The effects of short-term, progressive exercise training on disease activity in smouldering multiple myeloma and monoclonal gammopathy of undetermined significance: a single-arm pilot study

BACKGROUND

High levels of physical activity are associated with reduced risk of the blood cancer multiple myeloma (MM). MM is preceded by the asymptomatic stages of monoclonal gammopathy of undetermined significance (MGUS) and smouldering multiple myeloma (SMM) which are clinically managed by watchful waiting. A case study (N = 1) of a former elite athlete aged 44 years previously indicated that a multi-modal exercise programme reversed SMM disease activity. To build from this prior case study, the present pilot study firstly examined if short-term exercise training was feasible and safe for a group of MGUS and SMM patients, and secondly investigated the effects on MGUS/SMM disease activity.

METHODS

In this single-arm pilot study, N = 20 participants diagnosed with MGUS or SMM were allocated to receive a 16-week progressive exercise programme. Primary outcome measures were feasibility and safety. Secondary outcomes were pre- to post-exercise training changes to blood biomarkers of MGUS and SMM disease activity- monoclonal (M)-protein and free light chains (FLC)- plus cardiorespiratory and functional fitness, body composition, quality of life, blood immunophenotype, and blood biomarkers of inflammation.

RESULTS

Fifteen (3 MGUS and 12 SMM) participants completed the exercise programme. Adherence was 91 ± 11%. Compliance was 75 ± 25% overall, with a notable decline in compliance at intensities > 70% V̇O2PEAK. There were no serious adverse events. There were no changes to M-protein (0.0 ± 1.0 g/L, P =.903), involved FLC (+ 1.8 ± 16.8 mg/L, P =.839), or FLC difference (+ 0.2 ± 15.6 mg/L, P =.946) from pre- to post-exercise training. There were pre- to post-exercise training improvements to diastolic blood pressure (- 3 ± 5 mmHg, P =.033), sit-to-stand test performance (+ 5 ± 5 repetitions, P =.002), and energy/fatigue scores (+ 10 ± 15%, P =.026). Other secondary outcomes were unchanged.

CONCLUSIONS

A 16-week progressive exercise programme was feasible and safe, but did not reverse MGUS/SMM disease activity, contrasting a prior case study showing that five years of exercise training reversed SMM in a 44-year-old former athlete. Longer exercise interventions should be explored in a group of MGUS/SMM patients, with measurements of disease biomarkers, along with rates of disease progression (i.e., MGUS/SMM to MM).

REGISTRATION

https://www.isrctn.com/ISRCTN65527208 (14/05/2018).

8 Unexpected retinopathy in a patient presenting with bilateral optic disc swelling

A 12-year-old boy presented with 5 day history of blurry vision, 'wobbly eyes', tinnitus and difficulty seeing at night. Local ophthalmology noted bilateral optic disc swelling and referred him urgently for neurological investigations.Clinical Findings: At presentation VA was RE 0.00 and LE 0.2 with normal Ishihara colour vision. His extraocular movements were full without manifest strabismus. Fundoscopy showed bilateral optic disc swelling. Electrophysiology unexpectedly revealed a functionally cone isolated retina with markedly abnormal rod function. Pattern VEPs indicated bilateral macular pathway dysfunction affecting left eye more than right eye. Wide field imaging showed bilateral diffusely scattered yellow-white flecks in the midperiphery of each eye. His kinetic visual fields were moderately restricted bilaterally. MRI showed a Chiari 1 malformation with cerebellar tonsil herniation, but LP opening pressure was normal.Differential diagnosis included RDH5 retinopathy or vitamin A deficiency. On questioning he reported a diet restricted to only meat and biscuits. His vitamin A levels were subnormal at 0.14 umol/L (reference range 0.9-2.5umol/l) and he was started on high-dose Vitamin A supplements.Four months after supplementation retinal appearances had normalised, the rod ERGs recovered, nyctalopia and visual field restriction resolved. PVEPs had improved but an element of LE macular pathway dysfunction remained. Optic disc swelling settled leaving mild temporal pallor, particularly of the LE with some RNFL loss.It is important to recognise nutritional Vitamin A deficiency in children as prompt recognition and treatment can improve symptoms, reverse retinal pathology which we have demonstrated with electrophysiological findings.

9 MOG associated encephalitis presenting as idiopathic intracranial hypertension

A young Caucasian male (7y) with normal BMI was atypical for his provisional diagnosis of Idiopathic Intracranial Hypertension (IIH), that resolved following a Lumbar Puncture (LP). At 8y he presented with a 2-week history of headaches and vomiting that started some weeks after flu vaccination and an upper respiratory infection.Visual Acuity (VA) and colour vision were normal. Ocular motility was full. Fundoscopy and OCT showed recurrence of papilloedema, with enlarged blind spots on Kinetic perimetry.LP opening pressure was 30cm H2O and CSF white cells were elevated (23). Repeat brain and spine imaging showed new white matter signal changes in keeping with neuroinflammation, as well as enhancement of the left optic nerve extending to the chiasm and optic tract. VA, colour vision and pupillary reactions remained normal.Pattern VEP peak times were prolonged from the left eye compared to right eye to small check widths, consistent with relative macular-cortex pathway dysfunction. Hemifield PVEPs were slightly prolonged and reduced from the bitemporal fields indicating chiasmal dysfunction. Normal PERGs excluded PVEP delay associated with primary RGC disease.Further investigations showed oligoclonal band and serum-MOG antibody positivity.Management: Initial treatment with Acetazolamide 125mg bd for a week, following LP, was changed to IV methylprednisolone followed by oral prednisolone.Symptoms improved significantly following LP and steroid treatment. He will be followed in a Demyelination Clinic.MOG-associated disease has been reported with raised intracranial pressure and should be considered especially in children with atypical clinical phenotype for IIH.

An extradural cyst in a French Bulldog

CASE HISTORY

A 7-year-old, male neutered French Bulldog was referred to a specialist veterinary hospital for evaluation of progressive paraparesis of 6-months' duration. The owners reported both faecal and urinary incontinence at home.

CLINICAL FINDINGS

The dog presented with ambulatory paraparesis and pelvic limb ataxia that was more pronounced in the right pelvic limb. The pelvic limb withdrawal response and sciatic myotatic response were reduced bilaterally. Postural reaction responses were delayed in both pelvic limbs, and this was more obvious in the right pelvic limb. The anal tone and perineal sensation were normal at the time of examination.An L4-S3 myelopathy was suspected. CT of the spine revealed a compressive, bilobed, extramedullary, cyst-like structure within the vertebral canal, between L7 and S3. Surgical removal of the cyst via a L7-S1 dorsal laminectomy was performed. Histopathological examination and additional immunohistochemistry of the excised structure indicated a probable ependymal cyst with a ciliated lining. The dog recovered well post-operatively, and at follow-up 3 weeks later had some improvement of his neurological signs. The paraparesis and pelvic limb ataxia had improved; however, the remaining neurological examination was similar to the pre-surgical examination.

DIAGNOSIS

Extradural cyst.

