Acetylcholinesterase inhibitors are ineffective in MuSK-antibody positive myasthenia gravis: Results of a study on 202 patients

BACKGROUND

Myasthenia gravis (MG) with MuSK antibodies (MuSK-MG) represents a distinct subtype with different responses to treatments compared to patients with AChR antibodies, especially in terms of tolerance to acetylcholinesterase inhibitors (AChEI). However, AChEI are often used as first line symptomatic treatment in MuSK-MG, despite reports that they are poorly tolerated, seldom effective or even deleterious.

METHODS

We analyzed demographic, clinical and therapeutic responses and side-effects in the large cohort of 202 MuSK-MG patients cared for at the MG Clinic of Azienda Ospedaliero-Universitaria Pisana.

RESULTS

165 patients had received AChEI at first evaluation. Only 7/165 patients (4.2%) reported an initial clinical benefit. Conversely, 76.9% of patients reported at least one side effect, most commonly neuromuscular hyperexcitability (68.4%), gastrointestinal (53.9%) and neurovegetative (35.8%) disturbances. 56 (33.9%) patients reported a concomitant worsening of muscle weakness and twelve patients (7.3%) suffered a cholinergic crisis. According to these patients, the severity of cholinergic side effects was greater at higher doses of AChEI, but side effects occurred regardless of the dose administered and ceased once the drug was discontinued.

CONCLUSIONS

This is the largest population of MuSK-MG patients reported for perceived responsiveness and tolerance to AChEI treatment. Our obervations strongly suggest avoiding this treatment in MuSK-MG.

Curiosity, Surprise, and the Recall of Tobacco-Related Health Information in Adolescents

A key goal of health communications designed to prevent smoking initiation during adolescence is for the tobacco-related information to be retained in memory beyond immediate message exposure. Here, we test the role for epistemic emotions, specifically curiosity and surprise, in facilitating memory for tobacco-related health information. Participants (n = 294 never-smoking adolescents, ages 14-16 years) performed a trivia guessing task wherein they guessed the answers to general trivia and smoking-related trivia questions. A subset of participants (n = 154) completed a surprise trivia memory task one week later and answered the previously viewed questions. Results indicate that curiosity about the answers to smoking-related trivia is associated with more accurate recall of smoking-related trivia answers one week later. Surprise also facilitated memory for smoking-related trivia, but the association was limited to cases where confidence in prior knowledge was low. Indeed, when participants had high confidence in their prior knowledge, surprise about the answer to trivia questions was associated with worse recall. Findings suggest that engendering states of curiosity for smoking-related information may facilitate retention of that information in never-smoking adolescents and highlight the need to examine both surprise and confidence in health communications to avoid low message recall.

Sudden Infant Death Syndrome: Risk Factors and Newer Risk Reduction Strategies

Sudden infant death syndrome (SIDS) continues to be one of the top causes of infant death in the U.S. Despite significant public health initiatives focused on high-risk populations to enhance sleep environments and techniques. The SIDS rate has remained stable in recent years. Risk factors and newer risk reduction strategies for SIDS are the focus of this review article. We conducted a comprehensive literature search on Medline, Cochrane, Embase, and Google Scholar until July 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "SIDS," "Sudden Infant Death" and "SUID". We explored the literature on SIDS for its epidemiology, pathophysiology, the role of various etiologies and their influence, associated complications leading to SIDS, and preventive and treatment modalities. Despite a more than 50% drop-in rates since the start of the "Back to Sleep" campaign in 1994, sudden infant death syndrome (SIDS) continues to be the top cause of post-neonatal mortality in the United States, despite continued educational initiatives that support safe sleep and other risk reduction strategies. The new American Academy of Pediatrics guidelines for lowering the risk of SIDS include a lot of emphasis on sleeping habits, bedding, and environment but also include elements that are frequently ignored (i.e., prenatal care, smoking, alcohol and drug use, and childhood vaccinations). This study highlights these less-frequently discussed aspects and identifies treatments that have produced beneficial behavioral shifts that benefit newborns as well as their mothers' health and wellbeing.

Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective

BACKGROUND

The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations.

METHODS

Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%).

RESULTS

Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance.

CONCLUSIONS

This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.

Implementation of an Online External Ventricular Drain Training Module-An Educational Initiative to Improve Proficiency of Perioperative Health Care Providers: Results of a Retrospective Study

BACKGROUND

An external ventricular drain (EVD) training module may improve the knowledge and proficiency of perioperative health care providers (HCPs).

METHODS

We examined knowledge gaps, self-reported comfort in managing EVDs, and improvement in self-assessment scores among HCPs from 7 academic medical centers based on an online EVD training module.

RESULTS

Of the 326 HCPs who completed the module, 207 (70.6%) reported being uncomfortable managing EVDs. The median pretest scores were 6 (interquartile range=2), and posttest scores were 8 (interquartile range=1), out of a maximum possible score of 9. The most frequent incorrectly answered questions were: (a) maximum allowed hourly cerebrospinal fluid volume drainage (51%), (b) the components of a normal intracranial pressure waveform (41%), and (c) identifying the correct position of the stopcock for accurate measurement of intracranial pressure (41%). The overall gain in scores was 2 (interquartile range=2) and highest among HCPs who had managed 1 to 25 EVDs (2.51, 95% confidence interval: 2.23-2.80), and without self-reported comfort in managing EVDs (2.26, 95% confidence interval: 1.96-2.33, P <0.0001). The majority of participants (312, 95.7%) reported that the training module helped them understand how to manage EVDs, and 276 (84.7%) rated the module 8 or more out of 10 in recommending it to their colleagues.

