Can quantifying the extent of 'high grade' features help explain prognostic variability in anaplastic astrocytoma?

PURPOSE

Both phenotypic and genotypic variations now underpin glioma classification, thus helping to more accurately guide their clinical management. However, WHO Grade III anaplastic astrocytoma (AA) remains an unpredictable, heterogeneous entity; displaying a variable prognosis, clinical course and treatment response. This study aims to examine whether additional tumour characteristics influence either overall survival (OS) or 3-year survival in AA.

MATERIALS AND METHODS

Data were collected on all newly diagnosed cases of AA between 2003 and 2014, followed up for a minimum of 3 years. Molecular information was obtained from case records and if missing, was re-analysed. Histological slides were independently examined for Ki-67 proliferation index, cellularity and number of mitotic figures. Kaplan-Meier and Cox regression analyses were used to assess OS.

RESULTS

In total, 50 cases were included with a median OS of 14.5 months (range: 1-150 months). Cumulative 3-year survival was 31.5%. Median age was 50 years (range: 24 - 77). Age, IDH1 mutation status, lobar location, oncological therapy and surgical resection were significant independent prognostic indicators for OS. In cases demonstrating an OS ≥ 3 years (n = 15), Ki-67 index, number of mitotic figures and percentage areas of 'high cellularity' were significantly reduced, i.e. more characteristic of lower-grade/WHO Grade II glioma.

CONCLUSIONS

IDH1 status, age, treatment and location remain the most significant prognostic indicators for patients with AA. However, Ki-67 index, mitotic figures and cellularity may help identify AA cases more likely to survive < 3 years, i.e. AA cases more similar to glioblastoma and those cases more likely to survive > 3 years, i.e. more similar to a low-grade glioma.

Recovery of major cognitive deficits following awake surgery for insular glioma: a case report

Background: Resection of insular tumours utilising modern neurosurgical techniques has become commonplace since its safety and reduced morbidity was first established. Interest has grown in the cognitive consequences of insula neurosurgery and studies have largely shown postoperative stability or minor decline. Major or widespread improvements in cognitive functioning following resection of insular tumours have not previously been reported.Case description: A 34-year-old, left-handed man with a right insular low-grade glioma (LGG) presented with seizures, nausea, altered sensation, poor balance and extensive cognitive decline. Comprehensive neuropsychological assessment highlighted a striking left hemispatial neglect and impairments in attention, working memory, verbal learning and fluency. During an awake craniotomy with functional cortical mapping, he reported intraoperative improvements in hand function and processing speed. Resolution of the neglect and significant improvements in cognition, mood and functioning were observed at follow-up and sustained over several years.Conclusions: This case highlights that right insular LGGs can cause significant cognitive and functional deficits and that neurosurgery has the potential to alleviate these difficulties to an extent beyond those documented in the extant literature.

Glioblastoma and Radiotherapy: a multi-center AI study for Survival Predictions from MRI (GRASP study)

BACKGROUND

The aim was to predict survival of glioblastoma at eight months after radiotherapy (a period allowing for completing a typical course of adjuvant temozolomide), by applying deep learning to the first brain MRI after radiotherapy completion.

METHODS

Retrospective and prospective data were collected from 206 consecutive glioblastoma, IDH-wildtype patients diagnosed between March 2014-February 2022 across 11 UK centers. Models were trained on 158 retrospective patients from three centers. Holdout test sets were retrospective (n=19; internal validation), and prospective (n=29; external validation from eight distinct centers).Neural network branches for T2-weighted and contrast-enhanced T1-weighted inputs were concatenated to predict survival. A non-imaging branch (demographics/MGMT/treatment data) was also combined with the imaging model. We investigated the influence of individual MR sequences; non-imaging features; and weighted dense blocks pretrained for abnormality detection.

RESULTS

The imaging model outperformed the non-imaging model in all test sets (area under the receiver-operating characteristic curve, AUC p=0.038) and performed similarly to a combined imaging/non-imaging model (p>0.05). Imaging, non-imaging, and combined models applied to amalgamated test sets gave AUCs of 0.93, 0.79, and 0.91. Initializing the imaging model with pretrained weights from 10,000s of brain MRIs improved performance considerably (amalgamated test sets without pretraining 0.64; p=0.003).

CONCLUSIONS

A deep learning model using MRI images after radiotherapy, reliably and accurately determined survival of glioblastoma. The model serves as a prognostic biomarker identifying patients who will not survive beyond a typical course of adjuvant temozolomide, thereby stratifying patients into those who might require early second-line or clinical trial treatment.

