific journals to identify relevant articles. Draft guidelines were prepared and serially revised in an iterative manner until all co-authors gave final approval of content.

A guidelines document was produced after approval by all 19 co-authors. The final document gives guidance on; the decision to treat, baseline screening prior to commencement of treatment, and ongoing monitoring during antidepressant treatment. The guidelines state or reference screening protocols that may detect medical causes of depression as well as screening and monitoring protocols to investigate specific adverse effects associated with antidepressant treatments that may be reduced or identified earlier by baseline screening and agent-specific monitoring after commencing treatment.

The implementation of safety monitoring guidelines for treatment of clinical depression may significantly improve outcome, by improving a patient's overall physical health status.

Despite an expanding body of research pertaining to Borderline Personality Disorder (BPD) in child and adolescent populations, controversy remains regarding the validity of youth BPD.

To determine the aetiological and psychopathological validity of youth BPD.

Electronic databases were searched for studies examining the aetiological (i.e., the extent to which youth and adult BPD share common risk factors) and psychopathological (i.e., the extent to which youth and adult BPD share common symptoms and associated behaviours) validity of BPD in populations under 18 years of age. Forty-three studies were identified satisfying the predetermined inclusion criteria for meta-analysis.

Statistically significant pooled associations with youth BPD were observed for sexual (OR=4.90; 95% CI=3.12, 7.70) and physical (OR=2.82; 95% CI=1.95, 4.07) abuse; maternal hostility/verbal abuse (OR= 3.28; 95% CI= 2.39, 4.51); and neglect (OR=3.45; 95% CI= 2.26, 5.28). Several psychopathological features were also associated with youth BPD, including comorbid mood (OR= 3.29; 95% CI= 2.36, 4.59), anxiety (OR= 2.13; 95% CI=1.45, 3.14) and substance use (OR=4.59; 95% CI=2.84, 7.43) disorders; self-harm (OR: 5.53; 95% CI=2.59, 11.81) and suicide ideation (OR=3.71; 95% CI =2.22, 6.21).

Findings indicate that adult and youth BPD share common aetiological and psychopathological correlates. This indicates some diagnostic validity of youth BPD and supports clinical recognition in this age group.