The MOG antibody non-P42 epitope is predictive of a relapsing course in MOG antibody-associated disease

BACKGROUND

Myelin oligodendrocyte glycoprotein (MOG) IgG seropositivity is a prerequisite for MOG antibody-associated disease (MOGAD) diagnosis. While a significant proportion of patients experience a relapsing disease, there is currently no biomarker predictive of disease course. We aim to determine whether MOG-IgG epitopes can predict a relapsing course in MOGAD patients.

METHODS

MOG-IgG-seropositive confirmed adult MOGAD patients were included (n=202). Serum MOG-IgG and epitope binding were determined by validated flow cytometry live cell-based assays. Associations between epitopes, disease course, clinical phenotype, Expanded Disability Status Scale and Visual Functional System Score at onset and last review were evaluated.

RESULTS

Of 202 MOGAD patients, 150 (74%) patients had MOG-IgG that recognised the immunodominant proline42 (P42) epitope and 115 (57%) recognised histidine103/serine104 (H103/S104). Fifty-two (26%) patients had non-P42 MOG-IgG and showed an increased risk of a relapsing course (HR 1.7; 95% CI 1.15 to 2.60, p=0.009). Relapse-freedom was shorter in patients with non-P42 MOG-IgG (p=0.0079). Non-P42 MOG-IgG epitope status remained unchanged from onset throughout the disease course and was a strong predictor of a relapsing course in patients with unilateral optic neuritis (HR 2.7, 95% CI 1.06 to 6.98, p=0.038), with high specificity (95%, 95% CI 77% to 100%) and positive predictive value (85%, 95% CI 45% to 98%).

CONCLUSIONS

Non-P42 MOG-IgG predicts a relapsing course in a significant subgroup of MOGAD patients. Patients with unilateral optic neuritis, the most frequent MOGAD phenotype, can reliably be tested at onset, regardless of age and sex. Early detection and specialised management in these patients could minimise disability and improve long-term outcomes.

Primary leptomeningeal melanoma: the prognostic significance of its genetic signature and embryological origin

Primary leptomeningeal melanomas are rare, comprising less than one percent of all brain tumours. They are aggressive and radioresistant tumours, with a poor prognosis. The mainstay of treatment is complete surgical resection and chemotherapy with limited success. Distinguishing a primary leptomeningeal melanoma from the more common metastatic disease can be difficult, and often requires the use of ancillary molecular testing. Primary central nervous system melanomas, including uveal melanomas, frequently exhibit mutations in GNAQ and GNA11, rare in the cutaneous and mucosal counterparts.A case of a primary leptomeningeal melanoma of the cerebellopontine angle is described. Molecular studies identified a GNA11 p.Q209L and a KIT p.M541L missense variant, with losses of chromosomes 1p and 3p demonstrated with cytogenetic studies. Complete surgical resection was not possible and leptomeningeal metastatic disease rapidly ensued despite immunotherapy. Further understanding of the molecular signature may translate to improved diagnosis, prognostication and development of targeted therapies.

A systematic approach to the hip-spine relationship and its applications to total hip arthroplasty

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research.

Cite this article: Bone Joint J 2019;101-B:808–816.

Feasibility of single-use 3D-printed instruments for total knee arthroplasty

Aims

This aim of this study was to assess the feasibility of designing and introducing generic 3D-printed instrumentation for routine use in total knee arthroplasty.

Materials and Methods

Instruments were designed to take advantage of 3D-printing technology, particularly ensuring that all parts were pre-assembled, to theoretically reduce the time and skill required during surgery. Concerning functionality, ranges of resection angle and distance were restricted within a safe zone, while accommodating either mechanical or anatomical alignment goals. To identify the most suitable biocompatible materials, typical instrument shapes and mating parts, such as dovetails and screws, were designed and produced.