Phytophthora

Many members of the Oomycota genus Phytophthora cause economic and environmental impact diseases in nurseries, horticulture, forest, and natural ecosystems and many are of regulatory concern around the world. At present, there are 223 described species, including eight unculturable and three lost species. Twenty-eight species need to be redescribed or validated. A lectotype, epitype or neotype was selected for 20 species, and a redescription based on the morphological/molecular characters and phylogenetic placement is provided. In addition, the names of five species are validated: P. cajani, P. honggalleglyana (Synonym: P. hydropathica), P. megakarya, P. pisi and P. pseudopolonica for which morphology and phylogeny are given. Two species, P. ×multiformis and P. uniformis are presented as new combinations. Phytophthora palmivora is treated with a representative strain as both lecto- and epitypification are pending. This manuscript provides the updated multigene phylogeny and molecular toolbox with seven genes (ITS rDNA, β-tub, COI, EF1α, HSP90, L10, and YPT1) generated from the type specimens of 212 validly published, and culturable species (including nine hybrid taxa). The genome information of 23 types published to date is also included. Several aspects of the taxonomic revision and phylogenetic re-evaluation of the genus including species concepts, concept and position of the phylogenetic clades recognized within Phytophthora are discussed. Some of the contents of this manuscript, including factsheets for the 212 species, are associated with the "IDphy: molecular and morphological identification of Phytophthora based on the types" online resource (https://idtools.org/tools/1056/index.cfm). The first version of the IDphy online resource released to the public in September 2019 contained 161 species. In conjunction with this publication, we are updating the IDphy online resource to version 2 to include the 51 species recently described. The current status of the 223 described species is provided along with information on type specimens with details of the host (substrate), location, year of collection and publications. Additional information is provided regarding the ex-type culture(s) for the 212 valid culturable species and the diagnostic molecular toolbox with seven genes that includes the two metabarcoding genes (ITS and COI) that are important for Sanger sequencing and also very valuable Molecular Operational Taxonomic Units (MOTU) for second and third generation metabarcoding High-throughput sequencing (HTS) technologies. The IDphy online resource will continue to be updated annually to include new descriptions. This manuscript in conjunction with IDphy represents a monographic study and the most updated revision of the taxonomy and phylogeny of Phytophthora, widely considered one of the most important genera of plant pathogens. Taxonomic novelties: New species: Phytophthora cajani K.S. Amin, Baldev & F.J. Williams ex Abad, Phytophthora honggalleglyana Abad, Phytophthora megakarya Brasier & M.J. Griffin ex Abad, Phytophthora pisi Heyman ex Abad, Phytophthora pseudopolonica W.W. Li, W.X. Huai & W.X. Zhao ex Abad & Kasiborski; New combinations: Phytophthora ×multiformis (Brasier & S.A. Kirk) Abad, Phytophthora uniformis (Brasier & S.A. Kirk) Abad; Epitypifications (basionyms): Peronospora cactorum Lebert & Cohn, Pythiacystis citrophthora R.E. Sm. & E.H. Sm., Phytophthora colocasiae Racib., Phytophthora drechsleri Tucker, Phytophthora erythroseptica Pethybr., Phytophthora fragariae Hickman, Phytophthora hibernalis Carne, Phytophthora ilicis Buddenh. & Roy A. Young, Phytophthora inundata Brasier et al., Phytophthora megasperma Drechsler, Phytophthora mexicana Hotson & Hartge, Phytophthora nicotianae Breda de Haan, Phytophthora phaseoli Thaxt., Phytophthora porri Foister, Phytophthora primulae J.A. Toml., Phytophthora sojae Kaufm. & Gerd., Phytophthora vignae Purss, Pythiomorpha gonapodyides H.E. Petersen; Lectotypifications (basionym): Peronospora cactorum Lebert & Cohn, Pythiacystis citrophthora R.E. Sm. & E.H. Sm., Phytophthora colocasiae Racib., Phytophthora drechsleri Tucker, Phytophthora erythroseptica Pethybr., Phytophthora fragariae Hickman, Phytophthora hibernalis Carne, Phytophthora ilicis Buddenh. & Roy A. Young, Phytophthora megasperma Drechsler, Phytophthora mexicana Hotson & Hartge, Phytophthora nicotianae Breda de Haan, Phytophthora phaseoli Thaxt., Phytophthora porri Foister, Phytophthora primulae J.A. Toml., Phytophthora sojae Kaufm. & Gerd., Phytophthora vignae Purss, Pythiomorpha gonapodyides H.E. Petersen; Neotypifications (basionym): Phloeophthora syringae Kleb., Phytophthora meadii McRae Citation: Abad ZG, Burgess TI, Bourret T, Bensch K, Cacciola S, Scanu B, Mathew R, Kasiborski B, Srivastava S, Kageyama K, Bienapfl JC, Verkleij G, Broders K, Schena L, Redford AJ (2023). Phytophthora: taxonomic and phylogenetic revision of the genus. Studies in Mycology 106: 259-348. doi: 10.3114/sim.2023.106.05.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

A split-mouth randomized controlled trial to compare the rate of canine retraction after a soft tissue procedure compared against a corticotomy procedure for accelerated tooth movement

Background and Aim

Various methods to accelerate the orthodontic tooth movement have been used, among which corticotomy is considered to be the most common one. The suggested reasoning for such acceleration was the regional acceleratory phenomenon (RAP). Since the RAP is a property of both the hard and soft tissues, we designed a soft tissue flap procedure to compare the effects with the conventional corticotomy procedure. A split-mouth study was conducted where the two procedures were assessed in a single participant.

Patients and Methods

The total sample size was calculated to be 40 with 20 participants in each group. The rate of tooth movement was the primary outcome measure, and the secondary outcomes were dentoalveolar changes, which were studied in both the conventional corticotomy and the flap-only procedure based on a cone-beam computed tomography (CBCT) wherein the alveolar bone density (BD) around canines, tipping, and rotational changes in canines, premolars, and molars were assessed.

Results

Corticotomy resulted in greater canine angulation, lesser canine rotation and premolar rotation, and greater molar rotation compared with flap elevation, but these differences were statistically insignificant.

Conclusion

Though the corticotomy resulted in higher BD, the differences were statistically insignificant. There was no significant difference in the rate of space closure assessed by the two techniques compared.

