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Q&A with Mr Ludvic Zrinzo

 

Mr Ludvic ZrinzoMr Ludic Zrinzo is a Senior Lecturer at UCL and a Consultant Neurosurgeon at The National Hospital for Neurology and Neurosurgery. His specialist interest is in the surgical management of chronic neurological diseases. In particular, he concentrates much of his clinical practice and research on the continued improvement in the surgical care of patients undergoing Deep Brain Stimulation (DBS).

Mr Zrinzo kindly took time this month to speak with us about his work, which he is now bringing to his own private practice at the Queen Square Private Consulting Rooms.

 

Q: Firstly, perhaps you could tell us a little about your background and what prompted your decision to not only specialise in neurosurgery but specifically, the surgical treatment of chronic conditions?

My family comes from Malta and my parents are both doctors. As a teenager, I was fascinated by Mathematics, Physics and Engineering and had never seriously considered Medicine as a career. That all changed when a hijacked Egyptair Flight was forced to land in Malta. It was a brutal affair with terrorists shooting passengers in the head as they made their demands. The ordeal only came to an end after a bloody assault by Egyptian commandoes. Many passengers lost their lives but two survived gunshot injuries to the head. My father, Laurence, was the neurosurgeon who had operated on them. This darkest of days triggered my resolve to become a neurosurgeon.

As a medical student, I became increasingly fascinated with the human brain and how it gives rise to our movements, feelings and thoughts. When I moved to London for neurosurgical training, I had the opportunity to work with Prof Hariz (neurosurgeon) and Prof Limousin (neurologist) within the Unit of Functional Neurosurgery. Their patient-focused approach and the very positive results that surgery could provide in selected patients were inspiring.

After a fellowship in functional neurosurgery at UCLA, Los Angeles, I was appointed Consultant in Neurosurgery at Queen Square 9-years ago. The Unit has rapidly expanded since to include another two consultant colleagues - Dr Foltynie (neurologist) and Mr Hyam (Neurosurgeon). Our Unit is now the busiest deep brain stimulation (DBS) center in the UK with a track record that has been described as an “international benchmark” in safety and efficacy.

 

Q: What does DBS surgery involve and what can it be used for?

Deep brain stimulation (DBS) surgery improves brain function by changing the way the brain processes information. It is the most commonly used technique in functional neurosurgery. DBS involves placing tiny electrodes very precisely within the brain and connecting them to a “brain pacemaker” implanted under the skin, below the collarbone (Figure 1). Delivery of a small electrical current can disrupt abnormal brain activity and lead to a dramatic improvement in the symptoms of some chronic neurological conditions.

DBS Placement

Traditionally, DBS surgery had to be performed under local anaesthesia so that doctors could refine the electrode location within the brain by observing the effect that the surgery was having on the patient’s symptoms. However, our pioneering research has changed the way DBS surgery is performed. Neurosurgeons can now rely on detailed MRI sequences to both guide and verify electrode location within the brain. In practice this means that surgery is safer and can be performed under general anaesthesia – while the patient is asleep. Of course, this is much less stressful for patients.

There is a huge amount of scientific evidence supporting the use of DBS in selected patients with Parkinson’s disease, tremor and dystonia. Over 120 000 DBS procedures have been performed worldwide in the last 25 years. The success of DBS in treating patients with these movement disorders has prompted researchers around the world - including our group at Queen Square - to investigate whether DBS can be useful for other brain disorders, including chronic pain syndromes (like cluster headache) and some neuropsychiatric disorders (such as Tourette syndrome and obsessive compulsive disorder). Much more research is required but the results of DBS for some of these other conditions are encouraging.


Q: Which patients might benefit from DBS surgery?

When symptoms respond well to medications, DBS surgery does not need to be considered. However, medications can cause intolerable side effects or may fail to provide adequate symptom control throughout the day. These patients may benefit from DBS.

Parkinson’s disease (PD) is the commonest indication for DBS. Some patients with PD develop “motor fluctuations” where tremor, rigidity and slowness appear in an increasingly unpredictable fashion throughout the day. DBS can “smooth out” these fluctuations, allowing more consistent symptom control and a reduction in the amount and number of medications required.

Essential or familial tremor is another common movement disorder that responds well to DBS.