CLINICAL RELEVANCE

Spinal cysts can contribute to clinical signs that resemble other common chronic spinal cord diseases, such as intervertebral disc disease. Therefore, this disease should be considered as a differential when dealing with cases of progressive paraparesis and pelvic limb ataxia. This case report may potentially provide opportunities in the future for further understanding of the pathogenesis, behaviour, outcomes and subclassification of spinal cysts in dogs.

Influence of smoking status on acute biomarker responses to successive days of arduous military training

INTRODUCTION

Habitual smoking is highly prevalent in military populations despite its association with poorer training outcomes. Smoking imposes challenges on the immune and endocrine systems which could alter how smokers acutely respond to, and recover from, intensive exercise particularly over multiple days of training.

METHODS

Over a two-day period, 35 male British Army recruits (age 22±3 years; mass 76.9±8.0 kg; height 1.78±0.06 m; 15 smokers) completed a 16.1 km loaded march (19.1 kg additional mass) on the first morning and a best-effort 3.2 km 'log race' (carrying a 60 kg log between six and eight people) on the subsequent morning. Blood samples were obtained on waking and immediately postexercise on both days and analysed for C reactive protein (CRP), interleukin 6 (IL-6), testosterone to cortisol ratio and insulin-like growth factor 1 (IGF-1).

RESULTS

Independent of smoking group, the exercise bouts on both days evoked significant increases in IL-6 (p<0.001) and decreases in testosterone to cortisol ratio (p<0.05). CRP concentrations on day 2 were significantly higher than both time points on day 1 (p<0.001), and a 9% decline in IGF-1 occurred over the two-day period, but was not significant (p=0.063). No significant differences were observed between smokers and non-smokers (p>0.05).

CONCLUSIONS

Military-specific tasks elicited inflammatory and endocrine responses, with systemic CRP and IGF-1 indicating that the physiological stress generated during the first training day was still evident on the second day. Despite the well-established impacts of smoking on resting levels of the markers examined, responses to two days of arduous military-specific training did not differ by smoking status.

Imaging Breast Microcalcifications Using Dark-Field Signal in Propagation-Based Phase-Contrast Tomography

Breast microcalcifications are an important primary radiological indicator of breast cancer. However, microcalcification classification and diagnosis may be still challenging for radiologists due to limitations of the standard 2D mammography technique, including spatial and contrast resolution. In this study, we propose an approach to improve the detection of microcalcifications in propagation-based phase-contrast X-ray computed tomography of breast tissues. Five fresh mastectomies containing microcalcifications were scanned at different X-ray energies and radiation doses using synchrotron radiation. Both bright-field (i.e. conventional phase-retrieved images) and dark-field images were extracted from the same data sets using different image processing methods. A quantitative analysis was performed in terms of visibility and contrast-to-noise ratio of microcalcifications. The results show that while the signal-to-noise and the contrast-to-noise ratios are lower, the visibility of the microcalcifications is more than two times higher in the dark-field images compared to the bright-field images. Dark-field images have also provided more accurate information about the size and shape of the microcalcifications.

INZ-701, a recombinant ENPP1-Fc protein, effectively treats and prevents neointimal proliferation in WT and ENPP1 Deficient mice

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Inozyme Pharma

Inactivating mutations in ENPP1, which encodes the ecto-nucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1), underlie the rare inherited disorder, generalized arterial calcification of infancy (GACI)/autosomal recessive hypophosphatemic rickets type 2 (ARHR2) also known as ENPP1 Deficiency. ENPP1 Deficiency is characterized by calcification of large and medium sized arteries and marked neointimal proliferation of arteries, leading to arterial stenosis and severe cardiovascular and skeletal complications. ENPP1 Deficiency is associated with a 50% mortality rate in the first six months of life, and there are no approved treatments.

Previous research demonstrated that INZ-701 protein prevented arterial calcification in an ENPP1 deficient mouse model (Enpp1 asj/asj). This study was designed to determine whether INZ-701 can prevent neointimal proliferation in WT and an ENPP1 deficient mouse model (ttw/ttw). Carotid ligation was performed to induce intimal proliferation in the mice.

In the preventive arm of the study, INZ-701 (10mg/kg) or vehicle was administered subcutaneously every other day starting in 6-week-old ttw/ttw-mice. Carotid ligation was performed in these mice at the age of 7 weeks and dosing continued for another 2 weeks. Carotid intimal and medial area caudal from the ligation were analyzed by histomorphometry 14 days and 21 days after carotid ligation. In the therapeutic arm of the study, INZ-701 (10 mg/kg) or vehicle was administered subcutaneously every other day starting 7 days after carotid ligation, when intimal proliferation had already developed, in 8-week-old ttw/ttw-mice. After one week of treatment, histomorphometry was performed.

Fourteen days after carotid ligation, ttw/ttw-mice preventatively treated with INZ-701 showed a significantly reduced intimal area (p&lt;0.001) and intimal/medial (I/M) ratio (p&lt;0.001) compared to those treated with vehicle. This effect was also observed in mice treated with INZ-701, which were treated for 28 days and were subsequently dissected 21 days after carotid ligation. Interestingly, similar effects of INZ-701 were found in WT mice in the preventative study.  In the therapeutic arm of the study, subcutaneous injection of INZ-701 beginning at 7 days post carotid ligation also led to a significant reduction in the I/M ratio (p&lt;0.001) in the INZ-701 treated group compared to vehicle treated ttw/ttw-mice.

These findings demonstrate that INZ-701 prevents neointimal proliferation after carotid injury in a murine model of ENPP1 Deficiency. INZ-701 is hypothesized to restore circulating levels of AMP and adenosine, both potent inhibitors of intimal hyperplasia. Neointimal proliferation is a key feature in the pathophysiology of ENPP1 Deficiency and our results build on prior evidence to support the potential of INZ-701 to treat this rare and life-threatening disease.

Laser-induced ultrasound transmitters for large-volume ultrasound tomography

We present a protocol for the design, fabrication and characterisation of laser-induced ultrasound transmitters with a specific, user-defined frequency response for the purpose of ultrasound tomography of large-volume biomedical samples. Using an analytic solution to the photoacoustic equation and measurements of the optical and acoustic properties of the materials used in the transmitters, we arrive at a required mixture of carbon black and polydimethylsiloxane to achieve the desired frequency response. After an in-depth explanation of the fabrication and characterisation approaches we show the performance of the fabricated transmitter, which has a centre frequency of 0.9 MHz, 200% bandwidth and 45.8 ∘ opening angle, multi-kPa pressures over a large depth range in water.

Paediatric spinal cord low-grade gliomas-evaluation and management of post-surgical residual disease

PURPOSE

To assess the evaluation and management of post-surgical residual disease for low-grade intramedullary spinal cord tumours (IMSCT) in childhood.

METHODS

A single-centre retrospective review of low-grade IMSCTs treated between 2000 and 2019. All surgeries were performed with intent of safe maximal resection guided by intra-operative neurophysiological monitoring (IONM). Pre- and post-operative MRIs were reviewed to assess the extent of resection (EOR), recorded as follows: gross total resection (GTR), near total resection (NTR), sub-total resection (STR) and partial resection (PR). Outcome measures were time to recurrence, need for and modality of additional therapy and ambulatory status at last follow-up.