CONCLUSIONS

This online EVD training module was well-received by participants. Overall, improved scores reflect enhanced knowledge among HCPs following completion of the module. The greatest benefit was observed in those reporting less experience and feeling uncomfortable in managing EVDs. The impact on the reduction in EVD-associated adverse events deserves further examination.

Current status of point of care ultrasonography for the perioperative care of trauma patients

PURPOSE OF REVIEW

The incorporation of point of care ultrasound into the field of anesthesiology and perioperative medicine is growing at rapid pace. The benefits of this modality align with the acuity of patient care and decision-making in anesthetic care of a trauma patient.

RECENT FINDINGS

Cardiac ultrasound can be used to diagnose cardiac tamponade or investigate the inferior vena cava to assess volume status in patients who may suffer from hemorrhagic shock. Thoracic ultrasound may be used to rapidly identify pneumothorax or hemothorax in a patient suffering chest wall trauma. In addition, investigators are exploring the utility of ultrasonography in traumatic airway management and elevated intracranial pressure. In addition, the utility of gastric ultrasound on trauma patients is briefly discussed.

SUMMARY

Incorporation of point of care ultrasound techniques into the practice of trauma anesthesiology is important for noninvasive, mobile and expeditious assessment of trauma patients. In addition, further large-scale studies are needed to investigate how point of care ultrasound impacts outcomes in trauma patients.

Evaluation of catch-up growth in severe pediatric Hashimoto's hypothyroidism

BACKGROUND

We aimed to evaluate catch-up growth in children with severe Hashimoto's hypothyroidism (HH) after thyroid hormone replacement therapy (HRT).

METHODS

A multicenter retrospective study was conducted including children referred for growth slowdown that led to the diagnosis of HH between 1998 and 2017.

RESULTS

A total of 29 patients were included, with a median age of 9.7 years (13-172 months). Median height at diagnosis was -2.7 [-4.6; -0.1] standard deviation score (SDS), with a height loss of 2.5 [0.7; 5.4] SDS compared to height before growth deflection (p<0.0001). At diagnosis, the median TSH level was 819.5 mIU/L [100; 1844], the median FT4 level was 0 pmol/L [undetectable; 5.4], and the median anti-thyroperoxidase antibody level was 1601 UI/L [47; 25,500]. In the 20 patients treated only with HRT, there were significant differences between height at diagnosis and height at 1 year (n = 19, p<0.0001), 2 years (n = 13, p = 0.0005), 3 years (n = 9, p = 0.0039), 4 years (n = 10, p = 0.0078), and 5 years (n = 10, p = 0.0018) of treatment but not in the case of final height (n = 6, p = 0.0625). Median final height was -1.4 [-2.7; 1,5] SDS (n = 6), with a significant difference between height loss at diagnosis and total catch-up growth (p = 0.003). The other nine patients were also given growth hormone (GH). They were smaller at diagnosis (p = 0.01); however, there was no difference in final height between those two groups (p = 0.68).

CONCLUSION

Severe HH can lead to a major height deficit, and catch-up growth seems to be insufficient after treatment with HRT alone. In the most severe cases, administration of GH may enhance this catch-up.

Effect of TAVR generation on conduction abnormalities – is newer always better?

Objective

Transcatheter aortic valve replacement has become an established approach to treat severe symptomatic aortic stenosis in patients of all risk levels. Development of conduction abnormality and the need for a permanent pacemaker are known complications of TAVR. The introduction of third generation valves with cuffs has resulted in a significant decrease in post-deployment perivalvular regurgitation. However, there is concern for an increase in development of a new onset left bundle branch (LBBB) and the need for permanent pacemaker (PPM) implantation. This study aimed to identify whether newer valve generations along with the move away from transesophageal echocardiography (TEE) guidance for valve deployment is associated with changes in frequency of conduction block.

Methods

601 consecutive patients who underwent transfemoral TAVR implantation with a balloon expandable valve in a native aortic valve at a single institution from July 2009 to March 2019 were included in the study. 40 patients with LBBB and 91 patients with pacemakers prior to TAVR were excluded from the LBBB analysis. Multivariate logistic regression was used to test for significance.

Results

New LBBB occurred significantly more frequently with the newer generation valves, 1st Gen 2/104 (1.9%), 2nd Gen 9/88 (10.2%), 3rd Gen 33/278 (11.9%) (p&lt;0.01). There was no statistically significant increase in pacemakers across valve generations, 1st Gen 7/113 (6.2%), 2nd Gen 7/92 (7.6%), 3rd Gen 30/305 (9.8%). Use of TEE guidance had no effect on either LBBB or pacemaker. There was a strong trend (p=0.057) toward need for pacemaker as larger valves where used, with OR of pacemaker relative to 29 mm valve for 23 mm valve of 0.26 and for 26 mm valve of 0.63.

Conclusion

Newer TAVR valves, although beneficial in reducing perivalvular regurgitation, increases the risk of LBBB, without increasing risk need for pacemaker, suggesting possibly different mechanisms for the two complications. Understanding the mechanism for avoiding these complications may be important to avoiding them, as we move to a lower risk population where complication free results are even more important.