Results

Before and after steam sterilization, dimensional analysis showed that acrylonitrile butadiene styrene could not withstand the temperatures without dimensional changes. Oscillating saw tests with slotted cutting blocks produced debris, fractures, or further dimensional changes in the shape of Nylon-12 and polymethylmethacrylate (MED610), but polyetherimide ULTEM 1010 was least affected.

Conclusion

The study showed that 3D-printed instrumentation was technically feasible and had some advantages. However, other factors, such as whether all procedural steps can be accomplished with a set of 3D-printed instruments, the logistics of delivery, and the economic aspects, require further study. Cite this article: Bone Joint J 2019;101-B(7 Supple C):115–120

Voice abnormalities at school age in children born extremely preterm

BACKGROUND AND OBJECTIVES

Voice abnormality is a frequent finding in school age children born at <25 weeks' gestation in Western Australia. The objective of this study was to determine the frequency of voice abnormality, voice-related quality of life, and demographic and intubation factors in this population.

METHODS

Survivors <25 weeks' gestational age in Western Australia born from 1996 to 2004 were included. Voice assessments (auditory perceptual assessment scale and Pediatric Voice Handicap Index) were carried out by speech pathologists. Intubation history was obtained by retrospective chart review.

RESULTS

Of 251 NICU admissions, 154 (61%) survived. Exclusions were based on severe disability (11) or distant residence (13). Of 70 assessed, 67 completed assessments, 4 (6%) were in the normal range and 39 (58%) showed moderate-severe hoarseness. Simultaneous modeling of demographic and intubation characteristics showed an increased odds of moderate-severe voice disorder for children who had more than 5 intubations (odds ratio 6.96, 95% confidence interval 2.07-23.40, P = .002) and for girls relative to boys (odds ratio 3.46, 95% confidence interval 1.12-10.62, P = .030). Tube size and duration of intubation were not significant in the multivariable model. Median scores of parent-reported voice quality of life on the Pediatric Voice Handicap Index were markedly different for preterm (22) and term (3) groups, P < .001.

CONCLUSIONS

Voice disorders in this population were much more frequent than expected. Further studies are required to assess voice across a broader range of gestational ages, and to investigate voice-protective strategies in infants requiring multiple episodes of intubation.

Image-guided, stereotactic perforator flap surgery: a prospective comparison of current techniques and review of the literature

BACKGROUND

Image-guided stereotaxy is a recent advancement in imaging technology, allowing computer guidance to aid surgical planning and accuracy. Despite the use of multiple techniques for patient registration in several surgical specialities, only fiducial marker registration has been described for use in soft tissue reconstructive surgery. The current study comprises an evaluation of the current techniques available for this purpose.

METHODS

A cohort of nine consecutive patients planned for elective free flaps were recruited, with the first five patients (four for the abdominal wall and one anterolateral thigh donor site) undergoing fiducial marker registration with a variable number of fiducial markers in order to determine the optimal number of fiducial markers to be used. Four subsequent patients undergoing perforator flap surgery underwent registration using three available registration modalities: fiducial marker registration, surface matching pointer/landmark and surface matching laser registration.

RESULTS

For the abdominal wall, registration was not able to be achieved with five fiducial markers, and was successfully achieved in all cases with either six or seven fiducial markers. For the anterolateral thigh, registration was achieved with either nine or ten markers. The four patients who also underwent surface-landmark registration and 'Z-touch' laser surface matching registration all failed the registration process.

CONCLUSION

Stereotactic navigation is a useful adjunct to the preoperative imaging of perforator flaps. Fiducial marker registration was able to be achieved in all cases, can be successfully achieved with a low and predictable number of fiducial markers, is highly accurate, and was the only reliable registration process in our experience.

The cost-utility of high dose oral mesalazine for moderately active ulcerative colitis

BACKGROUND

Mesalazine (mesalamine) is standard first line treatment for moderately active ulcerative colitis (UC). Recently, doubling the mesalazine dose (Asacol 4.8 g/day) was shown to improve efficacy with no increase in adverse events. The cost-effectiveness of this strategy remains unknown.