Optical Coherence Tomography (OCT) evaluation of culprit lesions in patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS)

Funding Acknowledgements

Type of funding sources: None.

Background

OCT is an excellent tool to determine plaque morphology in Acute Coronary Syndromes. While plaque rupture has been determined to be the dominant morphology in ST Elevation Myocardial Infarction, there is paucity of literature in NSTE-ACS, which includes Non–ST Segment Elevation Myocardial Infarction (NSTEMI) and Unstable angina (UA).

Purpose

To characterize culprit lesion morphology by OCT in NSTE-ACS and to evaluate the frequency of each type of lesion in patients presenting with NSTEMI and UA.

Methods

In this single-centre observational study, OCT imaging of culprit lesion was acquired during coronary angioplasty of culprit lesions of 50 patients presenting with NSTE-ACS between August 2020 to July 2021. A comparison of the frequency of each type of lesion between NSTEMI and UA was performed.

Results

OCT of culprit vessel in the entire cohort of NSTE-ACS showed plaque erosion in 32% (n=16), plaque rupture in 32% (n=16), tight stenosis in 26% (n=13) and calcific nodule in 10% (n= 5) patients. Lipid plaque was seen in a higher number of patients with plaque erosion and plaque rupture (93.8% and 87.5% respectively). Comparison of the frequency of these lesions in NSTEMI and UA, revealed that among NSTEMI patients (n=25), 48% had plaque erosion, 36% had plaque rupture, 12% had tight stenosis and 4% had calcific nodule whereas, among UA patients (n=25), 16% had plaque erosion, 28% had plaque rupture, 40% had tight stenosis and 16% had calcific nodule. There was a statistically significant increase in plaque erosion in NSTEMI compared to UA (p=0.015) while tight stenosis was significantly more common in UA (p=0.024). Similarly, red thrombus and spotty calcium (p=0.002 and 0.008 respectively) were higher in NSTEMI compared to UA. There was no significant difference in frequency of thin cap fibroatheroma, macrophages, cholesterol crystals, white thrombus, and neovascularization among the two groups.

Conclusions

OCT provides unique insights into the mechanisms of NSTE-ACS. In our study plaque erosion and plaque rupture were both equally seen in patients presenting with NSTE- ACS. However, NSTEMI patients had a higher frequency of plaque erosion, red thrombus, and spotty calcium when compared to UA. While UA patients had a higher incidence of tight stenosis.

Levetiracetam as a first-line antiseizure medication in WHO grade 2 glioma: Time to seizure freedom and rates of treatment failure

OBJECTIVE

The high seizure burden seen in World Health Association (WHO) grade 2 gliomas is well documented. This study aims to identify factors that influence the probability of seizure freedom (12 months of seizure remission) and treatment failure (antiseizure medication [ASM] cessation or introduction of an alternative) in patients with WHO grade 2 glioma.

METHODS

This is a retrospective observational analysis of patients from a regional UK neurosurgical center with histologically proven (n = 146) WHO grade 2 glioma and brain tumor related epilepsy. Statistical analyses using both Kaplan-Meier and Cox proportional hazards models were undertaken, with a particular focus on treatment outcomes when the commonly prescribed ASM levetiracetam (n = 101) is used as first line.

RESULTS

Treatment with levetiracetam as a first-line ASM resulted in a significant increase in the probability of seizure freedom (p < .05) at 2 years compared with treatment with an alternative ASM. Individuals presenting with focal seizures without bilateral tonic-clonic progression were between 39% and 42% significantly less likely to reach seizure freedom within 10 years (p < .05) and 132% more likely to fail treatment by 5 years (p < .01) when compared to individuals who had seizures with progression to bilateral tonic-clonic activity. ASM choice did not significantly affect treatment failure rates.

SIGNIFICANCE

More than two-thirds of patients with WHO grade 2 glioma related epilepsy treated with levetiracetam first line achieve seizure freedom within 2 years and it is a reasonable first-choice agent. Experiencing mainly focal seizures without progression infers a significant long-term reduction in the chance of seizure freedom. Further studies are needed to inform ASM selection.

SURG-29. CAN NEOADJUVANT CHEMOTHERAPY INCREASE EXTENT OF RESECTION IN DIFFUSE LOWER-GRADE GLIOMA?

INTRODUCTION

Maximal safe surgical resection remains front-line treatment for diffuse lower-grade gliomas (DLGGs). Greater extent of resection (EOR) can delay transformation, control seizures, and improve survival. EOR is limited by the infiltrative nature of DLGGs and eloquent brain location preponderance. We investigated the role of neoadjuvant chemotherapy in tumour volume reduction (TVR) for cases in which a meaningful EOR was deemed unachievable.

METHODS

Retrospective review (2000-2020) of patients in a large tertiary UK brain tumor centre who serendipitously underwent management that did or could mimic a neoadjuvant chemotherapy pathway. Inclusion criteria: &gt;18 years at diagnosis; histologically-proven WHO grade 2 supratentorial glioma; received chemotherapy alone after biopsy then +/- debulking. Tumour volume delta +/- EOR were calculated on serial MRI T2/FLAIR sequences using a semi-automated quantitative analysis tool (Smartbrush, BrainLab® AG).