Funding Acknowledgement

Type of funding sources: None.

OS06.7.A Underlying mechanisms of verbal fluency in glioma patients: language or executive functioning?

Background Glioma patients often suffer from cognitive deficits, such as in language and executive functioning (EF). A sensitive test to identify these deficits is verbal fluency (VF). In VF, participants are asked to generate as many unique words within a given semantic category (category fluency - CF) or starting with a given letter (letter fluency - LF) within one minute. While both language and EF play a role in VF, the relative contribution of both domains remains unclear. We aim to retrospectively investigate performance on VF and, for the first time, on Non-Verbal Fluency (NVF), requiring to connect 5 points in different patterns within three minutes. Additionally, we aim to explore the influence of language and EF on VF performance in glioma patients.

Materials and Methods 69 adults with gliomas in eloquent areas underwent a comprehensive neuropsychological test-battery at 1-2 months before surgery (T1) and 3 (T2) and 12 months (T3) after surgery. The protocol consisted of VF (CF: animals, professions, LF: D-A-T/K-O-M), language tests (Repetition (Akense Afasie Test), Token Test, Boston Naming Test) and EF tests (Five Point Test, Trail Making Test, Stroop Colour-Word Test, Wisconsin Modified Card Sorting Task). VF and NVF performance were compared 1) to healthy population using one sample t-tests/Wilcoxon rank-tests (all patients), and 2) between T1, T2, and T3 with paired sample t-tests/Wilcoxon rank-tests (31 patients). Linear regression analyses were conducted to investigate the predictive value of language and EF on VF for all patients.

Results Preoperatively, patients were impaired on all VF tasks. Especially CF profession performance was more prone to deterioration after surgery at T2 and T3. In contrast, NVF was intact and even improved after surgery (T1-T3, T2-T3). NVF (p = .032, EF) was a predictor for CF animals while the Token Test (p = .023, language) was a predictor for CF professions. Both NVF (p = .032, EF) and the Token Test (p = .004, language) were predictors for LF.

Conclusion First, glioma patients were preoperatively impaired in VF but were preserved in NVF, as is in line with the literature. Secondly, CF professions appeared to be particularly sensitive to detect long-term postoperative decline. Thirdly, the main result of this study is that both language and EF mechanisms appeared to be responsible for VF performance in glioma patients. These findings are useful for interpreting VF impairment in glioma patients and for therapeutic interventions, suggesting a combination of language and EF training materials.

Point-of-Care Ultrasound for the Trauma Anesthesiologist

Purpose of Review

With advances in technology and availability of handheld ultrasound probes, studies are focusing on the perioperative care of patients, but a limited number specifically on trauma patients. This review highlights recent findings from studies using point of care ultrasound (POCUS) to improve the care of trauma patients.

Recent Findings

Major findings include the use of POCUS to assess volume status of trauma patients upon arrival to measure the major vasculature. Additionally, several studies have advanced the use of POCUS to identify pneumothorax in trauma patients. Finally, the ASA POCUS certification and ASRA expert guidelines are examples of international organizations establishing guidelines for utilization and training of anesthesiologists in the field of POCUS, which will be discussed.

Summary

Despite the COVID-19 pandemic, and considerable resources being diverted to fight this global healthcare crisis, advances are being made in utilization of POCUS to aid the care of trauma patients.

The use of OCT in good visual acuity MOGAD and AQP4-NMOSD patients; with and without optic neuritis

Myelin oligodendrocyte-antibody-associated disease (MOGAD) often presents with severe optic neuritis (ON) but tends to recover better than in aquaporin-4 antibody neuromyelitis optica spectrum disorder (AQP4-NMOSD). We measured OCT and VEP in MOGAD and AQP4-NMOSD eyes with good visual function, with or without previous ON episodes. Surprisingly, OCT and/or VEPs were abnormal in 84% MOGAD-ON versus 38% AQP4-NMOSD-ON eyes (p = 0.009) with good vision, compared with 18% and 17% respectively of eyes with no previous ON. A sub-group with macular OCT performed as part of a research study confirmed both retinal and macular defects in visually-recovered MOGAD eyes. These findings have implications for investigation and management of MOGAD patients.

OS07.5A Diagnostic Instrument for Mild Aphasia (DIMA): sensitive and valuable addition to standard language assessment in glioma patients

BACKGROUND

Low-grade glioma (LGG) patients typically suffer from mild aphasia that often cannot be detected with standard aphasia tests. The Diagnostic Instrument for Mild Aphasia (DIMA) is the first standardized test-battery to assess mild language disorders. We investigate pre- and postoperative linguistic abilities of LGG and high-grade glioma (HGG) patients with the DIMA.

METHODS

The DIMA consists of subtests that tap phonology (word, compound, non-word, sentence repetition), semantics (odd-picture-out), and syntax (sentence completion). Additionally, we administered the Boston Naming Test, Category- and Letter Fluency, and the Token Test. Patients were assessed before awake surgery (T1, N=98), three-months (T2, N=69), and one-year (T3, N=30) postoperatively. DIMA performance was compared to healthy controls (N=214). Group differences were examined with parametric (t-test) and nonparametric (Mann-Whitney-U, Wilcoxon) tests.