AIM

To assess the cost-utility of high dose (HD) mesalazine (Asacol 4.8 g/day) compared with standard dose (SD) mesalazine (Asacol 2.4 g/day) as first line treatment for moderately active UC.

METHODS

The costs and benefits associated with a treatment pathway beginning with HD or SD mesalazine were determined over 12 weeks using a decision tree analytical model.

RESULTS

A 12-week treatment pathway starting with HD mesalazine cost an average of 2382 pounds per patient compared with 2474 pounds for SD mesalazine and generated 0.0016 more quality adjusted life years (QALYs). HD mesalazine dominated SD mesalazine, being both more effective and less costly. HD mesalazine treatment resulted in fewer patients requiring surgery or hospitalization for intensive pharmacological treatment. Probabilistic sensitivity analysis indicated a 72% chance that HD mesalazine was cost effective, based on a cost/QALY threshold of 30,000 pounds.

CONCLUSIONS

This study suggests that HD mesalazine represents a cost-effective alternative to SD mesalazine for moderately active UC, while potentially reducing the need for hospitalization.

More about recruitment--pick me!

In the search for the elusive perfect job, one critical activity you should not neglect is reading. Read solid books and articles about what is new and happening in the medical record/health information management environment. But also through reading and research, pursue insights into the ever-changing healthcare environment so that healthcare administrators can be impressed with your up-to-the-minute knowledge and awareness of issues. Do not neglect to bone up on career planning and recruitment. How-to's about the career chase can be most helpful. We hope that our review of the recruitment picture from the candidate's point of view will help you reach your job placement goals. A career advancement can be an energizing and invigorating experience. If you win and get what you want, as soon as you can, be sure to document how you did it and the errors or pitfalls you experienced. The next time you enter the job candidate pool, you can profit by your experiences. Do not forget to thank those who helped you in your endeavors. You will be glad later that you did because those receiving your thanks will remember you favorably.

News from the front

How is the whirlwind of interest in healthcare quality assessment and healthcare databanks affecting medical record practitioners as it sweeps across the country? JAMRA interviewed the liaisons from the JCAHO Agenda for Change pilot hospitals and medical record spokespersons from states with mandated healthcare information databanks. What they shared with us is reported in this article.

AMRA's golden years: 1979-1988

Ten years ago AMRA had a golden anniversary celebrating 50 years of existence. Today, in 1988, we have accumulated 60 years of service to our members, to health record science, to the world of allied health, and to the protection of patients' confidentiality rights. Inasmuch as the first years of AMRA were chronicled in articles appearing in Medical Record News, August 1978 and February 1979, this article will review only the golden years, the period following our 50th anniversary.

Inquiring minds want to know: students query leaders in the profession, Part II

This is the conclusion of a two-part article. As explained in Part I, which appeared in the September 1988 issue of JAMRA, medical record students submitted questions they wished to have acknowledged medical record leaders respond to. Members of JAMRA's Editorial Review Board answered these questions with thought and insight.

Dr. Weed's computer world

This article is about the electronic Problem-Knowledge Couplers developed by Dr. Weed and how they will extend and enhance medical record documentation capabilities.

Early detection of bacterial growth in blood culture by impedance monitoring with a Bactometer model 32

A Bactometer model 32 was evaluated for use in early detection of bacterial growth. Experiments with simulated cultures showed that 2 ml of broth introduced into the Bactometer module wells could detect 10(2) and 10(6) CFU/ml in 6 h and 2 h respectively. Both Brain Heart Infusion (BHI) and Fastidious Anaerobic broths supported good growth. Detection of nine of 10 organisms inoculated at approximately 10(6) CFU/ml in BHI were detected within 8.5 h. A culture of Bacteroides fragilis failed to grow under these conditions. Of 189 blood cultures, tested by incubation of 2 ml of BHI, 18 were positive by both conventional and Bactometer methods. False-positive or false-negative specimens were not observed using the Bactometer. Use of the Bactometer enables growth detection at least 12 h earlier than culture methods.