RESULTS

Thirty patients underwent surgery for IMSCT (median age 6.9 years). EOR was GTR = 8, NTR = 4, STR = 9, PR = 9. All patients were alive at last follow-up (median follow-up 73 months [IQR 93 months]). Eighteen patients (60%) remained radiologically stable. Twelve patients (40%) developed recurrence during surveillance. Progression free survival was significantly better in cases with GTR + NTR in comparison to either STR or PR (p = 0.039). 10/30 (33%) patients were treated with additional therapy. At last follow-up, 26/30 patients were independently mobile.

CONCLUSION

Survival rates for low-grade IMSCT are excellent. Radical micro-surgical resection, guided by IONM provides effective means of balancing the objectives of maximal safe resection, functional outcome and tumour control. Whilst evidence of 'residual disease' was identified in over 2/3 of immediate post-operative MRI scans, additional treatment was required in only 1/3 of cases. Critical appraisal of post-operative imaging findings is required to better define 'residual disease'. Small volume residual disease (< 5%) does not compromise progression-free survival.

CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?

Cardiovascular disease (CVD) is the leading cause of death in the UK, whilst millions live with various forms of the disease. Coronary artery disease constitutes a significant portion of this morbidity and mortality, and is the leading cause of premature death. Increasing focus is thus being placed on the optimisation of CVD prevention, where risk screening plays a key role. Indeed, the decline in age-adjusted cardiovascular mortality achieved up to now has been largely attributed to primary preventative therapies (e.g., statins) introduced earlier in the disease process. National initiatives exist to improve cardiovascular health at a population level, but in its current form, CVD screening at the individual level is predominantly undertaken using multivariate risk scores based on population-based data. These have multiple innate flaws, highlighted in this review. Non-invasive imaging plays a key role in the screening of other disease processes, helping to personalise the screening process. Although the coronary artery calcium score as a screening tool has a role in national and international guidance, whether a shift to screening with computed tomography coronary angiography (CTCA) is now appropriate is open for discussion. Image acquisition techniques continue to improve with reducing radiation exposure and an ever-expanding evidence-base for additional prognostic data offered by CTCA. This enables the potential identification of sub-clinical atherosclerosis, including with novel artificial intelligence techniques. This review aims to report current guidelines regarding cardiac CT imaging in the asymptomatic primary prevention setting, advances in various CT technologies and future opportunities for progress in this field.

Understanding needs and expectations of heart failure patients and their caregivers regarding digital health - the PASSION-HF project

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): INTERREG-NWE

Background/Introduction

Current heart failure (HF) healthcare provision is not sufficient. Due to demographic changes and subsequent increases in comorbidities, along with unequal distribution of medical care in rural areas, alternative approaches need be sought. The use of eHealth applications has potential to enable patients to become more self-sufficient. The "PASSION-HF" project aims to develop an interactive decision-making system – a virtual doctor – that provides solutions based on current guidelines and artificial intelligence. Patient independence is maximized through 24/7 access to personalized HF-management. Furthermore, the application defines decision points, where medical professionals need to be included.

Purpose

To understand needs and expectations of HF patients and their informal caregivers in regard to a virtual doctor.

Methods

We conducted an exploratory mixed-methods study within the Netherlands, UK, Ireland and Germany. Semi-structured qualitative interviews were supplemented by a standardized questionnaire. The interviews focused on i) acceptance and motivation to use a virtual doctor and ii) experience and perception of current health care provision. The interviews were analysed using the content analysis according to Mayring (2010) with the help of "ATLAS.TI" software. Additional information about the role of informal caregivers, technology acceptance and decision-making processes was collected via questionnaires.

Results

A total of 49 patients and 33 informal caregivers were interviewed. Most patients were male (76%), aged between 60 and 69 years (43%). Three key themes were identified in regard to an interactive decision-making system: 1) Reassurance, because patients felt uncertain about their condition and their symptoms, they had a strong desire for an application that could monitor their health 24/7, was able to spot deteriorations, before they occured and gave them instant feedback about their current health status; 2) Personalized advice, e.g. patients wanted the virtual doctor to adapt medication, sport activities and food recommendations to their current health status; and 3) Transparency, e.g. patients wanted to know, where the recommendations are coming from and justifications for management modifications. Interview findings also identified that the HF-nurses play a significant role in the care and management of the condition. Across all countries with HF-nurses, they were the primary point of contact, when patients had any HF related concerns. 

Conclusion

The findings provide valuable information for the development and implementation of eHealth solutions. Patients want reassurance, independently of the availability of healthcare services, combined with personalized advice regarding day-to-day management of their HF. For the next step, we are planning a multicentre clinical trial to test the prototype of the application. Here all decisions are examined by a clinical committee and benefits are evaluated.

Peatland-fire interactions: A review of wildland fire feedbacks and interactions in Canadian boreal peatlands

Boreal peatlands store a disproportionately large quantity of soil carbon (C) and play a critical role within the global C-climate system; however, with climatic warming, these C stores are at risk. Increased wildfire frequency and severity are expected to increase C loss from boreal peatlands, contributing to a shift from C sink to source. Here, we provide a comprehensive review of pre- and post-fire hydrological and ecological interactions that affect the likelihood of peatland burning, address the connections between peatland fires and the C-climate cycle, and provide a conceptual model of peatland processes as they relate to wildland fire, hydro-climate, and ecosystem change. Despite negative ecohydrological feedback mechanisms that may compensate for increased C loss initially, the cumulative effects of climatic warming, anthropogenic peatland fragmentation, and subsequent peatland drying will increase C loss to the atmosphere, driving a positive C feedback cycle. However, the extent to which negative and positive feedbacks will compensate for one another and the timelines for each remains unclear. We suggest that a multi-disciplinary approach of combining process knowledge with remotely sensed data and ecohydrological and wildland fire models is essential for better understanding the role of boreal peatlands and wildland fire in the global climate system.

Impact of Systemic Dipeptidyl Peptidase-4 Inhibitor Use in Diabetic Macular Edema

BACKGROUND AND OBJECTIVE

To evaluate impact of baseline systemic dipeptidyl peptidase-4 (DPP-4) inhibitor use in diabetic macular edema (DME).

PATIENTS AND METHODS

This was a post hoc exploratory analysis of previously completed randomized, controlled clinical trials (VISTA and VIVID) in patients with DME evaluating intravitreal aflibercept injection (IAI) every 4 weeks (2q4) or every 8 weeks (2q8) or macular laser photocoagulation.

RESULTS

Overall, a small number of patients (12.2% [n = 35], 9.7% [n = 28], and 15.4% [n = 44]) in the laser control, 2q4, and 2q8 groups reported baseline DPP-4 inhibitor use. There were no differences in changes from baseline in best-corrected visual acuity, central subfield thickness, or rates of 2-or-greater-step improvement in Diabetic Retinopathy Severity Scale score based on DPP-4 inhibitor use within each treatment group.