RESULTS

DIMA: Preoperatively, patients deviated on sentence repetition and sentence completion (p&lt;0.05). HGG patients performed worse than LGG on word, non-word, and sentence repetition (p&lt;0.05). There was no effect of hemispheric tumor localization. At T2, compound repetition and odd-picture-out also became impaired (p&lt;0.05) and there was a decline compared to T1 on all repetition tasks (p&lt;0.05). At T3, only sentence completion remained impaired (p&lt;0.01) with a deterioration compared to T1 (p&lt;0.01).

Standard tests: At T1, patients were impaired on BNT, Category- and Letter Fluency (p&lt;0.01). HGG patients performed worse than LGG patients on BNT and TT (p&lt;0.01). Patients with left-hemispheric tumors performed worse on BNT and Letter Fluency compared to right-hemispheric tumors (p&lt;0.05). At T2, TT also became impaired (p&lt;0.05) and patients declined compared to T1 on Verbal Fluency tests (p&lt;0.01). At T3, only BNT and Category Fluency remained impaired (p&lt;0.05), with no significant declines compared to T1.

CONCLUSION

The DIMA is the first test-battery to detect peri-operative impairments at different linguistic levels (phonology, semantics, syntax) in patients with left- or right-hemispheric gliomas. It even appeared more sensitive to detect surgical effects than standard tests: all phonological DIMA subtests captured short-term decline (T1-T2), in line with earlier evidence for the value of (non-)word repetition. DIMA sentence completion detected long-term decline (T1-T3), reflecting earlier spontaneous speech analyses. As expected, Verbal Fluency was also sensitive to short-term postoperative decline. Left-hemispheric tumor localization only affected standard test performance. HGG patients had more severe impairments than LGG on DIMA repetition and standard tests (BNT and TT). We advise adding the DIMA to standard language evaluation of glioma patients, as it allows for more detailed counseling about language outcome.

OS10.7.A Localization patterns of language errors during direct electrical brain stimulation: a systematic review

BACKGROUND

Awake craniotomy with direct electrical stimulation (DES) is the standard treatment for patients with eloquent area gliomas. Language errors (paraphasias) are detected with DES and they indicate functional boundaries that need to be maintained to preserve quality of life. However, it is not fully clear in which brain locations paraphasias at different linguistic modalities and levels (production, comprehension, reading, writing, phonology, semantics, syntax) occur.

MATERIALS AND METHODS

A systematic review was conducted. We included 102 studies reporting on specific paraphasias and the corresponding brain locations during awake craniotomy with DES in adult glioma patients.

RESULTS

First, a wide distribution of brain locations for all paraphasias (n=930) was found, but patterns were observed. Cortically, paraphasias occurred most often in the precentral gyrus (22%), while subcortically, they occurred mainly at the inferior fronto-occipital fascicle (IFOF: 10%). Localization patterns for different paraphasia types and the corresponding language functions were also found: production/articulation (n=393)-precentral gyrus (41%), inferior frontal gyrus (9%), frontal aslant/striatal tract (4%), postcentral gyrus (3%); semantics (n=128)-IFOF (57%), superior temporal gyrus (9%); phonology (n=115)-arcuate fascicle (52%), superior longitudinal fascicle (10%), uncinate fascicle (3%); reading (n=25)-temporal lobe (48%), inferior longitudinal fascicle (32%); syntax (n=15)-inferior frontal gyrus (27%); speech initiation (n=9)-supplementary motor area (33%), frontal aslant tract (22%), frontal striatal tract (22%); writing (n=7)-superior parietal gyrus (71%). Second, 59% of all paraphasias occurred cortically, 40% subcortically and 1% at both levels.

CONCLUSION

The localization of most paraphasias are consistent with the assumed functionality of those brain locations as presented in the Dutch Linguistic Intraoperative Protocol model. However, new locations for production/articulation, phonology, reading and writing were found. This needs to be taken into consideration for future selection of pre, intra and postoperative language tasks at different language modalities and levels. Additionally, DES should always be applied at the subcortical level as a standard addition to the routine cortical mapping during awake craniotomy. In conclusion, this is the first systematic review on the localization of specific paraphasias during awake craniotomy. Based on the identified language localization patterns, language tasks could be selected more accurately. This could guide, and perhaps improve, pre, intra and postoperative language testing and monitoring, which in turn, may pave the way to a better postoperative language outcome. The possible relation between different intraoperative paraphasias and language outcome has yet to be determined.

OS10.3.A Predicting delirium after craniotomy in neuro-oncology

BACKGROUND

Post-operative delirium (POD) is a frequent and severe complication after neurosurgical operations. Good prediction of POD after craniotomy in neuro-oncologic patients is important to install prophylactic measures, increase recognition and apply early treatment. Hence, we compared logistic regression with machine learning to build an accurate predictive model in a large dataset.

MATERIAL AND METHODS

POD was defined in case of a Delirium Observation Scale (DOS) ≥ 3 or start of antipsychotic treatment for delirium within 10 days after surgery. Adult patients undergoing a craniotomy for a neuro-oncologic disease in the Erasmus Medical Centre in Rotterdam were retrospectively included. The cohort was split into a training (75%), after three-fold cross validation, and test set (25%). Logistic regression and Lasso Elastic-Net Regularized Generalized Linear Models (GLMNet) were trained based on 19 pre- and intra-operative features and risk factors were identified based on the superior model.