RESULTS

Group 1 (neoadjuvant chemotherapy and then surgery, n=4): debulking was considered unachievable initially but then possible post-chemotherapy. Median TVR post-chemotherapy was 16.90% (range 0.45–64.90%). Mean EOR was 68.67% (33.72–100%). Median overall survival (OS) and progression free survival (PFS) were 85 (18–154) and 62 (13–153) months, respectively. Group 2 (biopsy followed by chemotherapy alone, n=7): debulking was considered unachievable initially. Median TVR post-chemotherapy was 25.68% (-294.95–46.02%, one patient progressed during chemotherapy). Median OS and PFS were 92 (6–135) and 27 (3–80) months, respectively. On re-review, and based on Group 1 results, some Group 2 patients may have been able to undergo debulking with meaningful EOR post-chemotherapy.

CONCLUSIONS

Chemotherapy can have a significant impact on reducing tumour volumes, such that cases initially deemed unsuitable for debulking may be converted into those in which a meaningful EOR can be achieved. Larger, multicentre, retrospective studies, and prospective trials are needed to determine the role of chemotherapy as a neoadjuvant tool in the management of DLGGs.

NCOG-28. LEEDS LOW GRADE GLIOMA SERVICE 2010-2022: A 12-YEAR EXPERIENCE

INTRODUCTION

We present our 12-year experience of the surgical management of lower-grade gliomas (LGGs) by a multidisciplinary team in a large tertiary UK brain tumour centre.

METHODS

Retrospective analysis of all adult patients who underwent surgery in the Leeds Low Grade Glioma Service between January 2010 and January 2022. Data collected included demographics, procedure type, extent of resection, histological diagnosis, morbidity, mortality, tumour location, seizure control, adjuvant therapy, cognitive outcomes, progression-free survival (PFS) and overall survival (OS). Results were statistically analysed by Kaplan-Meier and Log Rank (Cox Proportional Regression Hazard) Testing (p&lt; 0.05).

RESULTS

254 patients underwent surgery between 2010-2022. Of these, 77 patients underwent a second resection surgery, 9 a third, and 1 patient had a total of 4 resections. 184 operations were carried out awake, 115 asleep and 42 patients underwent biopsy only. The most common histology at initial surgery was astrocytoma, IDH1m, WHO Grade 2 (41.7%) with oligodendroglioma, IDH1m, WHO Grade 2 being the second most common. The majority of tumors were located in the right frontal lobe (24%) followed by the left frontal lobe (18%). 32% of tumors were on the left side. The median time between diagnosis and first surgery was 36.5 months. 8 patients died during this time frame, 7 who had resection, 1 had biopsy.

CONCLUSION

Our experience of the surgical management of LGG over the last 12 years shows that maximal safe surgical resection remains important as first-line treatment. Greater extent of resection (EOR) can delay transformation, control seizures and improve survival. Awake surgery is well tolerated and can preserve eloquent function. A multidisciplinary team approach achieves the best outcomes, and is appreciated by our patients

INNV-28. A PILOT STUDY EVALUATING THE FEASIBILITY OF USING AN ULTRA-FAST DIGITAL CONFOCAL MICROSCOPY SCANNER FOR REAL-TIME INTRA-OPERATIVE BRAIN TUMOUR DIAGNOSIS

INTRODUCTION

Real-time intra-operative brain tumour tissue analysis in the operating room (OR) can shorten turnaround times and facilitate repeated sampling; the latter can improve diagnostic accuracy and guide resection to maximise extent. We evaluated the feasibility of using an ultra-fast confocal microscopy scanner (Histolog®, SamanTree Medical SA) in the OR for real-time intra-operative brain tumour tissue diagnosis. This study is the first use of Histolog® on primary human brain tissue globally.

METHODS

An observational pilot study with varying brain tumour types was conducted in a tertiary UK brain tumour centre. Multiple, freshly excised tissue samples were stained with Acridine Orange, and images captured within 60 seconds on Histolog® in the OR in parallel to current diagnostic pathways. A Consultant Neuropathologist performed a blinded correspondence assessment between Histolog® and current gold standard histopathology. Qualitative logging of diagnostic features was performed.

RESULTS

Cases studied (n=12) included glioma, metastasis, meningioma, schwannoma, and pituitary adenoma. Concordance between Histolog® and traditional (frozen section) intra-operative histopathological diagnosis was 83% (10/12 cases). One Histolog® case demonstrated superior diagnostic accuracy to frozen section. Histolog® images demonstrated specific diagnostic features such as clusters of cohesive epithelioid cells (metastatic carcinoma), sheet-like variably cellular and pleomorphic cells (gliomas), diffuse sheet-like monomorphic round nuclei (pituitary adenoma), elongated spindle cells (schwannoma), and nodular architecture and oval nuclei (meningioma).

DISCUSSION

Ultra-fast confocal microscopy scanning with Histolog® is feasible in the OR and Histolog® image resolution is adequate to identify histopathological features necessary for intra-operative brain tumour diagnosis. Training and clinico-radiological details are important in minimising discordance. A larger study with greater numbers and tumour types will now be performed to define an optimal scanning protocol and determine the strengths and limitations of the technology. Future studies should investigate the effect of real-time margin zone analysis on extending resection.

QLTI-19. EVALUATION OF INTRA-OPERATIVE BRAIN TUMOUR DIAGNOSTIC SERVICES – A LARGE TERTIARY UK CENTRE EXPERIENCE

INTRODUCTION

Brain tumour intraoperative diagnosis (smear cytology, frozen section) is a commonly performed, routine diagnostic service. Currently, samples must be transported from the operating room (OR) to pathology, impacting turnaround time (TAT), carbon emissions (if cross-site), and motivation for repeat sampling. We performed a broad evaluation of current practice in a large, tertiary, UK brain tumour centre, to identify potential gains in real-time tissue diagnosis.