CONCLUSION

DPP-4 inhibitor use at baseline did not influence the magnitude of visual and anatomic benefit in patients with DME being treated with IAI or laser. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:226-234.].

Cranial findings detected by second-trimester ultrasound in fetuses with myelomeningocele: a systematic review

Background

Abnormal intracranial findings are often detected at mid‐trimester ultrasound (US) in fetuses with myelomeningocele (MMC). It is unclear whether these findings constitute a spectrum of the disease or are an independent finding, which should contraindicate fetal surgery.

Objective

To ascertain the spectrum and frequency of US‐detected cranial findings in fetuses with MMC.

Search strategy

MEDLINE, Embase, Web of Science and CENTRAL were searched from January 2000 to June 2020.

Selection criteria

Study reporting incidence of cranial US findings in consecutive cases of second‐trimester fetuses with MMC.

Data collection and analysis

Publication quality was assessed by Newcastle–Ottawa Scale (NOS) and modified NOS. Meta‐analysis could not be performed as a result of high clinical diversity and study heterogeneity.

Main results

Fourteen cranial US findings were reported in 15 studies. Findings in classic Chiari II malformation (CIIM) spectrum included posterior fossa funnelling (96%), small transcerebellar diameter (82–96%), ‘banana’ sign (50–100%), beaked tectum (65%) and ‘lemon’ sign (53–100%). Additional cranial findings were small biparietal diameter (BPD) and head circumference (HC) (<5th centile; 53 and 71%, respectively), ventriculomegaly (45–89%), abnormal pointed shape of the occipital horn (77–78%), thinning of the posterior cerebrum, perinodular heterotopia (11%), abnormal gyration (3%), corpus callosum disorders (60%) and midline interhemispheric cyst (42%).

Conclusions

We identified 14 cranial findings by second‐trimester US in fetuses with MMC. The relatively high incidence of these findings and their unclear prognostic significance might not contraindicate fetal surgery in the case of normal fetal genetic testing. Some cranial findings may independently affect postnatal outcome, however. Long‐term detailed follow‐up is required to investigate this.

Tweetable abstract

A high rate of cranial abnormalities found on second‐trimester ultrasound in fetuses with myelomeningocele.

A high rate of cranial abnormalities found on second‐trimester ultrasound in fetuses with myelomeningocele.

The gut microbiota is associated with psychiatric symptom severity and treatment outcome among individuals with serious mental illness

BACKGROUND

Emerging evidence implicates the gut microbiota in central nervous system functioning via its effects on inflammation, the hypothalamic-pituitary axis, and/or neurotransmission. Our understanding of the cellular underpinnings of the brain-gut relationship is based almost exclusively on animal models with some small-scale human studies. This study examined the relationship between the gut microbiota and psychiatric symptom severity and treatment response among inpatients with serious mental illness.

METHOD

We collected data from adult inpatients (N = 111). Measures of diagnoses, suicide severity, trauma, depression, and anxiety were collected shortly after admission, while self-collected fecal swabs were collected early in the course of hospitalization and processed using 16S rRNA gene sequencing and whole genome shotgun sequencing methods.

RESULTS

Results indicate that depression and anxiety severity shortly after admission were negatively associated with bacterial richness and alpha diversity. Additional analyses revealed a number of bacterial taxa associated with depression and anxiety severity. Gut microbiota richness and alpha diversity early in the course of hospitalization was a significant predictor of depression remission at discharge.

CONCLUSIONS

This study is among the first to demonstrate a gut microbiota relationship with symptom severity among psychiatric inpatients as well as a relationship to remission of depression post-treatment. These findings are consistent with animal models and limited human studies as well as with the broader literature implicating inflammation in the pathophysiology of depression. These findings offer the foundation for further studies of novel therapeutic approaches to the treatment, prevention of, or recurrence of serious mental illness.

Changes in neovascular activity following fixed dosing with an anti-vascular endothelial growth factor agent over 52 weeks in the phase III VIEW 1 and VIEW 2 studies

BACKGROUND/AIMS

To understand changes in disease activity as assessed by leakage and retinal fluid status in patients with neovascular age-related macular degeneration (nAMD) receiving fixed dosing with an anti-vascular endothelial growth factor (anti-VEGF) agent.

METHODS

In the phase III VIEW 1 (NCT00509795) and VIEW 2 (NCT00637377) studies, eyes with nAMD were treated with intravitreal aflibercept or ranibizumab. Independent, masked reading centres determined the presence/absence of leakage (fluorescein angiography) and retinal fluid (optical coherence tomography) at baseline, week 24 and week 52. In this integrated, post hoc analysis of the VIEW studies, the relationship between leakage/fluid status and best-corrected visual acuity (BCVA) was assessed. The impact of baseline lesion type (predominantly classic (PC), minimally classic (MC), occult) was also evaluated. Data from all treatment groups were pooled.

RESULTS

2373 eyes were included in this analysis. At baseline, 95.4% of eyes presented with both leakage and fluid. By week 52, leakage and fluid were present in 16.0% of eyes. Mean BCVA gains at week 52 were numerically greater in eyes without leakage and fluid versus eyes with both leakage and fluid (10.3 vs 9.2 letters). At week 52, 11.6%, 15.3% and 20.1% of eyes with PC, MC and occult lesions, respectively, had both leakage and fluid present.

CONCLUSION

In this post hoc analysis, fixed dosing with an anti-VEGF agent over 52 weeks eliminated disease activity (absence of both leakage and fluid) in most eyes. The effect of anti-VEGF treatment on leakage/fluid status favoured PC versus occult lesions.

Difference in Treatment Effect Between Intravitreal Aflibercept Injection and Laser by Baseline Factors in Diabetic Macular Edema

BACKGROUND AND OBJECTIVE

To evaluate the effect of baseline factors on differences in vision gains with intravitreal aflibercept injection (IAI) versus laser control in patients with diabetic macular edema (DME).

PATIENTS AND METHODS

This was an integrated post-hoc subanalysis of two phase 3 trials (VISTA, VIVID) in patients with DME. Least square (LS) mean differences of patients treated with IAI compared to laser control in best-corrected visual acuity (BCVA) change from baseline at week 100 were evaluated for association with baseline demographics and baseline systemic disease characteristics.

RESULTS

At week 100, LS mean differences in BCVA change from baseline with IAI compared to laser control were not significant for association with baseline age, gender, and race or status of glycosylated hemoglobin, body mass index, renal impairment, hypertension, cerebrovascular disease, and ischemic heart disease.

CONCLUSION

Vision gains with IAI were significantly greater than laser control and were not influenced by demographics and systemic disease control at baseline. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:167-173.].

Outcomes in Patients with Diabetic Macular Edema Requiring Cataract Surgery in VISTA and VIVID Studies

PURPOSE

To evaluate the impact of cataract surgery on visual and anatomic outcomes in patients with diabetic macular edema treated with intravitreal aflibercept injection (IAI) or laser control and who did not require rescue therapy.

DESIGN

Post hoc analysis of 2 phase 3 trials, Study of Intravitreal Aflibercept Injection in Patients with Diabetic Macular Edema (VISTA) and Intravitreal Aflibercept Injection in Vision Impairment Due to DME (VIVID).