RESULTS

We included 1025 neuro-oncologic craniotomies between June 2017 and September 2020. Overall incidence of POD was 18.6% (95%CI 17.4–19.8). Compared to logistic regression, Lasso GLMNet performed superior (AUC 0.73 vs. 0.76) based on the optimal tuning parameters (α=1, λ=0.014). Several non-modifiable risk factors such as age (OR1.01), prior delirium (OR1.04), memory problems (OR1.12), surgery duration (OR1.01) and modifiable risk factors, such as low potassium (OR0.97) levels and opioid administration (OR1.03), were identified.

CONCLUSION

POD is a frequent complication after craniotomy in neuro-oncologic patients. Lasso GLMNet was useful in predicting POD in this cohort. Validation in a prospective cohort of this model should be applied to further evaluate its value in diminishing POD.

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey

BACKGROUND

Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments.

OBJECTIVES

We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation.

METHODS

Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model.

RESULTS

Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations.

CONCLUSIONS

Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.

POS0494 AN INVESTIGATION OF JOINT INFLAMMATION DEFINED BY COMPREHENSIVE ULTRASOUND ASSESSMENT AND PAIN SENSITISATION IN PATIENTS WITH ACTIVE RA

Background:

Treat-to-target strategies have improved outcomes in patients with RA. Targets based on clinical assessments of tender (TJC) and swollen joints (SJC) were developed when most patients had active inflammatory disease. It is now recognised some patients have pain sensitisation often termed fibromyalgia (FM), making clinical assessment of inflammatory disease more complex. An indicator of pain sensitisation is the difference between TJC and SJC, an observation we described in a pilot study (1).

Objectives:

To study patients with RA to describe the relationships between enhanced clinical and patient-reported outcome measures (PROMS) and active inflammatory joint disease detected by comprehensive PDUS.

Methods:

158 sequential patients with RA with a DAS28ESR score >¬3.2 were enrolled from GSTT Rheumatology after informed consent. They were assessed by a rheumatologist for 66SJC, 68TJC, fibromyalgia tender points & physician global. Recorded PROMS were: patient global, widespread pain index (WPI), symptom severity score (somatic & fatigue), FACIT fatigue, HAQ, EQ5D QoL, GAD7, PHQ9 and PHQ15. All patients had a 44 joint US scored for PD and grey scale by the EULAR scale blind to all patient data. Data were recorded on MedSciNet and statistical analysis used STATA.

Results:

Patients meeting the ACR 2010 criteria for FM2(n=72) vs those that did not(n=86) had similar demographics. SJC and US doppler scores were higher in the non-FM group, whereas rheumatoid factor, DAS28 and PROMs were higher in the FM group. Analysis of group differences using multinomial logistic regression and subsequent regularised (lasso) logistic regression, showed the FM group related to higher 28TJC, FACIT-F and PHQ15, with the non-FM group related to higher 28SJC, logESR, and lower Differences in 28S/TJC, Physician Global and FACIT-F. Patients were divided into four groups based on presence or absence of at least one PDUS+ joint and FM criteria; -FM-PD, -FM+PD, +FM-PD and +FM+PD, data summarised Table 1. The -FM-PD and -FM+PD groups related to Physician Global and negatively related to FACIT-F, Difference in 28S/TJC, and PHQ15 (-FM-PD). The +FM-PD group related positively to FACIT-F, Difference 28S/TJC, PHQ15, and negatively to Physician Global with +FM+PD related to PHQ9, FACIT-F and DAS28ESR.

TABLE 1.

-FM -PD -FM +PD +FM -PD +FM +PD p-value

Female34 (79%)33 (77%)35 (83%)22 (73%)0.77Total power doppler score0.0 (0.0-1.0)16.0 (10.0-25.0)0.0 (0.0-0.0)9.0 (8.0-20.0)<0.001Total gray scale score40.0(34.0-48.0)57.5(45.0-82.0)34.5(20.0-43.0)60.0(46.0-84.0)<0.001Total Swollen JC3.0 (1.0-5.0)6.0 (3.0-9.0)2.0 (0.0-5.0)5.5 (2.0-10.5)<0.001Total Tender5.5 (3.0-12.0)8.0 (4.0-11.0)13.0 (8.0-20.0)15.0 (8.0-20.0)<0.001Tender-Swollen JC Difference4.0 (0.0-8.0)2.0 (0.0-4.0)8.0 (4.0-18.0)5.5 (2.5-13.5)<0.001ESR mm/hour10.0 (8.0-16.0)14.0 (10.0-30.0)12.0 (7.0-23.0)19.5 (11.5-42.5)0.021Pain VAS50.0 (40.0-65.0)50.0 (30.0-60.0)60.0 (47.5-77.5)67.5 (55.0-80.0)<0.001Patient VAS50.0 (30.0-70.0)40.0 (30.0-70.0)60.0 (40.0-80.0)65.0 (50.0-80.0)0.006Physician VAS30.0 (20.0-50.0)50.0 (40.0-60.0)30.0 (20.0-40.0)50.0 (32.5-70.0)<0.001DAS28 (ESR)4.2 (3.7-4.9)4.7 (4.1-5.2)4.7 (3.9-5.8)5.6 (4.9-6.6)<0.001

Conclusion:

These data using comprehensive US assessment to detect inflammatory joint disease, demonstrate that active inflammation defined as at least 1PDUS+ joint, may account for disease activity in slightly less than half of unselected patients with RA with a DAS28ESR score >3.2. This study shows how frequently pain sensitisation accounts for symptoms and signs in RA. We suggest in addition to central sensitisation, often called FM, another group identified here as -FM-PD, may have pain from joint damage or peripheral pain sensitisation of joints, likely due to different mechanisms than central pain sensitisation.

