Aberrant DNA methylation distorts developmental trajectories in atypical teratoid/rhabdoid tumors

Atypical teratoid/rhabdoid tumors (AT/RTs) are pediatric brain tumors known for their aggressiveness and aberrant but still unresolved epigenetic regulation. To better understand their malignancy, we investigated how AT/RT-specific DNA hypermethylation was associated with gene expression and altered transcription factor binding and how it is linked to upstream regulation. Medulloblastomas, choroid plexus tumors, pluripotent stem cells, and fetal brain were used as references. A part of the genomic regions, which were hypermethylated in AT/RTs similarly as in pluripotent stem cells and demethylated in the fetal brain, were targeted by neural transcriptional regulators. AT/RT-unique DNA hypermethylation was associated with polycomb repressive complex 2 and linked to suppressed genes with a role in neural development and tumorigenesis. Activity of the several NEUROG/NEUROD pioneer factors, which are unable to bind to methylated DNA, was compromised via the suppressed expression or DNA hypermethylation of their target sites, which was also experimentally validated for NEUROD1 in medulloblastomas and AT/RT samples. These results highlight and characterize the role of DNA hypermethylation in AT/RT malignancy and halted neural cell differentiation.

Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography

PURPOSE

The objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT).

METHODS

A total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital's emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39-79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%).

RESULTS

Two (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma.

CONCLUSION

The extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.

Motor dysfunction as a primary symptom predicts poor outcome: multicenter study of glioma symptoms

Background and objectives

The objectives of this study were to investigate the prognostic value of primary symptoms and leading symptoms in adult patients with diffuse infiltrating glioma and to provide a clinical perspective for evaluating survival.

Methods

This study included a retrospective cohort from two tertiary university hospitals (n = 604, 2006-2013, Tampere University Hospital and Turku University Hospital) and a prospective cohort (n = 156, 2014-2018, Tampere University Hospital). Preoperative symptoms were divided into primary and leading symptoms. Results were validated with the newer WHO 2021 classification criteria.

Results

The most common primary symptoms were epileptic seizure (30.8% retrospective, 28.2% prospective), cognitive disorder (13.2% retrospective, 16.0% prospective), headache (8.6% retrospective, 12.8% prospective), and motor paresis (7.0% retrospective, 7.1% prospective). Symptoms that predicted better survival were epileptic seizure and visual or other sense-affecting symptom in the retrospective cohort and epileptic seizure and headache in the prospective cohort. Predictors of poor survival were cognitive disorder, motor dysfunction, sensory symptom, tumor hemorrhage, speech disorder and dizziness in the retrospective cohort and cognitive disorder, motor dysfunction, sensory symptom, and dizziness in the prospective cohort. Motor dysfunction served as an independent predictor of survival in a multivariate model (OR = 1.636).

Conclusion

Primary and leading symptoms in diffuse gliomas are associated with prognoses in retrospective and prospective settings. Motor paresis was an independent prognostic factor for poor survival in multivariate analysis for grade 2-4 diffuse gliomas, especially in glioblastomas.

Impact of timing of surgery and adjuvant treatment on survival of adult IDH-wildtype glioblastoma: a single-center study of 392 patients

BACKGROUND

The purpose of our study was to analyze the impact of time interval from referral to surgery and from surgery to adjuvant treatment on survival of adult IDH-wildtype glioblastomas.

METHODS

Data on 392 IDH-wildtype glioblastomas diagnosed at the Tampere University Hospital in 2004-2016 were obtained from the electronic patient record system. Piecewise Cox regression was used to calculate hazard ratios for different time intervals between referral and surgery, as well as between surgery and adjuvant treatments.

RESULTS

The median survival time from primary surgery was 9.5 months (interquartile range: 3.8-16.0). Survival among patients with an interval exceeding four weeks from referral to surgery was no worse compared to <2 weeks (hazard ratio: 0.78; 95% confidence interval: 0.54-1.14). We found indications of poorer outcome when the interval from surgery to radiotherapy exceeded 30 days (hazard ratio: 1.42; 95% confidence interval: 0.91-2.21 for 31-44 days and 1.59; 0.94-2.67 for over 45 days).

CONCLUSIONS

Interval from referral to surgery in the range of 4-10 weeks was not associated with decreased survivals in IDH-wildtype glioblastomas. In contrast, delay exceeding 30 days from surgery to adjuvant treatment may decrease long-term survival.