PARTICIPANTS

Fifty-four patients (laser treatment, n = 11; IAI, n = 43) who underwent cataract surgery during the study period.

METHODS

In VISTA and VIVID, patients received IAI 2 mg every 4 weeks, IAI 2 mg every 8 weeks after 5 monthly doses, or laser control through week 100. Starting at week 24, if rescue treatment criteria were met, IAI patients received laser therapy, and laser therapy patients received IAI 2 mg every 8 weeks (after 5 monthly doses). Patients who received rescue treatment before cataract surgery were excluded.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) in the laser control and pooled IAI groups before and after cataract surgery.

RESULTS

The cumulative incidence of cataract surgery did not depend on treatment group assignment (rate ratio, = 1.517; 95% confidence interval, 0.782-2.944; P = 0.2174). At the last study visit before surgery, BCVA was 62.2 and 56.9 letters and CRT was 342 μm and 301 μm in the laser control and IAI groups, respectively. At the first study visit after cataract surgery, BCVA was improved significantly in both the laser control and IAI groups to 73.5 letters (P = 0.010 compared with last visit before surgery) and 67.2 letters (P < 0.001 compared with last visit before surgery), respectively. Corresponding change in CRT was a modest increase to 364 μm (P > 0.05 compared with last visit before surgery) and 359 μm (P = 0.013 compared with last visit before surgery), respectively.

CONCLUSIONS

Incidence of cataract surgery was similar in both treatment groups. Despite a modest worsening in CRT after cataract surgery, BCVA was improved in both treatment groups.

Efficacy and Safety of Alirocumab 300 mg Every 4 Weeks in Individuals With Type 2 Diabetes on Maximally Tolerated Statin

CONTEXT

In the ODYSSEY CHOICE I trial, alirocumab 300 mg every 4 weeks (Q4W) was assessed in patients with hypercholesterolemia. Alirocumab efficacy and safety were evaluated in a patient subgroup with type 2 diabetes mellitus (T2DM) and who were receiving maximally tolerated statins with or without other lipid-lowering therapies.

METHODS

Participants received either alirocumab 300 mg Q4W (n = 458, including 96 with T2DM) or placebo (n = 230, including 50 with T2DM) for 48 weeks, with alirocumab dose adjustment to 150 mg every 2 weeks at Week (W) 12 if W8 low-density lipoprotein cholesterol (LDL-C) levels were ≥70 mg/dL or ≥ 100 mg/dL, depending on cardiovascular risk, or if LDL-C reduction was <30% from baseline. Efficacy end points included percentage change from baseline to W24 for lipids, and time-averaged LDL-C over W21 to W24.

RESULTS

In individuals with T2DM, LDL-C reductions from baseline to W24 and the average of W21 to W24 were significantly greater with alirocumab (-61.6% and -68.8%, respectively) vs placebo. At W24, alirocumab significantly reduced levels of non-high-density lipoprotein cholesterol (HDL-C) and other lipids. At W24, 85.9% and 12.5% of individuals in the alirocumab and placebo groups, respectively, reached both non-HDL-C <100 mg/dL and LDL-C <70 mg/dL. At W12, In total, 18% of alirocumab-treated participants received dose adjustment. The most common treatment-emergent adverse events were upper respiratory tract infection and injection-site reaction. No clinically significant changes in fasting plasma glucose and glycated hemoglobin were observed.

CONCLUSION

In individuals with T2DM, alirocumab 300 mg Q4W was generally well tolerated and efficacious in reducing atherogenic lipoproteins.

Propagation-based x-ray phase-contrast tomography of mastectomy samples using synchrotron radiation

PURPOSE

Propagation-based phase-contrast computed tomography (PB-CT) is a method for three-dimensional x-ray imaging that utilizes refraction, as well as absorption, of x rays in the tissues to increase the signal-to-noise ratio (SNR) in the resultant images, in comparison with equivalent conventional absorption-only x-ray tomography (CT). Importantly, the higher SNR is achieved without sacrificing spatial resolution or increasing the radiation dose delivered to the imaged tissues. The present work has been carried out in the context of the current development of a breast CT imaging facility at the Australian Synchrotron.

METHODS

Seven unfixed complete mastectomy samples with and without breast cancer lesions have been imaged using absorption-only CT and PB-CT techniques under controlled experimental conditions. The radiation doses delivered to the mastectomy samples during the scans were comparable to those approved for mammographic screening. Physical characteristics of the reconstructed images, such as spatial resolution and SNR, have been measured and compared with the results of the radiological quality assessment of the complete absorption CT and PB-CT image stacks.

RESULTS

Despite the presence of some image artefacts, the PB-CT images have outperformed comparable absorption CT images collected at the same radiation dose, in terms of both the measured objective image characteristics and the radiological image scores. The outcomes of these experiments are shown to be consistent with predictions of the theory of PB-CT imaging and previous reported experimental studies of this imaging modality.

CONCLUSIONS

The results presented in this paper demonstrate that PB-CT holds a high potential for improving on the quality and diagnostic value of images obtained using existing medical x-ray technologies, such as mammography and digital breast tomosynthesis (DBT). If implemented at suitable synchrotron imaging facilities, PB-CT can be used to complement existing imaging modalities, leading to more accurate breast cancer diagnosis.

Recommendation to include hydroxyethyl (meth)acrylate in the British baseline patch test series

BACKGROUND

(Meth)acrylates are potent sensitizers and a common cause of allergic contact dermatitis (ACD). The frequency of (meth)acrylate ACD has increased with soaring demand for acrylic nails. A preliminary audit has suggested a significant rate of positive patch tests to (meth)acrylates using aimed testing in patients providing a clear history of exposure. To date, (meth)acrylates have not been routinely tested in the baseline patch test series in the U.K. and Europe.

OBJECTIVES

To determine whether inclusion of 2-hydroxyethyl methacrylate (2-HEMA) 2% in petrolatum (pet.) in the baseline series detects cases of treatable (meth)acrylate ACD.

METHODS

During 2016-2017, 15 U.K. dermatology centres included 2-HEMA in the extended baseline patch test series. Patients with a history of (meth)acrylate exposure, or who tested positive to 2-HEMA, were selectively tested with a short series of eight (meth)acrylate allergens.

RESULTS

In total 5920 patients were consecutively patch tested with the baseline series, of whom 669 were also tested with the (meth)acrylate series. Overall, 102 of 5920 (1·7%) tested positive to 2-HEMA and 140 (2·4%) to at least one (meth)acrylate. Had 2-HEMA been excluded from the baseline series, (meth)acrylate allergy would have been missed in 36 of 5920 (0·6% of all patients). The top (meth)acrylates eliciting a positive reaction were 2-HEMA (n = 102, 1·7%), 2-hydroxypropyl methacrylate (n = 61, 1·0%) and 2-hydroxyethyl acrylate (n = 57, 1·0%).

CONCLUSIONS

We recommend that 2-HEMA 2% pet. be added to the British baseline patch test series. We also suggest a standardized short (meth)acrylate series, which is likely to detect most cases of (meth)acrylate allergy.