References:

[1]Mian A et al, BMC Musculoskelet Disord. 2016;17: 404

[2]Wolfe F et al, Arth Care & Res 2010; 62:600

Disclosure of Interests:

Khaldoun Chaabo: None declared, Estee Chan: None declared, Toby Garrood: None declared, Zoe Rutter-Locher: None declared, Alexandra Vincent: None declared, James Galloway Speakers bureau: Dr Galloway has received speaker fees / honoraria from Abbvie, BMS, Celgene, Chugai, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi and UCB, Sam Norton: None declared, Bruce Kirkham Speakers bureau: Professor Bruce Kirkham has received speaker fees / honoraria from Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer,and UCB., Grant/research support from: Professor Bruce Kirkham has received research support from Lilly, Novartis and UCB.

Professor Bruce Kirkham has received speaker fees / honoraria from Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer and UCB.

Trauma in Obstetrical Patients

INTRODUCTION

Pregnant trauma patients are an underdescribed cohort in the medical literature. Noting injury patterns and contributors to mortality may lead to improved care.

METHODS

Female patients between 14 and 49 years of age were identified among entries in the 2017 National Trauma Data Bank. Data points were compared using Chi-square test, Fisher's exact test, Student's t-test, Mann-Whitney rank-sum, or multiple logistic regression as appropriate. P < 0.05 was used to determine the findings of significance.

RESULTS

There were 569 pregnant trauma patients identified, which was 0.54% of the 105,507 women identified. Overall, mortality was low among all women and not different between groups (1.2% for pregnant women vs. 2.2% for nonpregnant, P = 0.12). Pregnant women with head injuries had a higher mortality rate than pregnant women without (4.2% vs. 0.47%, P < 0.01). Head injuries (Abbreviated Injury Severity Score [AIS] head >1) were associated with an increased risk for mortality (odds ratio: 3.33, 95% confidence interval: 3.0-3.7, P < 0.01).

CONCLUSION

There was no increase in mortality for trauma patients who are pregnant when controlling for covariates. Factors such as head injuries, the need for blood, and comorbid diseases appear to have a more significant contribution to mortality. We also report the prevalence of head, cervical spine, and extremity injuries in pregnant trauma patients. Multidisciplinary simulation, jointly crafted protocols, and expanding training in regional anesthesia may be the next steps to improving care for pregnant trauma patients.

Systemic delivery of human GlyR IgG antibody induces GlyR internalization into motor neurons of brainstem and spinal cord with motor dysfunction in mice

Aims

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a life‐threatening condition often associated with highly raised serum antibodies to glycine receptors (GlyRs); these bind to the surface of large neurons and interneurons in rodent brain and spinal cord sections and, in vitro, inhibit function and reduce surface expression of the GlyRs. The effects in vivo have not been reported.

Methods

Purified plasma IgG from a GlyR antibody‐positive patient with PERM, and a healthy control (HC), was injected daily into the peritoneal cavity of mice for 12 days; lipopolysaccharide (LPS) to open the blood–brain barrier, was injected on days 3 and 8. Based on preliminary data, behavioural tests were only performed 48 h post‐LPS on days 5–7 and 10–12.

Results

The GlyR IgG injected mice showed impaired ability on the rotarod from days 5 to 10 but this normalized by day 12. There were no other behavioural differences but, at termination (d13), the GlyR IgG‐injected mice had IgG deposits on the neurons that express GlyRs in the brainstem and spinal cord. The IgG was not only on the surface but also inside these large GlyR expressing neurons, which continued to express surface GlyR.

Conclusions

Despite the partial clinical phenotype, not uncommon in passive transfer studies, the results suggest that the antibodies had accessed the GlyRs in relevant brain regions, led to antibody‐mediated internalization and increased GlyR synthesis, compatible with the temporary loss of function.

Liposomal Nanotherapy for Treatment of Atherosclerosis

Atherosclerosis is a chronic disease that can lead to life-threatening events such as myocardial infarction and stroke, is characterized by the build-up of lipids and immune cells within the arterial wall. It is understood that inflammation is a hallmark of atherosclerosis and can be a target for therapy. In support of this concept, an injectable nanoliposomal formulation encapsulating fluocinolone acetonide (FA), a corticosteroid, is developed that allows for drug delivery to atherosclerotic plaques while reducing the systemic exposure to off-target tissues. In this study, FA is successfully incorporated into liposomal nanocarriers of around 100 nm in size with loading efficiency of 90% and the formulation exhibits sustained release up to 25 d. The anti-inflammatory effect and cholesterol efflux capability of FA-liposomes are demonstrated in vitro. In vivo studies carried out with an apolipoprotein E-knockout (Apoe^-/- ) mouse model of atherosclerosis show accumulation of liposomes in atherosclerotic plaques, colocalization with plaque macrophages and anti-atherogenic effect over 3 weeks of treatment. This FA-liposomal-based nanocarrier represents a novel potent nanotherapeutic option for atherosclerosis.