Ultimately, a detailed assessment by a neurologist and neurosurgeon with a specialist interest in functional neurosurgery is required to determine whether a particular patient will benefit from DBS.

 

Q: What outcomes might patients who undergo this type of surgery be able to expect/hope for?

DBS surgery does not provide a “cure” for the disease. However, in well-selected patients DBS can have a dramatic positive effect on symptoms and quality of life. DBS surgery needs to be “tailored” to the individual patient and a thorough clinical evaluation combined with a number of specific tests allow the DBS team to counsel individual patients on the likely benefit.

It is important to realise that DBS is not simply an operation - it is a lifelong therapy. A positive outcome requires a meticulous approach to surgery combined with regular optimisation of medication and stimulation parameters in the years that follow.

 

Q: How does our location in Queen Square aid you and your team?

A multidisciplinary approach is essential to obtaining good outcomes after functional neurosurgery. The National Hospital at Queen Square brings together the country’s foremost experts in functional neurosurgery, neurology and neuroimaging with support from dedicated healthcare specialists when required, including psychologists, specialist DBS nurses and speech and language therapists. We are also fortunate to have the country’s first operating theatre with a built in MRI scanner to facilitate our “MRI-verified” approach to DBS surgery.

This multidisciplinary approach is also extended to other chronic neurological conditions such as trigeminal neuralgia where I work closely with Dr Matharu, consultant neurologist with a specialist interest in headache, to provide a comprehensive service to patients with trigeminal neuralgia, cluster headache and similar problems.

 

Q: How are patients able to find out whether or not DBS is a treatment option for them?

Patients and their immediate family are seen in joint consultation with a neurologist and neurosurgeon from the DBS team. The symptoms that are causing the most concern are identified. Specific investigations may be requested and the results then reviewed. The DBS team will then counsel the patient and family as to whether DBS is a treatment option for them and what the likely outcome is in their particular case.

 

Mr Zrinzo holds regular clinics for private patients at the Queen Square Private Consulting Rooms, 23 Queen Square. If you would like to discuss a referral, please contact his secretary Lottie Wade at This e-mail address is being protected from spambots. You need JavaScript enabled to view it. , or contact the Private Consulting Room directly on 020 344 88948.

This month, we speak with Dr Susie Henley, who has recently brought her expertise in Clinical Psychology to a clinic at the Queen Square Private Consulting Rooms.

Dr Henley has particular expertise in working with individuals who have neurological disease, and those who have concerns over their mood or mental health.


Q: Dr Henley, thank you for taking the time to speak with us today. Firstly, would you be able to elaborate a little on your particular area of expertise?

A: Like all Clinical Psychologists I’m trained to use talking therapy to help people with a range of concerns about their mood or mental health, but my work tends to have a particular focus on helping people who have a neurological problem – such as dementia, stroke or epilepsy – and are perhaps anxious, low or frustrated in part because of that neurological problem. For example, I’ve worked with people with a dementia diagnosis who are very anxious about forgetting what to say in social situations and have become a bit withdrawn as a result, and people whose speech is much slower than normal after a stroke which has really knocked their self-esteem and affected their mood.


Q: How can your work help patients who are trying to manage the physical effects of a neurological condition?

A: There are lots of ways in which a talking therapy can help. Sometimes people with a neurological condition really want to understand the condition better, and I’ll use my neuropsychological knowledge, and a little model brain I work with, to sit down and spend time helping them understand how the brain works, what parts are working less well in their case, and how that translates into the day-to-day difficulties they are experiencing. This can be really useful for families and friends as well as the patient themselves. Sometimes people are really very anxious or low about their symptoms or what the future holds. In that case I would tend to suggest a Cognitive Behavioural Therapy (CBT) approach (which has a really good evidence-base for anxiety and low mood) to help them identify certain patterns of thoughts, emotions and behaviours that are perhaps maintaining their anxiety or low mood, and think with them about ways of trying to do things differently to break out of those patterns. Sometimes the work is more about giving people and their families just some space and time to talk through how the diagnosis has impacted on them and their relationship; patients might find they have had to give up their job or retirement dreams, and partners often find they have taken over various household tasks that they’ve never had to do before. They often say that it is helpful to talk about these changes.