METHODS

All brain tumour samples (n=228) sent for intraoperative diagnosis in 2021 were analysed retrospectively. TAT was assessed by capturing different timepoints along the pathway. Concordance between diagnoses at the following stages was determined: preoperatively based on radiology, intraoperatively (frozen section or smear), provisional paraffin and final integrated. Additionally, we anonymously surveyed neurosurgeons’ opinions (n=18) on the current service.

RESULTS

The mean (±SD) specimen transportation time was 10.6±2.0 minutes, with an estimated total TAT of 30-60 minutes. Intraoperative diagnosis provided a slightly higher rate of concordance with provisional paraffin diagnosis than preoperative radiological diagnosis (89.5% vs 86.3%). Non-concordance was most commonly due to non-representative sampling (e.g., predominantly necrotic), with no repeat sample being sent/available intraoperatively. Prevailing neurosurgical opinion of the intraoperative diagnostic service was dissatisfaction or neutrality (50% and 39% of respondents), with a minority being positive (11%). Reasons for this included: intraoperative delay due to TAT (47%), perceived inaccuracy of results (41%), and perceived reduced out-of-hours availability (56%).

CONCLUSIONS

Current brain tumour intraoperative diagnostic practice relies on physical sample transportation and manual processing; the resultant long TAT causes surgeon dissatisfaction and dissuades repeat analysis in the case of non-representative sampling. Real-time tissue diagnostic technologies such as OR-sited probe-based confocal endomicroscopy, scanners and Raman spectroscopy should be considered to facilitate faster and repeated examination. The latter may have additional benefits in real-time expert pathology feedback, tumour margin-zone analysis and increased extent of resection.

Motor Seizures Confer Overall Survival Benefit in WHO Grade 2 Glioma

AIMS

The prevalence of epilepsy in WHO grade 2 glioma is high, with seizures often being the presenting symptom. We explore the epidemiology of seizures in this patient population in a regional neurosurgical centre.

METHOD

Electronic health records of patients with histologically-proven WHO grade 2 glioma (n=227) were reviewed with data collected including patient demographics, epilepsy prevalence and seizure semiology. Relationships between epilepsy and overall survival were calculated using a Cox proportional hazards model in the statistical software “R,” controlling for all other variables – including histological diagnosis.

RESULTS

Overall, 196/227 (86.3%) patients were diagnosed with epilepsy - either at presentation (179/196, 91.3%), or during the course of their disease (17/196, 8.7%) . Mean follow-up was 7.0 years. Diffuse astrocytoma histology was associated with reduced overall 10-year survival (HR 4.68, p&lt;0.001) compared with oligodendroglioma. The majority of patients experienced focal onset seizures (n=118) as their predominant seizure type, with generalised (n=64) and unknown onset seizures (n=14) less likely. Almost two-thirds (64.8%) of those with epilepsy had experienced at least one generalised tonic-clonic seizure. During seizures, loss of awareness (n=132) and presence of motor activity (n=147) were frequently encountered. Predominantly experiencing seizures without any motor activity also appeared to confer poorer survival outcomes (HR 2.39, p&lt;0.05), even when controlled for histology.

CONCLUSION

Most WHO Grade 2 glioma patients experience focal seizures, though generalised tonic-clonic seizures are common. Motor seizure activity is a frequent feature in WHO Grade 2 glioma and may confer a survival benefit, when compared to patients that have primarily non-motor seizure activity.

Prophylaxis is the new standard of care in patients with haemophilia

Randomised controlled clinical trial evidence on prophylaxis as optimal care for patients with haemophilia was generated more than a decade ago. However, this knowledge has not translated into clinical practice in South Africa (SA) owing to many barriers to prophylaxis. These include the high treatment burden imposed by prophylaxis (frequent injections two to four times a week), the need for intravenous access to administer replacement clotting factor therapies, and the higher volume of clotting factor required compared with episodic treatment. The recently introduced non-factor therapies in haemophilia care have addressed many of these barriers. For example, emicizumab, which is currently the only globally approved non-factor therapy, can be administered subcutaneously less frequently (weekly, fortnightly or every 4 weeks) and has led to global adoption of prophylaxis as the standard of care in haemophilia by the bleeding disorders community. Haemophilia A is the most prevalent clotting factor deficiency in SA, with &gt;2 000 people diagnosed to date. However, only a few of these patients are currently on prophylaxis. In this 'In Practice' article, we review the rationale for prophylaxis, outline its goals and benefits, and provide evidence-based guidance on which haemophilia patients should be prioritised for emicizumab prophylaxis. This consensus guidance facilitates the adoption of prophylaxis as a national policy and the new standard of care in haemophilia in SA.

Sculpting in Dentistry – Requirements, Methods and Limitations in Aesthetic Dentistry: A Minireview

The skill of sculpting is an interesting and important part of restorative and esthetic dentistry. This review article will help achieve an understanding on what we know about this art, the hurdles we have faced, advances achieved, the limitations we still face and would help to gain knowledge and information on how to further advance in the art of manipulation and sculpting of dental restorations. This article aimed to review available literature on manipulation techniques, to summarize the importance of sculpting and to identify methods to face the current limitations of the art. 