Alirocumab efficacy and safety by body mass index: A pooled analysis from 10 Phase 3 ODYSSEY trials

AIMS

Increased body mass index (BMI) contributes to cardiovascular risk and may influence efficacy of therapeutic antibodies. We investigated the effect of baseline BMI on efficacy and safety of alirocumab, a PCSK9 monoclonal antibody.

METHODS

In a post-hoc analysis, data were pooled from 10 Phase 3 trials (n=4975) of alirocumab vs. placebo/ezetimibe controls. Alirocumab dose was 150mg every 2 weeks in two trials, and 75mg every 2 weeks with possible increase to 150mg at 12 weeks (based on Week 8 low-density lipoprotein cholesterol [LDL-C]) in eight trials. Efficacy/safety data were assessed in baseline BMI subgroups of≤25,>25 to 30,>30 to 35, and>35kg/m².

RESULTS

Baseline LDL-C levels were lower among patients in the higher BMI subgroups. Significant LDL-C reductions from baseline were observed at Weeks 12 and 24 for alirocumab vs. controls, of similar magnitude regardless of baseline BMI (interaction P-value=0.7119). LDL-C<1.81mmol/L (<70mg/dL) was achieved at Week 24 by 69.8-76.4% of alirocumab-treated patients and 9.7-18.4% of control-treated patients, with no pattern by BMI. A greater proportion of patients in higher vs. lower BMI subgroups required alirocumab dose increase (P=0.0343); proportions were 22.5%, 24.9%, 31.7%, and 27.2% of patients across BMI subgroups of≤25,>25 to 30,>30 to 35, and>35kg/m², respectively. Adverse event frequencies were similar regardless of BMI; injection-site reaction frequency was higher with alirocumab (5.1-8.2% across BMI categories) vs. controls (3.6-4.8%).

CONCLUSIONS

Alirocumab provided consistent LDL-C reductions, with similar safety findings across BMI subgroups.

Incidence of New Choroidal Neovascularization in Fellow Eyes of Patients With Age-Related Macular Degeneration Treated With Intravitreal Aflibercept or Ranibizumab

Importance

Incidence of conversion to neovascular age-related macular degeneration (nAMD) in untreated fellow eyes of patients who are treated for nAMD in 1 eye with anti-vascular endothelial growth factor agents provides important prognostic information to clinically manage patients.

Objective

To investigate the association of treatment assignment (intravitreal aflibercept vs ranibizumab) and baseline characteristics with fellow eye conversion to nAMD in the VEGF (Vascular Endothelial Growth Factor) Trap-Eye: Investigation of Efficacy and Safety in Wet AMD (VIEW) studies.

Design, Setting, and Participants

This post hoc analysis of the VIEW 1 and VIEW 2 studies (randomized, double-masked, active-controlled, multicenter, 96-week, phase 3 trials comparing the efficacy and safety of intravitreal aflibercept in 2457 patients with treatment-naive eyes with nAMD) analyzed a subgroup of participants treated for nAMD in 1 eye who had untreated fellow eyes without neovascularization at baseline. All participants in the VIEW studies were included in 1 of 4 groups: ranibizumab, 0.5 mg, every 4 weeks; aflibercept, 2 mg, every 4 weeks; aflibercept, 0.5 mg, every 4 weeks; or aflibercept, 2 mg, every 8 weeks after 3 injections at 4-week intervals. Data collection in the VIEW studies occurred from July 2007 to August 2011; the data analysis presented in this report took place from April 2016 to November 2018.

Interventions

Patients received no treatment in the fellow eyes unless after conversion to nAMD, when any treatment approved by heath authorities was given per the investigators' discretion.

Main Outcomes and Measures

Incidence of conversion to nAMD in patients with untreated fellow eyes that had not had clinical signs of neovascularization at baseline.

Results

A total of 1561 participants were included in this analysis. At 96 weeks, 375 patients (24.0%) experienced cases of conversion to neovascular disease in the fellow eye, including 107 of the 399 individuals who received ranibizumab, 0.5 mg, every 4 weeks; 93 of the 387 individuals who received aflibercept, 2 mg, every 4 weeks; 84 of the 387 individuals who received aflibercept, 0.5 mg, every 4 weeks; and 91 of the 388 individuals who received aflibercept, 2 mg, every 8 weeks after 3 doses at 4-week intervals. The rates were 18.1, 16.2, 14.7, and 16.0 per 100 patient-years at risk at week 96, respectively. On multivariate analysis, fellow eye conversion was associated with increasing patient age (per 10 years) at baseline (hazard ratio [HR], 1.20 [95% CI, 1.05-1.36]), female sex (HR, 1.32 [95% CI, 1.06-1.63]), intraretinal fluid in the study eye at baseline (HR, 1.28 [95% CI, 1.02-1.61]), and increasing choroidal neovascularization lesion size (per 10 mm2) in the study eye at baseline (HR, 1.29 [95% CI, 1.06-1.57]). Rates of fellow eye conversion were similar with either of the treatments.

Conclusions and Relevance

In this secondary analysis of randomized clinical trial data, patients with active nAMD in 1 eye appeared to have a high risk for fellow eye conversion. Such patients should be monitored closely.

Impact of Age on the Efficacy and Safety of Alirocumab in Patients with Heterozygous Familial Hypercholesterolemia

Purpose

This post-hoc analysis examined whether age modified the efficacy and safety of alirocumab, a PCSK9 inhibitor, in patients with heterozygous familial hypercholesterolemia (HeFH), using pooled data from four 78-week placebo-controlled phase 3 trials (ODYSSEY FH I, FH II, LONG TERM, and HIGH FH).

Methods

Data from 1257 patients with HeFH on maximally tolerated statin ± other lipid-lowering therapies were analyzed by an alirocumab dose regimen and by age subgroups (18 to < 45, 45 to < 55, 55 to < 65, and ≥ 65 years). In the FH I and II trials, patients received 75 mg subcutaneously every 2 weeks (Q2W), with dose increase to 150 mg Q2W at week 12 if week 8 low-density lipoprotein cholesterol (LDL-C) was ≥ 70 mg/dl. In HIGH FH and LONG TERM, patients received 150 mg alirocumab Q2W.

Results

Baseline characteristics were similar between treatment groups across all age groups; the proportion of males decreased whereas the proportion of patients with coronary heart disease, diabetes, hypertension, and declining renal function increased with increasing age. Mean LDL-C reductions at week 24 were consistent across age groups (50.6–61.0% and 51.1–65.8% vs. placebo for the 75/150 and 150 mg alirocumab dose regimens, respectively; both non-significant interaction P-values). Treatment-emergent adverse events occurred in similar frequency in alirocumab- and placebo-treated patients regardless of age, except for injection-site reactions, which were more common in alirocumab than placebo but declined in frequency with age.

Conclusions

Alirocumab treatment resulted in significant LDL-C reductions at weeks 12 and 24 and was generally well tolerated in patients with HeFH across all age groups studied.

Electronic supplementary material

The online version of this article (10.1007/s10557-019-06852-6) contains supplementary material, which is available to authorized users.