Antibodies to neuronal surface proteins in Tourette Syndrome: Lack of evidence in a European paediatric cohort

In Tourette Syndrome (TS) a role for autoantibodies directed against neuronal proteins has long been suspected, but so far results are still inconsistent. The aim of this study was to look for antibodies to specific or undefined neuronal proteins that could be involved in the aetiology of the disease. Sera from children with Tourette Syndrome or another chronic tic disorder (TS/TD), collected as part of the longitudinal European Multicenter Tics in Children Study, were investigated. Participants included 30 siblings of patients with TS/TD prior to developing tics (preclinical stage) and the same children after the first tic onset (onset), and 158 patients in the chronic phase undergoing an acute relapse (exacerbation). Presence of antibodies binding to rodent brain tissue was assessed by immunohistology on rat brain sections and by immunofluorescent staining of live hippocampal neurons. Live cell-based assays were used to screen for antibodies to NMDAR, CASPR2, LGI1, AMPAR and GABA_AR. Immunohistology indicated evidence of antibodies reactive with brain tissue, binding mainly to the hippocampus, the basal ganglia or the cerebellum in 26/218 (12%), with 8% of the preclinical or onset sera binding to the dentate gyrus/CA3 region or cerebellum. Only two individuals (one pre-clinical, one chronic) had antibodies binding the NMDAR and the binding was only weakly positive. No other specific antibodies were detected. Despite some immunoreactivity towards neuronal antigens on brain tissue, this was not mirrored by antibodies binding to live neurons, suggesting the presence of non-specific antibodies or those that bind non-pathogenic intracellular epitopes. NMDAR or the other neuronal surface antibodies tested were very infrequent in these patients. The evidence for pathogenic antibodies that could be causative of TS is weak.

Hollow Microcapsules as Periocular Drug Depot for Sustained Release of Anti-VEGF Protein

Diseases affecting the posterior segment of the eye such as age-related macular degeneration and diabetic retinopathy are leading causes of blindness all over the world. The current treatment regimen for such diseases involves repeated intravitreal injections of anti- Vascular Endothelial Growth Factor (VEGF) proteins. This method is highly invasive and can lead to severe complications. In an attempt to develop less invasive alternatives, we propose the use of a controlled release system consisting of anti-VEGF loaded hollow microcapsules that can be administered periocularly to form drug eluting depots on the episcleral surface. The microcapsules with either positive or negative surface charge were prepared by a layer by layer approach and showed pH responsive permeability switching. An ex vivo experiment using porcine sclera indicated positively charged microcapsules remained on the episcleral surface over four days while the negatively charged microcapsules were washed away. These positively charged microcapsules were then loaded with anti-VEGF protein ranibizumab using pH dependent permeability switching and protein release from the microcapsules were studied using an in vitro setup. An ex vivo experiment utilizing porcine sclera demonstrated sustained release of ranibizumab over seven days with zero-order kinetics.

Acquired neuromyotonia in thymoma-associated myasthenia gravis: a clinical and serological study

Background and purpose

Acquired neuromyotonia can occur in patients with thymoma, alone or in association with myasthenia gravis (MG), but the clinical prognostic significance of such comorbidity is largely unknown. The clinico‐pathological features were investigated along with the occurrence of neuromyotonia as predictors of tumour recurrence in patients with thymoma‐associated myasthenia.

Methods

A total number of 268 patients with thymomatous MG were studied retrospectively. Patients with symptoms of spontaneous muscle overactivity were selected for autoantibody testing using immunohistology for neuronal cell‐surface proteins and cell‐based assays for contactin‐associated protein 2 (CASPR2), leucine‐rich glioma inactivated 1 (LGI1), glycine receptor and Netrin‐1 receptor antibodies. Neuromyotonia was diagnosed according to the presence of typical electromyography abnormalities and/or autoantibodies against LGI1/CASPR2.

Results

Overall, 33/268 (12%) MG patients had a thymoma recurrence. Five/268 (2%) had neuromyotonia, four with typical autoantibodies, including LGI1 (n = 1), CASPR2 (n = 1) or both (n = 2). Three patients had Netrin‐1 receptor antibodies, two with neuromyotonia and concomitant CASPR2+LGI1 antibodies and one with spontaneous muscle overactivity without electromyography evidence of neuromyotonia. Thymoma recurrence was more frequent in those with (4/5, 80%) than in those without (28/263, 10%, P < 0.001) neuromyotonia. Neuromyotonia preceded the recurrence in 4/5 patients. In univariate analysis, predictors of thymoma recurrence were age at thymectomy [odds ratio (OR) 0.95, 95% confidence interval (CI) 0.93–0.97], Masaoka stage ≥IIb (OR 10.73, 95% CI 2.38–48.36) and neuromyotonia (OR 41.78, 95% CI 4.71–370.58).

Conclusions

De novo occurrence of neuromyotonia in MG patients with previous thymomas is a rare event and may herald tumour recurrence. Neuronal autoantibodies can be helpful to assess the diagnosis. These observations provide pragmatic risk stratification for tumour vigilance in patients with thymomatous MG.