PATH-47. THE 2016 WHO CLASSIFICATION AND IT'S CLINICAL IMPACT: THE LEEDS TEACHING HOSPITALS NHS TRUST EXPERIENCE

INTRODUCTION

In 2016 the WHO Classification of Tumours of the Central Nervous System was updated to include molecular testing, in addition to the previous standard histological methods; producing a final integrated diagnosis. Although molecular information can guide treatment and aid in prognostication, it adds a significant workload to pathology and genetic testing services. Delayed diagnosis can also add anxiety to patients, at an already traumatic time. AIMS: To determine if final integrated diagnoses, for patients undergoing neurosurgery for CNS tumours, is being provided in an appropriate time frame, and whether it changes clinical management.

METHODS

All patients &gt;16 years at the time of surgery with a histopathologically-confirmed CNS tumour were identified from 2016-2020. A retrospective analysis of the time taken to produce an integrated histological diagnosis took place, using the date of surgery and date of verified final integrated report being the first and last data points respectively. Data were collected by accessing electronic and paper health records, and local databases. Changes in clinical management between the initial histology result and the final integrated diagnosis were classified as no change or a major change.

RESULTS

1390 surgical procedures for CNS pathology were identified between 2016-2020, producing 361 final integrated diagnosis reports. 64 (18%) of these reports resulted in a major change in clinical management when compared to the initial histology report. The turn-around time for initial histology from date of surgery was a mean of 9 days and a mean of 34 days for the final integrated diagnosis.

CONCLUSIONS

The integrated diagnosis is essential for providing the gold standard of treatment for patients, although for the majority of patients it does not change their clinical management. Further study and discussion is required about the role of the final integrated diagnosis in the management of patients with CNS tumours.

Steroids use in non-oxygen requiring COVID-19 patients: a systematic review and meta-analysis

BACKGROUND

Corticosteroids have become the mainstay treatment in severe COVID-19. However, its role is mild disease is controversial due to lack of robust scientific evidence. This systematic review and meta-analysis were conducted to assess effect of steroids in mild COVID-19 patients.

METHODS

PubMed, EMBASE, Web of Science and medRxiv were searched from 31 December 2019 to 14 May 2021 for studies that reported effectiveness of steroids in non-oxygen requiring COVID-19 patients in terms of progressing to severe disease, mortality, duration of fever, duration of viral clearance and length of hospital stay (LOHS). Studies on inhalational steroids, case reports and reviews were excluded. Risk of bias (ROB) was assessed by the Cochrane's ROB tool and ROBANS tool. Quantitative data synthesis was done using the generic inverse variance method.

RESULTS

A total of 6411 studies were identified, 2990 articles were screened after exclusion. Seven studies which fit the criteria (involving 2214 non-oxygen requiring COVID-19 patients) were included and analysed. Overall odds of progression to severe disease among the non-oxygen requiring COVID-19 patients receiving steroids was 5.97 [95% confidence interval (CI): 1.27-27.99, I2 = 0%] and odds of death (OR: 1.35, 95% CI: 1.01-1.79; I2 = 0%) as compared to the patients not receiving steroids. Mean duration of fever (7.4 days), duration to viral clearance (18.9 days) and LOHS (20.8 days) were significantly higher in the steroid arm, as compared to that in no-steroid arm (6.7, 16.5 and 15.2 days, respectively).

CONCLUSION

Steroids in non-oxygen requiring COVID-19 patients can be more detrimental than beneficial.

PROTOCOL REGISTRATION

The study was prospectively registered in PROSPERO (CRD 42021254951).

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients

BACKGROUND

Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.

AIM

Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).

DESIGN

This was a retrospective, single-centre, observational study.

METHODS

We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.

RESULTS

Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.

CONCLUSION

COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Readmission and reoperation rates after resection of malignant primary brain tumours in England 2013-2017

Aims

Morbidity and mortality following resection of malignant primary brain tumours is high. The benefits of reoperation for recurrent tumours are uncertain and it is not known how frequently patients in England undergo further tumour resections. The aim of this study was to describe 30-day and one-year readmission rates, the clinical reasons for readmission and the rate of resections for recurrent tumours.

Method

Patient data was extracted from Hospital Episode Statistics (the hospital administrative data for NHS hospitals in England) for all supratentorial, malignant, primary brain tumour resections performed from April 2013 to March 2017. All subsequent non-elective readmissions to any NHS hospital and all readmissions for further tumour resection within 30 days and one year were analysed for the primary clinical diagnosis and primary procedure performed.

Results

A total of 6,982 patients were identified and the 30-day and one-year readmission rates were 18.6% (n=1,298) and 57.4% (n=4,007), respectively. The rates of reoperation for tumour resection were 0.5% (n=33) and 6.2% (n=432), respectively. The commonest reasons for 30-day readmission were post-operative complications (17.9% of admissions), general medical complications (17.3%) and surgical site infection (9.6%). The most frequently performed neurosurgical procedures were for treatment of surgical site infection (37.6% of procedures). The commonest reasons for readmission within one year were general medical complications (17.4%), seizures (14%), systemic infections (11.4%) and post-operative complications (11%). Almost half of all neurosurgical procedures performed within one year were reoperation for tumour resection (45.6%), while treatment of surgical site infection (17.9%) and CSF shunt insertions and revisions (9.1%) were also common.

Conclusion

This study provides a descriptive analysis of the rates of readmission, diagnosis on readmission, and the need for further neurosurgical procedures. The rate of non-elective readmissions within one year is high and these data may be useful for service planning and for counselling patients about their treatment. Additionally, these data contribute to the development of quality indicators, for benchmarking and comparing quality of care provision between neurosurgical units. Further research, with linkage to histology data and performance status, would support an analysis of the role of resection of recurrent, malignant, primary brain tumours.