EPCO-11. GATEKEEPER INACTIVATION DRIVES TUMOR PROGRESSION TO GRADE IV ASTROCYTOMA

IDH-mutant low-grade diffuse astrocytomas frequently progress to grade IV astrocytomas with implications for patient prognosis. To better understand this process, we applied whole-genome and transcriptome sequencing to matched tumor samples collected before and after progression to grade IV astrocytomas from five patients. All tumors carried an IDH1 mutation. The number of chromosomal rearrangements was increased between 1.3 and 3.5-fold in the tumors upon progression, with the exception of one case, in which the increase was only 1.03-fold. This case exhibited a hypermutation signature caused by homozygous deletion of the MSH2 gene, which encodes a member of the DNA mismatch repair complex. The most common genomic alterations acquired at progression were homozygous deletions in the CDKN2A/ RB1 -pathway or hemizygous deletion of PTEN. Additionally, PDGFRA was amplified in two grade IV tumors, with concordantly increased expression. For one of these cases, a PDGFRA-amplified subclone is likely to be present already in the low-grade astrocytoma. We further detected intrachromosomal rearrangements closeby the genes NRG3 in the progressed tumors as well as in the The Cancer Genome Atlas (TCGA) cohort. The expression of NRG3 decreased with increasing grade in the TCGA cohort and the gene was frequently deleted. Lower NRG3 expression was associated with shorter survival in the TCGA cohort. Several miRNAs showed differential expression upon progression. For two miRNAs the predicted targets were associated with cell cycle regulation and we detected inverse correlation between miRNA and target mRNA expression. While progression seems to occur via different pathways, the predicted outcome for many of the alterations was the inactivation of tumor suppressor genes and further dysregulation of cell proliferation.

EPCO-34. INTEGRATIVE DNA METHYLATION ANALYSIS OF PEDIATRIC BRAIN TUMORS REVEALS TUMOR TYPE-SPECIFIC DEVELOPMENTAL TRAJECTORIES AND EPIGENETIC SIGNATURES OF MALIGNANCY

Understanding oncogenic epigenetic mechanisms in brain tumors is crucial for improved diagnosis and treatment. Recently DNA methylation has proven to be powerful for brain tumor characterization and diagnostic classification. To evaluate tumor type specific features, we compared atypical teratoid/rhabdoid tumors (AT/RTs), medulloblastomas (MBs), and choroid plexus tumors with each other by integrating DNA methylation (507 samples), gene expression (120 samples), and transcription factor (TF) -binding data. Different tumor entities were used to find unique changes affecting each of the entities and further to identify functions driven by these changes. Our results provide insight on how the aberrant DNA methylation induces oncogenesis of AT/RTs. These tumors are known for their aggressiveness and exceptionally low mutation rates. Our results suggest that in AT/RT, elevated DNA methylation masks the binding sites of TFs such as NEUROD1, ASCL1 and MYCN driving neural development. DNA methylation in AT/RTs is also associated with reduced gene expression for specific neural regulators such as NEUROG1 and NEUROD2. For MBs, DNA methylation patterns predict a more advanced differentiation state. In MB, we found masked TF binding sites for TFs such as REST and ZEB1 that normally inhibit neural differentiation. We then wanted to further characterize DNA methylation and compared these tumors to pluripotent stem cells (PSCs) and normal fetal brain samples. As a result, we were able to find two different regulatory programs in AT/RTs: One in which DNA methylation is similar to PSCs and which harbors mostly neural TF binding sites. Second program has AT/RT-specific DNA methylation, and these sites are uniquely associated with polycomb repressive complex 2 members. However, this second program also covers neural TF binding sites and is likely to have relevance in oncogenic regulation.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Chronic subdural hematoma-incidence, complications, and financial impact

OBJECTIVE

To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT).

METHODS

A retrospective cohort (1990-2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland).

RESULTS

The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4-6 weeks' postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia.

CONCLUSIONS

Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990-2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population

OBJECTIVE

The aim of this study was to determine the population-based epidemiology of chronic subdural hematoma (CSDH) over a 26-year period.

METHODS

A retrospective study was conducted of all adult patients (≥ 18 years and residents of Pirkanmaa [Finland]) with a diagnosis of CSDH between 1990 and 2015. The cases were identified using ICD codes. Detailed data collection was performed using medical records and death certificates. All patients were monitored until death or the end of year 2017. The annual number of inhabitants in the Pirkanmaa region was obtained from Statistics Finland (Helsinki, Finland).

