WP1-12 Reducing infection rates in an intrathecal baclofen service; closing the audit cycle

Objectives

Intrathecal baclofen (ITB) is a recognised treatment strategy for the management of spasticity. We have 30 years of experience, and 160 patients currently receiving treatment.

Design

An audit (Jan 13 – Jul 15) demonstrated complication rates of 4.4% (infection) and 4.92% (catheter). After this we recommended 1 vancomycin wash of the pump pocket, 2 occlusive dressing of pressure sores, 3 timely MRSA pre-screening, and this was introduced June-August 2016. We present a re-audit of the service.

Subjects

All patients admitted for ITB pump surgery between June 2016 and June 2018.

Methods

The database of patients was used, from which the patient notes were reviewed with information relating to each surgical procedure recorded.

Results

There were 92 surgical procedures and 78 patients (M 30, F 48). 12 patients had complications, requiring 18 surgical procedures. Out of 18 surgical procedures, 10 were catheter- and 7 pump-related). Our infection rate was lower at 1% of all surgeries (compared with 4.4%), or 0.6% of all ITB pump patients per year (compared with 3.4%), and our catheter complication rate was 6.25% of all patients per year. Our annual incidence rate of all complications was 5.6% in both groups.

Conclusions

The infection risk is lower and complication rate remains stable. We will discuss factors which may influence the risk of complication, and consider recommendations for the future.

Molecular Cytogenetic Characterization of a Karyotype of a Female Patient with Secondary Amenorrhea with a Cell Line Showing 46,X,+mar

Disorders of sex development (DSD) include a group of conditions in which genotypes do not correlate with the typical male and female phenotypes. Numerical and structural abnormalities involving both autosomes and sex chromosomes have been observed in DSD. Specifically, deletions, duplications, and translocations involving specific genes as well as point mutations and less common aberrations have been implicated in the pathogenesis of these conditions. Finally, recent advances in analytical tools, namely chromosomal microarrays and sequencing methods, have greatly enhanced the precision with which DSD are genetically characterized and phenotypically correlated. Herein we report a case of a 24-year-old female patient who presented with secondary amenorrhea. Cytogenetic studies of her peripheral blood showed an abnormal clone with 45,X in three cells and the other was initially observed by chromosome analysis as 46,X,+mar in 27 cells. Molecular cytogenetics were performed to characterize the marker chromosome that showed two copies of the SRY, two copies of the heterochromatin Yq12, and two copies of the Y centromere Yp11.1-q11.1 on the marker chromosome, resulting in the identification of an isodicentric Y chromosome. Females with a 46,XY karyotype have gonadal dysgenesis and typically present as mosaic, along with a 45,X cell line. Some show small deletions of the short arm of the Y chromosome. Further studies based on the clinical picture, as well as possible prophylactic gonadectomy due to an increased risk of gonadal malignancy, gonadoblastoma or dysgerminoma, are suggested. Genetic counseling was recommended.

Identifying avoidable switchboard delays in England's NHS hospitals: phase one of the national SWITCH project

BACKGROUND

Inter-hospital communication frequently requires mediation via a switchboard. Identifying and eliminating switchboard inefficiencies may improve patient care.

METHODS

All 175 acute hospital switchboards in England were contacted six times. Call contents and duration were recorded. No clinician calls or bleeps were connected.

RESULTS

The mean delay before contacting a switchboard operative was 55±46 seconds. 115 hospitals (66%) used automated switchboards; 34 of these (30%) had infection control messages. Robot operators introduced an additional 40 second delay versus humans (mean 70.3±28 versus 29.8±23 seconds, p<0.0001). Multivariate analysis identified robot operators (HR 5.1, p<0.0001) and infection control messages (HR 2.9, p=0.003) as predictors of delays over 60 seconds.

CONCLUSIONS

There are significant avoidable delays in contacting switchboard operatives across England. Quality improvement is underway.