Longitudinal Retinal Perfusion Status in Eyes with Diabetic Macular Edema Receiving Intravitreal Aflibercept or Laser in VISTA Study

PURPOSE

To evaluate changes in retinal perfusion status with intravitreal aflibercept injection (IAI) and laser treatment in the phase 3 VISTA study of patients with diabetic macular edema (DME).

DESIGN

Post hoc analysis of a double-masked, randomized, active-controlled, phase 3 trial.

PARTICIPANTS

Patients with center-involved DME in the study eye.

METHODS

VISTA randomized 466 patients to laser, IAI 2 mg every 4 weeks (2q4), or IAI 2 mg every 8 weeks after 5 monthly doses (2q8). One eye per patient was enrolled in the study. Retinal perfusion status was evaluated by fluorescein angiography based on the presence or absence of retinal nonperfusion (RNP) in quadrants intersecting at the optic nerve head by a masked independent reading center at weeks 24, 52, 72, and 100. Visual and anatomic outcomes were evaluated at all visits. In patients who received rescue treatment, data were censored from the time rescue treatment was given.

MAIN OUTCOME MEASURES

Change in perfusion status from baseline through week 100.

RESULTS

At week 100, the proportion of eyes with improvement in retinal perfusion (defined as a reduction from baseline in the total number of quadrants in which RNP is present) in the laser control, 2q4, and 2q8 groups was 14.6%, 44.7%, and 40.0%, respectively. The proportion of eyes that experienced worsening in retinal perfusion (defined as an increase from baseline in the total number of quadrants in which RNP is present) at week 100 in the laser control, 2q4, and 2q8 groups was 25.0%, 9.0%, and 8.6%, respectively.

CONCLUSION

Post hoc analysis of the phase 3 VISTA study in patients with DME provides evidence that regular IAI dosing not only can slow worsening of retinal perfusion associated with diabetic retinopathy but also may be able to improve retinal perfusion in some cases by decreasing zones of RNP.

FP2-7 Is whole spine imaging necessary in the evaluation of children with lumbosacral lipoma?

Objectives

Paediatric lumbosacral lipomas are commonly assessed by whole spine MRI, which is costly, time consuming and reduces imaging detail at the region of interest. This study evaluates the utility of whole spine vs local spine MRI in paediatric lumbosacral lipoma (LSL).

Design

Single centre, retrospective, radiological review.

Subjects

119 patients (77F:46M) aged 0.8 years (0.2–3.9) (median ±IQR) with complex LSL who had whole spine MRI between 2001–2017.

Methods

Lumbosacral lipomas were identified from a prospectively collected database. Cases where whole spine MRI was available were included. Type of lipoma and any associated spinal anomalies were recorded.

Results

347 patients had LSL, of which 119 (34%) patients had whole spine MRI. 3% were excluded due diagnosis of fatty filum terminale. 13% scans were unavailable. 119 patients were studied: 77F:46M aged 0.8 years at scan. Type of LML: transitional 36%; caudal 18%; dorsal 19%; unclassified 26%. Additional imaging abnormalities included: syrinx 18%; Chiari 1%; dermal sinus tract 13%; vertebral segmentation 13%; other 2%. None were associated with clinical symptoms nor required surgical treatment. Investigating the cost-benefit analysis of modality, lumbar spine required less MR time and cost less (40 vs 20 mins; £228.69 vs £282.39).

Conclusions

The low incidence of clinically relevant secondary lesions suggests that lumbosacral MRI only is necessary in the assessment of LSL. Imaging quality of the ROI can be optimised and MRI time and costs reduced.

Neurodevelopmental outcome of children with spina bifida aperta repaired prenatally vs postnatally: systematic review and meta-analysis

OBJECTIVE

To assess the neurodevelopmental outcome of children with spina bifida aperta (SBA) treated prenatally as compared to those treated postnatally.

METHODS

We performed a systematic review of the literature in PubMed/MEDLINE, EMBASE, Web of Science and The Cochrane Library, comparing the neurological outcome of infants with SBA treated prenatally vs postnatally. Only randomized controlled trials (RCTs) and non-randomized prospective controlled studies were included. The primary outcome assessed was neurodevelopmental impairment at the age of 1 year or later. Secondary outcomes were preterm birth, need for ventriculoperitoneal (VP) shunt by 12 months of age, absence of signs of hindbrain herniation at the first postnatal magnetic resonance imaging (MRI) evaluation and independent ambulation evaluated at 30 months.

RESULTS

Of 11 359 studies identified through the electronic search, six met the inclusion criteria and were assessed in full text and two, one RCT and one prospective cohort study, were ultimately included in the meta-analysis. Sensitivity analysis did not show any difference between the outcomes of the RCT alone and those of the pooled RCT and prospective cohort study. This allowed neurodevelopmental assessment of 213 children between 14 and 53 months of age. Neurodevelopment was assessed by the Bayley Scales of Infant Development II (BSID-II) mental development index corrected for chronological age, with a cut-off of ≥ 70 (representing no more than 2 SD below the mean). The presence of neurodevelopmental impairment was similar between children who underwent prenatal (25/105 (23.8%)) and those who had postnatal (30/108 (27.8%)) repair of SBA (odds ratio (OR), 0.82 (95% CI, 0.43-1.56); P = 0.54), although the risk of prematurity was higher in the prenatal-repair group (OR, 17.62 (95% CI, 7.60-40.87); P < 0.0001). For every two fetuses operated on before birth, there was, compared with those operated on after birth, one additional premature birth (number needed to harm = 2 (95% CI, 1-3)). The need for VP shunt placement by 12 months of age was lower in the prenatal-repair group (45/109 (41.3%)) than in children that had postnatal repair (93/112 (83.0%); OR, 0.14 (95% CI, 0.08-0.26); P < 0.0001). Data on neurodevelopmental impairment in children with a shunt were available only for patients from the prenatal-surgery group of the RCT; in this subgroup, the likelihood for impairment was similar between children who did (7/39 (17.9%)) and those who did not (4/48 (8.3%)) have shunt placement (P = 0.21). At first postnatal MRI evaluation, no signs of hindbrain herniation were detected in 28/88 (31.8%) children who were operated on prenatally compared with 4/89 (4.5%) who had postnatal repair (OR, 9.45 (95% CI, 3.12-28.64); P < 0.0001). Independent ambulation at 30 months was achieved by 41/109 (37.6%) children who underwent prenatal repair compared with 21/111 (18.9%) who had postnatal repair (OR, 2.59 (95% CI, 1.39-4.86); P = 0.003).

CONCLUSION

The risk of neurodevelopmental impairment in infants with SBA was similar between those who underwent prenatal and those who had postnatal surgical repair, despite an increased risk of prematurity in the prenatally repaired group. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Risk factors for surgical site infections in neurosurgery

INTRODUCTION

Surgical site infections (SSIs) are of profound significance in neurosurgical departments, resulting in high morbidity and mortality. There are limited public data regarding the incidence of SSIs in neurosurgery. The aim of this study was to determine the rate of SSIs (particularly those requiring reoperation) over a seven-year period and identify factors leading to an increased risk.