RESULTS

A total of 1168 patients with CSDH were identified from hospital records and death certificates; patients were considered as new-incidence cases if 2 years had elapsed following primary treatment and in cases involving a new contralateral CSDH. From 1990 to 2015, the overall incidence of CSDH doubled from 8.2 to 17.6/100,000/year. Among adults younger than 70 years, the incidence remained quite stable, whereas the incidence clearly increased among the ≥ 80-year-old population, from 46.9 to 129.5/100,000/year. The median age for a CSDH diagnosis increased from 73 to 79 years during the 26-year period. Head trauma was documented in 59% of cases. A ground-level fall was related to the CSDH in 31% of patients younger than 60 years and in 54% of those 80 years or older. The proportion of alcohol-related cases decreased toward the end of the study period (1990–1995: 16% and 2011–2015: 7%), because alcohol abuse was less frequent among the growing group of elderly patients. In contrast, the percentage of patients receiving anticoagulant or antiplatelet medication almost doubled toward 2015 (1990–1995, 27%; and 2011–2015, 49%). The patients’ neurological condition on admission, based on both Glasgow Coma Scale score (score < 13: 1990–1995, 18%; and 2011–2015, 7%; p < 0.001) and the modified Rankin Scale score (score 0–2: 1990–1995, 8%; and 2011–2015, 19%; p < 0.001), was better in recent years than in the early 1990s.

CONCLUSIONS

From 1990 to 2015, the incidence of CSDH has increased markedly. The incidence of CSDH among the population 80 years or older has nearly tripled since 1990. The use of anticoagulants has increased, but there has been no change regarding the ratio between a traumatic and a spontaneous CSDH etiology. As the world population becomes progressively older, the increasing incidence of CSDH will be a burden to patients and a future challenge for neurosurgical clinics.

Sähköinen valtakirjaan perustuva puolesta-asiointi terveydenhuollossa

Suomessa otettiin käyttöön joulukuussa 2017 valtakirjalla tapahtuva puolesta-asiointi muutamissa alueellisissa sähköisissä terveyspalveluissa, kuten Etelä-Savon Hyvis.fi - ja Oulun Omahoito.fi -palveluissa. Sähköiset valtakirjat tallennetaan tällä hetkellä kansalliseen valtuusrekisteriin Suomi.fi -valtuudet palvelussa. Toisen puolesta asioinnin mahdollistava kehitystyö lähti käyntiin sähköisissä asiointipalveluissa kansalaisilta tulleiden palautteiden myötä. Keskeiseen rooliin sosiaali- ja terveydenhuollon sähköisessä puolesta asioinnissa nousee lainsäädäntö ja muu sääntely. Terveyden- ja hyvinvoinnin laitos (THL) kokosi vuonna 2016 toiminnallisen määrittelydokumentin kehitystyötä varten. Puolesta-asioinnin mahdollistava toteutus eteni toiminnallisen määrittelyn kautta siirtyen teknisen toteutuksen ja mahdollistamisen kautta palveluita käyttävien hyödynnettäväksi. Tutkimuksen tarkoituksena oli selvittää, missä asioissa kansalaiset tekisivät puolesta-asioinnin sähköisiä valtuutuksia (valtakirjoja) terveydenhuollossa ja miten tärkeäksi he asian tällä hetkellä kokevat sekä saada lisää tietoa kansalaisten valtuutuksen tekemisen tarpeesta. Tässä tutkimuksessa käytettiin asiantuntijoiden antaman suosituksen mukaan termiä puolesta-asiointi terminä ja puolesta asiointi, kun se sisälsi määreen. Tämän tutkimus vahvisti aiempaa tietoa sähköistä asiointitapaa käyttävistä henkilöistä ja heidän mielipiteistään. Kansalaiset haluavat valtuuttaa asioimaan puolestaan terveydenhuollossa oman lapsensa. Puolesta-asiointia halutaan mieluiten käyttää sähköisissä asiointipalveluissa ajanvarauksen tekemiseen terveydenhuoltoon sekä reseptien katsomiseen ja uusimiseen. Mitä enemmän puolesta asioitavat asiat liittyvät itse sairauden hoitoon tai hoitamiseen, sitä enemmän epäröidään sähköistä puolesta-asioinnin tekemistä. Tämän tutkimuksen tulosten perusteella vaikuttaa siltä, ettei tarvetta puolesta asiointiin terveydenhuollossa osata täysin kuvitella ennen kuin tilanne ja todellinen tarve ovat käsillä.