NCOG-11. NEUROPSYCHOLOGICAL OUTCOMES FOLLOWING AWAKE CRANIOTOMY FOR LOW GRADE GLIOMA

BACKGROUND

Awake craniotomy is an established treatment for tumours in eloquent brain regions. It aims to achieve maximal resection without significant neurological and functional morbidity. There is an emerging evidence base about the neuropsychological outcomes following awake craniotomy for low grade gliomas (LGGs) with inconsistent findings potentially reflective of methodological confounders such as the inclusion of mixed tumour types and the use of varied neurocognitive measures and timescales for repeat testing. We describe detailed neuropsychological outcomes for a cohort of patients following awake craniotomy for LGGs.

METHOD

Data were collected from patients undergoing first-time awake resection of presumed LGGs at Leeds Teaching Hospitals, UK between 2010 and 2018. Patients were included if they consented to and completed the full battery of pre- and postoperative neuropsychological testing. Neuropsychometric testing involved assessment of general intellectual functioning, language, memory, executive functioning, perception, processing speed and mood. Data were analysed using paired-samples t-test or Wilcoxon signed-rank test with Bonferroni correction for multiple statistical comparisons.

RESULTS

Twenty-two patients undergoing awake craniotomy for presumed supratentorial LGG (13 left hemisphere, 9 right hemisphere; mean age 35 years) met the above inclusion criteria. Tumour location was heterogenous (11 insular, 9 frontal, 1 temporal, 1 parietal). Histopathology confirmed WHO Grade II diffuse astrocytoma (n=11), WHO Grade II oligodendroglioma (n=10) and WHO Grade III anaplastic oligodendroglioma (n=1). No statistical differences in neurocognitive test scores were found pre- and post-neurosurgery (mean follow-up was 61 weeks). Other outcomes including extent of resection and reliable change statistics for neurocognitive tests and measures of mood were also analysed.

CONCLUSION

No significant change in neurocognitive functioning was found in patients following recovery from awake craniotomy for LGG. Our findings suggest that awake craniotomy is a safe treatment for LGG and that neuropsychological input is an important part of the treatment pathway for patients with LGG.

Creating customized oral stents for head and neck radiotherapy using 3D scanning and printing

BACKGROUND

To evaluate and establish a digital workflow for the custom designing and 3D printing of mouth opening tongue-depressing (MOTD) stents for patients receiving radiotherapy for head and neck cancer.

METHODS

We retrospectively identified 3 patients who received radiation therapy (RT) for primary head and neck cancers with MOTD stents. We compared two methods for obtaining the digital impressions of patients' teeth. The first method involved segmentation from computed tomography (CT) scans, as previously established by our group, and the second method used 3D scanning of the patients' articulated stone models that were made during the conventional stent fabrication process. Three independent observers repeated the process to obtain digital impressions which provided data to design customized MOTD stents. For each method, we evaluated the time efficiency, dice similarity coefficient (DSC) for reproducibility, and the 3D printed stents' accuracy. For the 3D scanning method, we evaluated the registration process using manual and automatic approaches.

RESULTS

For all patients, the 3D scanning method demonstrated a significant advantage over the CT scanning method in terms of time efficiency with over 60% reduction in time consumed (p < 0.0001) and reproducibility with significantly higher DSC (p < 0.001). The printed stents were tested over the articulated dental stone models, and the trueness of fit and accuracy of dental anatomy was found to be significantly better for MOTD stents made using the 3D scanning method. The automated registration showed higher accuracy with errors < 0.001 mm compared to manual registration.

CONCLUSIONS

We developed an efficient workflow for custom designing and 3D-printing MOTD radiation stents. This workflow represents a considerable improvement over the CT-derived segmentation method. The application of this rapid and efficient digital workflow into radiation oncology practices can expand the use of these toxicity sparing devices to practices that do not currently have the support to make them.

A semiclassical theory of phase-space dynamics of interacting bosons

We study the phase-space representation of dynamics of bosons in the semiclassical regime where the occupation number of the modes is large. To this end, we employ the van Vleck-Gutzwiller propagator to obtain an approximation for the Green's function of the Wigner distribution. The semiclassical analysis incorporates interference of classical paths and reduces to the truncated Wigner approximation (TWA) when the interference is ignored. Furthermore, we identify the Ehrenfest time after which the TWA fails. As a case study, we consider a single-mode quantum nonlinear oscillator, which displays collapse and revival of observables. We analytically show that the interference of classical paths leads to revivals, an effect that is not reproduced by the TWA or a perturbative analysis.

First Results from the DEAP-3600 Dark Matter Search with Argon at SNOLAB

This Letter reports the first results of a direct dark matter search with the DEAP-3600 single-phase liquid argon (LAr) detector. The experiment was performed 2 km underground at SNOLAB (Sudbury, Canada) utilizing a large target mass, with the LAr target contained in a spherical acrylic vessel of 3600 kg capacity. The LAr is viewed by an array of PMTs, which would register scintillation light produced by rare nuclear recoil signals induced by dark matter particle scattering. An analysis of 4.44 live days (fiducial exposure of 9.87 ton day) of data taken during the initial filling phase demonstrates the best electronic recoil rejection using pulse-shape discrimination in argon, with leakage <1.2×10^{-7} (90% C.L.) between 15 and 31  keV_{ee}. No candidate signal events are observed, which results in the leading limit on weakly interacting massive particle (WIMP)-nucleon spin-independent cross section on argon, <1.2×10^{-44}  cm^{2} for a 100  GeV/c^{2} WIMP mass (90% C.L.).