METHODS

An age matched retrospective analysis was undertaken of a series of 16,513 patients at a single centre. All patients who required reoperation for suspected SSIs within a 7-year period were identified. Exclusion criteria comprised absence of infective material intraoperatively and patients presenting with primary infections. Clinical notes were reviewed to confirm presence or absence of suspected risk factors.

RESULTS

Of the 16,513 patients in the study, 1.20% required at least one further operation to treat a SSI. Wound leak (odds ratio [OR]: 27.41), dexamethasone use (OR: 3.55), instrumentation (OR: 2.74) and operative duration >180 minutes (OR: 1.85) were statistically significant risk factors for reoperation.

CONCLUSIONS

This is the first UK study of such a duration that has documented a SSI reoperation rate in a cohort of this size. Various risk factors are associated with the development of SSIs, making it essential to have robust auditing and monitoring of high risk patients to ensure excellent standards of healthcare. Departmental and public registers to record all SSIs may be beneficial, particularly for those treated solely by general practitioners, allowing units to address potential risk factors prior to surgical intervention.

Mobilising vitamin D from adipose tissue: The potential impact of exercise

Vitamin D is lipophilic and accumulates substantially in adipose tissue. Even without supplementation, the amount of vitamin D in the adipose of a typical adult is equivalent to several months of the daily reference nutrient intake (RNI). Paradoxically, despite the large amounts of vitamin D located in adipose tissue, individuals with obesity are often vitamin D deficient according to consensus measures of vitamin D status (serum 25-hydroxyvitamin D concentrations). Thus, it appears that vitamin D can become 'trapped' in adipose tissue, potentially due to insufficient lipolytic stimulation and/or due to tissue dysfunction/adaptation resulting from adipose expansion. Emerging evidence suggests that exercise may mobilise vitamin D from adipose (even in the absence of weight loss). If exercise helps to mobilise vitamin D from adipose tissue, then this could have important ramifications for practitioners and policymakers regarding the management of low circulating levels of vitamin D, as well as chronically low levels of physical activity, obesity and associated health conditions. This perspective led us to design a study to examine the impact of exercise on vitamin D status, vitamin D turnover and adipose tissue vitamin D content (the VitaDEx project). The VitaDEx project will determine whether increasing physical activity (via exercise) represents a potentially useful strategy to mobilise vitamin D from adipose tissue.

P95 Surgical approach and morbidity of paediatric fourth ventricular tumours: analysis of a large institutional series

Objectives

To characterise the surgical management of paediatric 4th ventricular tumours and their attendant neurological complications.

Design

Retrospective cohort study.

Subjects

Children referred to our institution with tumours of the 4th ventricle between 2008–2017 inclusive.

Methods

Clinical notes and imaging review. Two-tailed Fisher’s test used to determine differences between proportions.

Results

95 patients were seen (53 males, mean 5.81y). The commonest presenting symptom was vomiting (63.3%). The commonest tumour type was medulloblastoma (54 cases)>pilocytic astrocytoma (20)>anaplastic ependymoma (12)>ATRT(4)>Teratoma (2), with 3 miscellaneous lesions. 55 pts presented with hydrocephalus. 27.4% of patients had an EVD (30.8% of these prior to tumour surgery), and 23.3% a VP shunt sited. The surgical approach was either via telovelar (50%) or transvermian (50%) routes; 29.5% were done in the sitting position. In the first 5y of the series, 7/31 cases used the telovelar approach, whilst in the latter 5y, this proportion was 30/51 (p=0.0015). New post-operative deficit was evident in 68% of cases (42.4% gait abnormality, 23.9% cranial neuropathy, 16.3% diplopia). There was no significant difference in the rates of cerebellar mutism syndrome between telovelar or transvermian approaches (p=0.62). There was 1 mortality within 30d of operation.

Conclusions

Resection of paediatric 4th ventricular tumours is increasingly performed by the telovelar route, and carries significant morbidity, although surgical mortality remains low.

TM3-3 Correlation of lumbar puncture opening pressure with 24 hours intraparenchymal ICP monitoring: the effects of position on ICP

Objectives

Lumbar Puncture opening pressure in lateral decubitus has been considered the gold standard method of intracranial pressure (ICP) measurement for many years. The use of continuous intraparenchymal ICP monitoring is more recent and there is no consensus regarding what can be considered normal ICP with this method of measurement. A conversion factor between lumbar puncture opening pressure and 24 hours ICP monitoring could provide a better insight on the interpretation of ICP. This study investigates the differences between 24 hours ICP and ICP in lumbar puncture position.

Design

Single centre prospective observational study.

Subjects

Fifty-four patients (42F:12M, mean age 38±12 years) were included.

Methods

Patients investigated with 24 hours ICP monitoring who underwent a short exercise battery during the monitoring period were included. The exercise battery was standardised; patients were asked to stay in a supine, sitting, standing and lumbar puncture position for 2 min each.Mean ICP and pulse amplitude were calculated for each position.

Results

The mean 24 hours ICP was 4.9 mmHg (±6.9 SD) and the mean ICP in lumbar puncture position was 14.1 mmHg (±8.9 SD). The average increase in lumbar puncture position was 9.1 mmHg (±5.9 SD). Patients with normal lumbar puncture position ICP (<12 mmHg) had an average 24 hours ICP of 1.4 mmHg (±2.81 SD).

Conclusions

Our results suggest that ICP measured in lumbar puncture position is on average 9.1 mmHg higher than 24 hours ICP results. Larger studies will be needed to confirm these findings.

Assessment of the 1% of Patients with Consistent < 15% Reduction in Low-Density Lipoprotein Cholesterol: Pooled Analysis of 10 Phase 3 ODYSSEY Alirocumab Trials

PURPOSE

Clinical trials of statins and other lipid-lowering therapies (LLTs) often report large inter-individual variations in their effects on low-density lipoprotein cholesterol (LDL-C). We evaluated apparent hyporesponsiveness to the proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab (defined as < 15% LDL-C reduction from baseline at all timepoints) using data from 10 Phase 3 trials (3120 hypercholesterolemic patients).

METHODS

This report assessed the LDL-C percent reduction from baseline at weeks 4-104 (depending on study), and alirocumab serum levels and antidrug antibodies, in patients with apparent hyporesponsiveness.

RESULTS

Among the 3120 patients evaluated, 98.9% responded to alirocumab, and 33 (1.1%) had < 15% LDL C reduction at all measured timepoints. Pharmacokinetics data indicated that 13/33 apparent hyporesponders had not received alirocumab; no pharmacokinetics data were available for 14/33, and 6/33 had detectable alirocumab. For the six patients with confirmed alirocumab receipt, the degree of adherence to pre-study concurrent LLTs could not be determined after study start; one of these patients had persistent antidrug antibodies.

CONCLUSIONS

Apparent hyporesponsiveness to alirocumab appeared to be due to lack of receipt of alirocumab determined by serum alirocumab levels, possible lack of adherence to concurrent LLTs, a theoretical and rare possibility of biological non-responsiveness due to persistent antidrug antibodies, or other causes, as yet unidentified.