It is also really important to stress that a neurological or mental health condition can have a huge impact on partners and families as well as the patient. A lot of my work includes partners and families, even involving time with them on their own, without the patient present. Sometimes it is helpful to have a partner in the session – for example they might help the patient put into practice some of the things we have talked about – and sometimes partners and family members appreciate time on their own to share feelings such as guilt and anger that they prefer not to talk about in front of the patient.


Q: You also work with people who are anxious that they might have a neurological condition but have been reassured by your neurology colleagues that there is no evidence of one. How does your work help in these cases?

A: Yes, a significant part of my work is with people who are worried that something is wrong with their brain but for whom all the medical investigations have come back as “normal”. Most typically this is people in their 30s-50s who have noticed that they have forgotten some key events or appointments, and are anxious that they might be developing dementia. First of all, I try to get a good understanding of the bigger picture with these people; more often than not there are lots of other things going on in their lives, for example bereavement, difficulties at work, financial worries or a work-life balance that they are unhappy with, and we start to build up a picture of how all these things might be contributing to their worries. Secondly, I spend time helping them to understand the links between anxiety and thinking; many people are surprised to learn that when we are anxious, the hormones that our body produces actually affect our brain as well as our bodies and can impact on our thinking, and memory in particular. Again, I find the model brain really useful here and I’ve also got some standard information that we go through and that people can take away and look at in their own time. Finally, once we have that wider picture of the situation, and the person has developed that understanding of the links between anxiety and thinking, I would again typically suggest a CBT approach in which we work together to come up with ways of making some changes.


Q: When holding a clinic at the Queen Square Private Consulting Rooms, you are surrounded by consultants with a diverse range of clinical specialities. Do you think there are advantages in holding a clinic within a setting such as this?

A: Yes, I think this setting in Queen Square very much mirrors the multi-disciplinary approach that we use in the NHS, and it is helpful to me as a professional to know that there are a range of other professionals to whom I could refer someone if it seemed necessary. For example, if I saw someone who was worried about their memory, and I didn’t think, after an assessment, that this really could be explained by psychological and lifestyle factors on their own, I would be able to suggest that I refer them to a neurology colleague within the same clinical setting. Of course, it is really helpful to be based physically in the same place as those other colleagues because that makes it much easier to pop in and have a face-to-face chat with them about a patient.


Q: Wednesday 4th November 2015 was National Stress Awareness Day. Do you feel that management of stress and anxiety is getting sufficient attention, or do you think patient outcomes could be improved with more time dedicated to patient’s mental wellbeing?

A: I think that in Queen Square we are quite good at keeping a patient’s mental wellbeing in mind when we assess them, but not always aware of the resources that are available post-assessment that could be used to help with mental health issues alongside the standard medical pathways, which are of course really important for the patient. Nationally, in the field of dementia for example, there is evidence that a huge number of people with dementia feel anxious or depressed1, yet also lots of evidence that talking therapy can alleviate this and improve quality of life for both the person with dementia and their partner2.


Q: Finally, how are patients able to access your services? Do they need a referral?

A: It’s nearly always most appropriate for patients and families to come and see me after they have been assessed by a medical colleague, usually a neurologist. That means that when they start work with me we both have a good understanding of their condition or the fact that they have had investigations that have come back normal but they remain worried about their thinking. In that case, a referral letter from that other medical colleague is usually the best way to start.

However, I am happy for people with concerns about their mental health to contact me directly via my website, or via the private consulting rooms, without a referral. If they already have a diagnosis I would ask to see recent letters from their neurology consultant in order to make sure that I had a good understanding of that diagnosis, and I would also ask their consent to let that other consultant know that they were seeing me.

1 http://www.alzheimers.org.uk/infographic

2 Orgeta, V, A Qazi, Spector Ae, and M Orrell. 2014. “Psychological Treatments for Depression and Anxiety in Dementia and Mild Cognitive Impairment (Review).” Cochrane Database of Systematic Reviews (online) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009125.pub2/abstract


Dr Henley holds regular clinics at the Queen Square Private Consulting Rooms.

Appointments can be arranged by contacting the consulting rooms directly on 0203 448 8948,
or via Dr Henley by email to
This e-mail address is being protected from spambots. You need JavaScript enabled to view it. .