Johtamisen hyvät käytännöt sähköisten omahoitopalveluiden käyttöönotossa

ODA (Omat digiajan hyvinvointipalvelut) ja Virtuaalisairaala 2.0 -hankkeet kehittävät Suomeen uusia kansalaisille suunnattuja sähköisiä omahoitopalveluita. Sähköiset palvelut muuttavat terveysammattilaisten työtä ja aiheuttavat usein myös vastustusta. Uusien palveluiden onnistunut käyttöönotto niiden suunnittelusta ja kokeilusta vakiintuneeseen käyttöön asti vaatii, että muutokset tuodaan organisaatioon suunnitellusti. Tässä tutkimuksessa tunnistettiin käyttöönoton hyviä käytäntöjä tutkimuskirjallisuuden sekä ODA ja Virtuaalisairaala 2.0 -hankkeiden kokemusten perusteella sekä arvioitiin käytäntöjen toteutumista näissä hankkeissa. ODA-hankkeesta kartoitettiin kyselyllä siihen osallistuvien 14 sosiaali- ja terveysalan organisaation esimiesten ja johtajien (n=478) odotuksia Omaolo-palvelukokonaisuuden käyttöönotosta. Virtuaalisairaala 2.0 -hankkeen käyttöönottokokemuksia kerättiin haastattelemalla neljää Terveyskylän eri taloprojektin projektipäällikköä tai -koordinaattoria. Tulosten perusteella kokemukset käyttöönoton onnistumista tukevista käytännöistä ovat hyvin samansuuntaisia suomalaisissa hankkeissa sekä kansainvälisissä tutkimuksissa. Hyviksi käytännöiksi nousivat esimerkiksi selkeän vision ja tavoitteiden kommunikointi, johdon tuki, tehokas tiedottaminen palvelun käyttöönotosta ja sen hyödyistä sekä ammattilaisten ja asiantuntijoiden osallistuminen suunnitteluun. ODA-kyselyn tulosten mukaan käyttöönoton hyvät käytännöt eivät olleet kovin laajassa käytössä suomalaisissa sote-organisaatioissa. Tutkimuksessa tunnistetut hyvät käytännöt antavat vinkkejä käyttöönottotiimeille sekä johtajille ja esimiehille siitä, miten käyttöönoton voi toteuttaa suunnitelmallisemmin ja samalla tukea käyttöönoton onnistumista. Esimiehet ovat tärkeässä roolissa uusien sähköisten palveluiden organisaationlaajuisessa käyttöönotossa ja tunnistettuja käytäntöjä on tarkoitus hyödyntää esimiesten koulutuksen kehittämisessä.

Terveyskylässä palvelua asiakkaalle

Helsingin ja Uudenmaan sairaanhoitopiirin (HUS) koordinoima Virtuaalisairaala 2.0 -hanke on erikoissairaanhoidon palveluiden ja toiminnan muutoksen kehittämistä digitaalisten palvelukanavien avulla. Terveyskylä on osa Virtuaalisairaala 2.0 -hankkeen palvelutuotantoa. Terveyskylän palvelutasoja ovat kansalaisille avoimet palvelut, hoitopalvelut potilaille sekä palvelut ammattilaisille. eTerveyspalveluiden suunnittelu ja tuotanto perustuvat palveluarkkitehtuuriin. Terveyskylän palvelut suunnitellaan asiakaslähtöisesti potilaan ja ammattilaisen kommunikaatiota ja yhteistyötä rakentaviksi. Eri tuottajien muodostaman terveyden- ja sosiaalihuollon digitaalisten palveluiden ekosysteemin on toimittava kansalaisen kannalta palvelupeilinä, jotta hän saa sujuvaa ja saumatonta tukea ja ohjausta sekä hoitoa palvelujen virrassa. Digitaalisten palveluiden kehittämisen myötä kansalaisten, potilaiden, ammattilaisten ja organisaatioiden tarpeet sekä uusista palveluista saatavat hyödyt uudistavat palvelukulttuuria ja tuottavat toiminnan tehostamista. Tämän artikkelin tavoitteena on tarkastella, millainen palvelu Terveyskylä on.