Bone marrow failure and extramedullary hematopoiesis in McCune-Albright syndrome

In fibrous dysplasia/McCune-Albright syndrome (FD/MAS), bone and bone marrow are, to varying degrees, replaced by fibro-osseous tissue typically devoid of hematopoietic marrow. Despite the extensive marrow replacement in severely affected patients, bone marrow failure is not commonly associated with FD/MAS. We present a 14-year-old girl with FD/MAS, who developed pancytopenia and extramedullary hematopoiesis (EMH) with no identified cause, in the setting of iatrogenic thyrotoxicosis and hyperparathyroidism. Pancytopenia, requiring monthly blood transfusions, persisted despite multiple strategies to correct these endocrinopathies. Due to worsening painful splenomegaly, likely as a result of sequestration, splenectomy was performed. Following splenectomy, pancytopenia resolved and patient has since been transfusion-independent. We report the first detailed case of bone marrow failure and EMH in FD/MAS. The etiology of marrow failure is likely multifactorial and related to the loss of marrow reserve due to extensive polyostotic FD, exacerbated by iatrogenic thyrotoxicosis and hyperparathyroidism. Mini Abstract: A patient with fibrous dysplasia developed bone marrow failure and extramedullary hematopoiesis. The etiology likely involved loss of hematopoetic marrow space and uncontrolled endocrinopathies. Splenectomy was therapeutic.

Phase-space mixing in dynamically unstable, integrable few-mode quantum systems

Quenches in isolated quantum systems are currently a subject of intense study. Here, we consider quantum few-mode systems that are integrable in their classical mean-field limit and become dynamically unstable after a quench of a system parameter. Specifically, we study a Bose-Einstein condensate (BEC) in a double-well potential and an antiferromagnetic spinor BEC constrained to a single spatial mode. We study the time dynamics after the quench within the truncated Wigner approximation (TWA), focus on the role of motion near separatrices, and find that system relaxes to a steady state due to phase-space mixing. Using the action-angle formalism and a pendulum as an illustration, we derive general analytical expressions for the time evolution of expectation values of observables and their long-time limits. We find that the deviation of the long-time expectation value from its classical value scales as O(1/ln N), where N is the number of atoms in the condensate. Furthermore, the relaxation of an observable to its steady-state value is a damped oscillation. The damping is Gaussian in time with a time scale of O[(ln N)2]. We also give the quantitative dependence of the steady-state value and the damping time on the system parameters. Our results are confirmed with numerical TWA simulations.

Making decisions at the end of life when caring for a person with dementia: a literature review to explore the potential use of heuristics in difficult decision-making

OBJECTIVE

Decision-making, when providing care and treatment for a person with dementia at the end of life, can be complex and challenging. There is a lack of guidance available to support practitioners and family carers, and even those experienced in end of life dementia care report a lack of confidence in decision-making. It is thought that the use of heuristics (rules of thumb) may aid decision-making. The aim of this study is to identify whether heuristics are used in end of life dementia care, and if so, to identify the context in which they are being used.

DESIGN

A narrative literature review was conducted taking a systematic approach to the search strategy, using the Centre for Reviews and Dissemination guidelines. Rapid appraisal methodology was used in order to source specific and relevant literature regarding the use of heuristics in end of life dementia care.

DATA SOURCES

A search using terms related to dementia, palliative care and decision-making was conducted across 4 English language electronic databases (MEDLINE, EMBASE, PsycINFO and CINAHL) in 2015.

RESULTS

The search identified 12 papers that contained an algorithm, guideline, decision tool or set of principles that we considered compatible with heuristic decision-making. The papers addressed swallowing and feeding difficulties, the treatment of pneumonia, management of pain and agitation, rationalising medication, ending life-sustaining treatment, and ensuring a good death.

CONCLUSIONS

The use of heuristics in palliative or end of life dementia care is not described in the research literature. However, this review identified important decision-making principles, which are largely a reflection of expert opinion. These principles may have the potential to be developed into simple heuristics that could be used in practice.

Histoid Leprosy Presenting with Keloid Like Lesions

A 42 year old male presented with multiple, discrete, hyperpigmented, firm, non elastic, non tender papules and plaques on the posterior trunk of 5 months duration, resembling keloid. The patient had also a few skin colored papules on the anterior trunk and face. The sensations over the skin lesions were intact. The patient had glove and stocking type of anesthesia and bilaterally thickened, non tender peripheral nerve trunks. The slit skin smear for acid fast bacilli from the ear lobes, skin lesions and normal skin were highly positive for Mycobacterium leprae. A skin biopsy showed a well defined collection of spindle shaped histiocytes in the dermis packed with acid fast bacilli. We are presenting here a case of histoid leprosy presenting with keloid like lesions, probably the rarest presentation of histoid leprosy.

Spinal neuroschistosomiasis

We report a 20-year-old woman with a diagnosis of spinal neuroschistosomiasis that was confirmed histologically. Magnetic resonance imaging demonstrated an expanded, oedematous conus with intrinsic heterogeneous enhancement, which was initially thought to be a neoplastic lesion. This case demonstrates an alternative diagnosis to oncological lesions of the spinal cord which should be considered in patients who have recently travelled to endemic areas.