More information on Dr Henley’s services can be accessed on her website www.susiehenley.co.uk.

As QS Enterprises celebrates its 30th anniversary, we caught up with Queen Square chairman of the board, Mr Graham Faulkner.

Q: Hello Graham, thank you for taking the time to speak with us. Please could you tell us a little about your role at Queen Square?

A: I am now the chairman of the board but I’ve been a director with QSE for three or four years. I got to know Anthony Wheatley, the previous chairman, when I was the chief executive of the Epilepsy Society. Anthony was the chairman there as well and we worked together for a number of years. When he was coming to the end of his time at QSE, he got me involved as a board member then I took over as chairman when he stepped down.


Q: What inspired you to work with QS Enterprises?
A: It’s a bit of a cliché but I think what the company does is a tremendous example of private practice and a benefit to the NHS. I thought the way the company is operated, making money through private practice for the benefit of the NHS, is a fantastic model of care.


Q: How has QS Enterprises developed over the last 30 years?
A: Queen Square started just doing optical scans at the National Hospital but then it developed with the heart hospital as well. In the time I’ve been there, we’ve been looking at other ways to bring the QSE model to other areas of activity. At the moment we are discussing new developments to increase the role of QSE both with UCLH and elsewhere in London.


Q: What else can you tell us about upcoming developments at QS Enterprises?

A: Private practice within the NHS is becoming more common and I know UCLH are certainly keen to see the development of private medicine within the hospital environment. We’ve been talking about the role that QSE might have to help with that. We have a proven track record of dealing with private patients, which we think could be helpful to the hospitals on a wider scale. Our chief executive Jodee is going to be doing some work at the Nuffield ward in Queen Square over the next couple of months to look at how we might be able to bring the QSE approach to things within the hospital itself. This approach is gift-aiding the profits back to the hospital via the charitable trustees who then decide how that money’s going to be passed on to the hospital to improve facilities, perhaps to do things that wouldn’t be possible without that additional funding.

Q: With public suspicion of privitisation in the NHS, how does QSE communicate its benefit to the health service?
A: I think QSE is the acceptable face of privitisation. We’re working within the NHS envelope. The financial benefit of private practice is going to be fed back into the NHS to improve services so it’s not as though we are taking things out. It’s working alongside our colleagues at the NHS to benefit the patients, both private and NHS.

Q: What is QS Enterprises’ greatest achievement in your opinion?

A: The sheer amount of money that’s been made by QSE that has been channeled back into the hospital is probably in excess of £25m. This has funded things that wouldn’t have been possible without those charitable funds. A lot of the money for the new NMCCU unit came from QSE so it could be bought earlier in development than would otherwise have been the case. I think the sheer amount of money that’s been pumped into the NHS, long before I was involved, is a fantastic achievement.

Q: What challenges do you see QSE tackling in future?
A: We face the same challenges as the rest of the NHS in terms of funding. There will always be competition out there with other private providers within the health sector. We need to continue to generate the financial return we’ve made up until now.

Migraine: A Headache Specialist’s Perspective by Dr Kevin Shields, Consultant Neurologist

When I tell colleagues that I run a specialist headache clinic I am often met with a wry smile. I have always been perplexed by this curious reaction, as headache is one of the most common neurological complaints encountered in daily practice. Getting the management right can make a big difference in quality of life to many patients. This is because headache disorders represent a huge burden in terms of disability and lost economic productivity. Migraine may affect up to 1 in 6 of the population at some stage while potentially 4% of the population suffer from chronic daily headache. Analgesia overuse is a major problem and many people who would benefit from headache preventive treatments are not receiving them. In this article I am going to briefly cover some of the issues I encounter in managing migraine, one of the leading causes of neurology referrals.

 

Genetic and Environmental Influences

Patients often ask me why they have migraine. For the majority it is something they were born with. If you dig deeply enough there is often a history of a first-degree relative who also suffered from migraine and that can help with the diagnosis. There may also be a history of motion sickness or unexplained abdominal pain in childhood. Migraine has a genetic basis and it probably represents the end product of a complex interaction between a number of genes and the environment. Individual genes have been identified as causing hemiplegic migraine but this represents only a small proportion of the total number of people with migraine. The role that the environment plays in triggering migraine is poorly understood. As a general rule people who have migraine prefer routine. Change seems to be a trigger for attacks. A regular sleep pattern is important – too much sleep can be just as much of a trigger as too little. Hunger rather than exclusion of specific food groups in the diet per se seems to be more of a provocation. Hormonal fluctuations as part of the menstrual cycle or menopause may also be a significant determinant in females. Common sense behavior modification may therefore help with preventing some headaches. If a reliable trigger can be identified then it is best to avoid it if possible, but generally speaking I find that dramatic life-style changes are neither warranted nor particularly beneficial.