Team planning discussion and clinical performance: a prospective, randomised, controlled simulation trial

Planning held before emergency management of a critical situation might be an invaluable asset for optimising team preparation. The purpose of this study was to investigate whether a brief planning discussion improved team performance in a simulated critical care situation. Forty-four pairs of trainees in anaesthesia and intensive care were randomly allocated to either an intervention or control group before participating in a standardised simulated scenario. Twelve different scenarios were utilised. Groups were stratified by postgraduate year and simulated scenario, and a facilitator was embedded in the scenario. In the intervention group, the pairs had an oral briefing followed by a 4-min planning discussion before starting the simulation. The primary end-point was clinical performance, as rated by two independent blinded assessors on a score of 0-100 using video records and pre-established scenario-specific checklists. Crisis resource management and stress response (cognitive appraisal ratio) were also assessed. Two pairs were excluded for technical reasons. Clinical performance scores were higher in the intervention group; mean (SD) 51 (9) points vs. 46 (9) in the control group, p = 0.039. The planning discussion was also associated with higher crisis resource management scores and lower cognitive appraisal ratios, reflecting a positive response. A 4-min planning discussion before a simulated critical care situation improved clinical team performance and cognitive appraisal ratios. Team planning should be integrated into medical education and clinical practice.

The frequency of remission and low disease activity in patients with rheumatoid arthritis, and their ability to identify people with low disability and normal quality of life

OBJECTIVE

Treat-to-target in rheumatoid arthritis (RA) recommends targeting remission, with low disease activity (LDA) being an alternative goal. When deciding to target remission or LDA, important considerations are the likelihood of attaining them, and their impacts on function and health-related quality of life (HRQoL). We have addressed this by studying: (a) the frequency of remission and LDA/remission; (b) DAS28-ESR trends after remission; (c) ability of remission vs. LDA to identify patients with normal function (HAQ ≤ 0.5) and HRQoL (EQ-5D ≥ the normal population).

METHODS

We studied 571 patients in two clinical trials, and 1693 patients in a 10-year routine care cohort. We assessed the frequency and sustainability of remission and LDA/remission, variability in DAS28-ESR after remission, and sensitivity/specificity of remission and LDA/remission at identifying patients with low disability levels and normal HRQoL using Receiver Operator Characteristic (ROC) curves.

RESULTS

Point remission and remission/LDA were common (achieved by 35-58% and 49-74% of patients, respectively), but were rarely sustained (sustained remission and remission/LDA achieved by 5-9% and 9-16% of patients, respectively). Following attaining remission, DAS28-ESR levels varied substantially. Despite this, of those patients attaining point remission, the majority (53-61%) were in remission at study end-points. Whilst remission was highly specific at identifying patients with low disability (85-91%) it lacked sensitivity (51-57%); similar findings were seen for normal HRQoL (specificity 78-86%; sensitivity 52-59%). The optimal DAS28-cut-off to identify individuals with low disability and normal HRQoL was around the LDA threshold.

CONCLUSIONS

Our findings support both the treat-to-target goals. Attaining remission is highly specific for attaining low disability and normal HRQoL, although many patients with more active disease also have good function and HRQoL. Attaining a DAS28-ESR ≤ 3.2 has a better balance of specificity and sensitivity for attaining these outcomes, with the benefit of being more readily achievable. Although sustaining these targets over time is rare, even attaining them on a one-off basis leads to better function and HRQoL outcomes for patients.

Antiglycine receptor antibody related disease: a case series and literature review

BACKGROUND AND PURPOSE

Antibodies to glycine receptors (GlyR-Abs) were first defined in progressive encephalopathy with rigidity and myoclonus (PERM) but were subsequently identified in other clinical presentations. Our aim was to assess the clinical associations of all patients identified with GlyR-Abs in Queensland, Australia, between April 2014 and May 2017 and to compare these to cases reported in the literature.

METHODS

A literature review identified the clinical features of all published GlyR-Ab-positive cases through online databases. A case series was undertaken via collection of clinical information from all patients diagnosed or known to immunology, pathology or neurological services in Queensland during the study period of 3 years.

RESULTS

In all, 187 GlyR-Ab-positive cases were identified in the literature. The majority (47.6%) had PERM, 22.4% had epilepsy, but the remaining 30% included mixed phenotypes consisting of cerebellar ataxia, movement disorders, demyelination and encephalitis/cognitive dysfunction. By contrast, in our series of 14 cases, eight had clinical presentations consistent with seizures and epilepsy and only three cases had classical features of PERM. There was one case each of global fatiguable weakness with sustained clonus, laryngeal dystonia and movement disorder with hemiballismus and tics. The rate of response to immune therapy was similar in all groups.

CONCLUSION

Antibodies to glycine receptors are linked to a spectrum of neurological disease. The results of the literature review and our case series suggest a greater relationship between GlyR-Abs and epilepsy than previously reported.

IFT80 mutations cause a novel complex ciliopathy phenotype with retinal degeneration

Ciliopathies, a growing pleotropic class of diseases due to mutations in genes that play an important role in primary cilia function. These highly conserved organelles are key to cell signaling. We now know, that mutations in one gene may lead to more than one ciliopathy phenotype and that one ciliopathy phenotype may be due to mutations in more than one gene. We studied the case of a female child with a novel ciliopathy phenotype and identified two novel mutations in the gene IFT80. Previously, mutations in IFT80 have been associated with a very narrow rib cage and failure of the lungs. Bone anomalies are also part of this IFT80-condition but with no vision problems documented. Our case had none of the features known to be associated with IFT80 mutations and had retinal degeneration (RD). This work broadens the IFT80-phenotype spectrum and also shows RD can be a feature of many ciliopathies.