Prospective real-world analysis of OnabotulinumtoxinA in chronic migraine post-National Institute for Health and Care Excellence UK technology appraisal

BACKGROUND AND PURPOSE

The National Institute for Health and Care Excellence (NICE) in the UK recommends the use of OnabotulinumtoxinA (BoNTA, Botox^® ) in the management of chronic migraine (CM) following specific guidelines within the National Health Service. In view of the lack of data on the efficacy of this therapy following implementation of these guidelines in clinical practice and on the evaluation of guidance compliance, we aimed to evaluate the effectiveness and safety of BoNTA in patients with CM following the NICE guidelines.

METHODS

This was a prospective real-life audit study.

RESULTS

After two treatments, 127 of 200 patients (63.5%) obtained at least a 30% reduction in headache days. Those who continued the treatment up to 3 years reported a stable beneficial effect compared with baseline. Amongst responders, 68 patients (53.5%) were reclassified as episodic migraineurs. A total of 57 of these patients (83.8%) converted to an episodic migraine pattern at 6-month follow-up. The majority of those whose migraine became episodic after BoNTA extended the treatment intervals beyond 3 months (range 4-8 months) before noticing any worsening of headache. We observed no significant differences in the efficacy measures in patients treated with 155 U BoNTA compared with those treated with >155 U BoNTA.

CONCLUSIONS

When administered according to the NICE guidance, BoNTA produced a clinically meaningful effect in the long-term management of CM with and without medication overuse headache. Treatment discontinuation when CM becomes episodic may be useful in clinical practice to identify those who may benefit from extended treatment intervals. Our clinical experience indicates a lack of additional benefit from using the 'follow-the-pain' paradigm.

p53 orchestrates DNA replication restart homeostasis by suppressing mutagenic RAD52 and POLθ pathways

Classically, p53 tumor suppressor acts in transcription, apoptosis, and cell cycle arrest. Yet, replication-mediated genomic instability is integral to oncogenesis, and p53 mutations promote tumor progression and drug-resistance. By delineating human and murine separation-of-function p53 alleles, we find that p53 null and gain-of-function (GOF) mutations exhibit defects in restart of stalled or damaged DNA replication forks that drive genomic instability, which isgenetically separable from transcription activation. By assaying protein-DNA fork interactions in single cells, we unveil a p53-MLL3-enabled recruitment of MRE11 DNA replication restart nuclease. Importantly, p53 defects or depletion unexpectedly allow mutagenic RAD52 and POLθ pathways to hijack stalled forks, which we find reflected in p53 defective breast-cancer patient COSMIC mutational signatures. These data uncover p53 as a keystone regulator of replication homeostasis within a DNA restart network. Mechanistically, this has important implications for development of resistance in cancer therapy. Combined, these results define an unexpected role for p53-mediated suppression of replication genome instability.

Disordered eating behaviour in young adults with type 1 diabetes mellitus

BACKGROUND

The combination of eating disorders and diabetes is associated with increased risk of morbidity and mortality. The aim of this study is to compare the prevalence of disordered eating behaviour (DEB) in young adults with type 1 diabetes mellitus to a sample of non-diabetic controls, and to examine the relationship of DEB to glycaemic control.

METHODS

The Eating Disorder Examination Questionnaire (EDE-Q) was administered to 51 individuals aged 18-30 years attending an outpatient diabetic clinic in a large university teaching hospital. Glycaemic control was assessed by the glycosylated haemoglobin (HbA1c). The control group comprised a consecutive sample of 236 male and female students aged 18-30 years attending a university primary health care service.

RESULTS

The mean global EDE-Q score for the diabetes group was 0.82 ± 1.1 (mean ± SD) and the mean for the control group was 1.4 ± 1.3 (mean ± SD). The diabetes group was significantly more likely to have a lower global EDE-Q score compared to the control group. There was no association between the global EDE-Q score of the diabetes group and HbA1c level.

CONCLUSIONS

We did not find increased levels of disordered eating behavior (DEB) in young adults with type 1 diabetes mellitus compared to a non-diabetic control sample.