 

Migraine Aura

Migraine aura can often be a source of diagnostic confusion. Aura is experienced by a minority of migraineurs, perhaps only 15% of patients. It is important because though relatively uncommon, it may trigger unnecessary investigations for stroke. The history is crucial to avoid misdiagnosis. There is good evidence to suggest that aura corresponds to the experimental phenomenon of cortical spreading depression. Most commonly it manifests as a visual disturbance such as fortification spectra or a shimmering scotoma. It can also cause motor, sensory or speech symptoms depending on the area of cortex involved. Aura typically precedes the onset of the headache but this is not always the case. Isolated aura is well recognized and is perhaps more common in older males. Aura symptoms evolve slowly over minutes unlike the sudden instantaneous onset experienced during an ischaemic event. They may last for some time, but often no more than an hour, before they resolve. Once again this is often a gradual process. Patients often feel tired and “washed-out” following an isolated aura and this can be an additional clue in the history.

 

Treatment

The treatment of migraine can be divided into two arms: a) acute treatment to alleviate the immediate pain, b) prophylactic to reduce the severity and number of attacks.

 

Acute Treatment

Acute treatment may involve a combination of medications, depending on the severity and constellation of symptoms. The important thing is to treat the pain aggressively from its onset. Leaving treatment until the pain becomes intolerable is not a good strategy. It is my experience that this approach only allows the pain to become more entrenched and difficult to treat. Simple analgesics such as paracetamol, NSAIDs or codeine can all be used and may be adequate for many patients. Patients should also be offered an anti-emetic as gastric emptying is delayed during a migraine attack.

Triptans can be an invaluable acute treatment option for some, though not all, patients. Seven triptans are available. Each has its own particular characteristics in terms of speed of action, efficacy, side effect profile and risk of headache recurrence. They also come in a variety of formulations e.g. an intranasal sprays can be helpful if a rapid speed of onset is required or early onset of vomiting prevents enteric absorption. A given triptan should be used to treat at least three attacks before deciding if it is effective. Failure to respond to a triptan does not mean that the entire class will be ineffective. It is always worthwhile trying an alternative to see if it is better tolerated or more efficacious. The triptans can have unpleasant side effects including chest/neck tightness or excessive sedation. They are contraindicated if there is a history of coronary artery disease, coronary vasospasm or uncontrolled hypertension. Later generation triptans such as almotriptan may be better tolerated but they tend to be more expensive than sumatriptan. It is worth remembering that a triptan can be taken in combination with analgesics, especially NSAIDs. The combination of the two drugs can be synergistic. Some patients may be able to sense at the onset of a migraine whether or not it is going to be a severe attack. If so, I would suggest they take a triptan and a NSAID such as naproxen (provided it is not contra-indicated) together in an effort to terminate the attack.

A novel recent development in the acute management of migraine is the use of neurostimulator devices. Transcranial magnetic (TMS) and vagal nerve stimulation (VNS) are two methods of neuromodulation that are non-invasive and generally well tolerated. Their precise mechanism of action is not clear. TMS delivers magnetic pulses to the occipital cortex using a hand–held device while VNS delivers electrical pulses to the vagal nerve in the neck.

 

Analgesic and Triptan Overuse Headache

Overuse of acute treatments is a serious and common problem. Any analgesic – even paracetamol – will make migraine worse if used too frequently. Triptans are even more prone to causing over-use headache if taken excessively. Patients may suffer a “double hit” as overuse of acute treatments will not only make migraines worse, but may also block the action of prophylactic treatments. What however constitutes overuse? I consider consumption of painkillers on more than 2 days out of each week, or triptans on more than 6 days per month is too much. Patients will have to stop their acute treatments for at least 4-6 weeks for the effects of overuse to wear off. They may experience a rebound worsening of their headache in that time but there are ways of dealing with this. It is very important to ask specifically about this issue and sometimes a bit of probing is required. Patients may be reluctant to accept this and it often needs to be addressed gently but firmly. It must be remembered that some people have come to rely on their acute treatments. Being told to stop them – even temporarily – because they are making their headaches worse is anathema to them. It is important to stress that they will not improve until the overuse stops. It may help to point out that the very act of acute treatment withdrawal on its own may lead to a 50% reduction in headache days in 50% of patients.

 

Prophylactic treatments

I generally offer a prophylactic treatment to patients when they suffer four or more debilitating headache days per month. There are numerous treatment options but there are some general principles that must be observed. Firstly, prophylactic treatments may not work quickly. A patient may need to be on an effective dose of a prophylactic agent for up to four months before deciding it is working or not. There are therefore no quick fixes. They are usually started at a low dose but then it must be increased until either:

a) the maximum dose is reached

b) side effects prevent further dose increases

c) the headaches improve

 

Dose increases should be made every two to four weeks depending on tolerability, but one has to be flexible. Some patients may need to go more slowly but there is little point in maintaining a patient on a low dose if their headaches are not improving. If they get to an effective dose and are maintained on this for 3-4 months without improvement (and they are not overusing acute treatments) then they should be moved on to another treatment. With the exception of the CGRP-antagonists currently in development, no migraine prophylactic treatment was specifically designed for this purpose. Serendipity has played a part and this sometimes needs to be explained to patients. Some may be concerned to learn that they are receiving an anti-depressant or anti-epileptic medication and explaining this early on avoids confusion. Treatments range from Vitamin B2 to botulinum toxin but there is no “wonder-drug”. It may entail a process of trial and error before a preventive is found for an individual that is both tolerable and effective.

 

Conclusion

Migraine is a very common, debilitating but eminently treatable condition. Acute treatment often depends on using a combination of drugs to bring the pain and other symptoms under control as quickly as possible. Acute treatments may be a doubled edged sword however, and if used too frequently will ultimately lead to a worsening of headache. In such cases prophylactic treatments should be prescribed. Remember that there are a wide variety of prophylactic options but they may not work quickly. Perseverance is required and the dose should be increased if there is no response. It may involve a process of trial and error to find a drug that works and is tolerable. If it becomes apparent that a drug is ineffective, move on to another. It is worth the effort as getting it right can make a big difference to patient’s quality of life.

 

 

Dr Kevin Shields currently holds private specialist headache clinics at the Queen Square Private Consulting Rooms (23 Queen Square, WC1N 3AR). If you would like to make an appointment, please contact the Queen Square Private Consulting Rooms on 0203 448 8948.

Dr_Kevin_Shields

© Dr Kevin G. Shields 2015.

 

On Tuesday 7th October Queen Square Imaging Centre welcomed GPs to its educational evening at the National Hospital for Neurology and Neurosurgery.

  • Q&A with Mr Ludvic Zrinzo

    Wed-01-16 12:30:00

    Q&A with Mr Ludvic Zrinzo   Mr Ludic Zrinzo is a Senior Lecturer at UCL and a Consultant Neurosurgeon at The National Hospital for Neurology and Neurosurgery. His specialist interest is in the sur…

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  • This month, we speak with Dr Susie Henley…

    Mon-11-15 17:01:00

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  • Migraine: A Headache Specialist’s Perspective

    Tue-09-15 10:41:49

    Migraine: A Headache Specialist’s Perspective Dr Kevin Shields, Consultant Neurologist When I tell colleagues that I run a specialist headache clinic I am often met with a wry smile. I have alway…

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    As QS Enterprises celebrates its 30th anniversary, we caught up with Queen Square chairman of the board, Mr Graham Faulkner. Q: Hello Graham, thank you for taking the time to speak with us. Pl

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  • Attend our GP educational evening on 7th Oct 2014

    Fri-03-14 17:37:00

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  • QS Enterprises fund state-of-the art neuromuscular unit

    Wed-03-14 17:37:00

    UCLH Charity will soon open the UK’s first neuromuscular complex care unit (NMCCU) which has been created with the reinvestment of profits from QS Enterprises. The unit will provide the best possib…

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