Safety and Tolerability of Combining CGRP Monoclonal Antibodies with Gepants in Patients with Migraine: A Retrospective Study

INTRODUCTION

The introduction of clacitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) has revolutionized the treatment of migraines. In clinical practice gepants might be considered as a valid option to treat acute attacks in patients with migraine who are treated with mAbs. However, the safety and tolerability of such a combination is not well addressed in the real-world setting. We designed this study to evaluate the safety and tolerability of combining CGRP mAbs with gepants in the management of migraines.

METHODS

This was a retrospective, real-world, exploratory study. The participants included within the study were adult (≥ 18 years) patients diagnosed with migraine. Screening for patients who were treated with at least one GCRP mAbs was done. Data was collected from one site, the American Center for Psychiatry and Neurology, Abu Dhabi UAE. A total of 516 patients taking CGRP mAbs were identified. Extracted data from patients' electronic medical records included patient demographics, migraine characteristics, prescribed treatments, and adverse events (AEs). The tolerability and safety of the combination therapy was evaluated on the basis of documented AEs.

RESULTS

Among the identified 516 patients, 234 were administered gepants in addition to the CRGP mAb (215, rimegepant; 19, ubrogepant). Eleven of the 234 patients switched from rimegepant to urogepant as a result of lack of efficacy; one patient switched from urogepant to zolmitriptan because of the lack of insurance coverage of the former medication. Among all the patients included in this study, three AEs were documented. These AEs were generally mild and transient and hence did not lead to discontinuation of treatment. Moreover, 42 of the 234 (17.9%) patients were switched from one class of CGRP mAbs to another at least once while continuing treatment with the assigned gepants.

CONCLUSION

The findings of this study demonstrate that combining CGRP mAbs with gepants is a safe and well-tolerated treatment approach for migraine. Future studies are warranted to further validate these findings and explore long-term outcomes.

Ferulic acid grafted into β-cyclodextrin nanosponges ameliorates Paraquat-induced human MRC-5 fibroblast injury

Paraquat (PQ) is a commercially important and effective herbicide in the world. Nevertheless, it has higher toxicity causing acute organ damage and different complications, mainly in the lungs and kidneys. Ferulic acid (FA), 4-hydroxy-3-methoxycinnamic acid imposes multiple pharmacological impacts. No protective effect of FA on PQ poisoning-caused human embryonic lung fibroblast damage has not been reported. Despite their many beneficial effects, FA is characterized by poor water solubility, low bioavailability, and phytochemical instability. To solve the problem, β-cyclodextrin nanosponge (β-CD NSs) was utilized to increase the solubility of FA so that it was grafted into β-CD NSs to establish β-CD@FA NSs. The purpose of this work was to examine for the first time the protective effect of β-CD@FA NS on MRC-5 human lung cells damages induced by PQ poisoning. MTS assay was performed to investigate the viability of MRC-5 cells at different concentrations of FA/β-CD@FA NSs when cells were co-cultured with 0.2 μg/mL PQ. The flow cytometry study was carried out to determine apoptosis. Malondialdehyde (MDA), superoxide dismutase (SOD), and catalase (CAT) levels were detected using appropriate biochemistry kits. Compared with the PQ group, the cell activity, CAT, and SOD levels were significantly increased in the FA and chiefly in β-CD@FA NSs intervention groups, whereas apoptosis and MDA levels were markedly decreased. The inflammatory factors tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), and interleukin 22 (IL-22) were detected. The results demonstrate that β-CD@FA NSs can inhibit PQ-induced cell damage by enhancing antioxidant stress capacity and regulation of inflammatory responses.

Rare fatal poisoning through dermal exposure to paraquat

Paraquat skin contact occurs less frequently and is rarely fatal. This article reports a case of a 45-year-old man who presented with dysphagia, respiratory distress and grade two, and third skin burns focusing on the upper body after accidental exposure to paraquat. He was admitted to the hospital 6 days after the first contact. The urine sodium dithionate test was strongly positive. The O₂ saturation at admission was 52%, which reached 91% with a bag valve mask. Rising blood liver enzymes, urea, creatinine, and respiratory acidosis in the venous blood gas analysis were observed in the lab data. In the course of hospitalization, the patient was intubated due to oxygen level dropping. Evidence of acute respiratory distress syndrome and decreased level of consciousness was also observed. However, despite treatment with corticosteroids, antioxidants, and hemodialysis, he died on the fourth day of hospitalization. It is concluded that dermal exposure with paraquat could be life-threatening if the patient presented late with organ involvement.

An overview of the literature on emerging pollutants: Chlorinated derivatives of Bisphenol A (ClxBPA)

CONTEXT

Bisphenol A (BPA) is a ubiquitous contaminant with endocrine-disrupting effects in mammals. During chlorination treatment of drinking water, aqueous BPA can react with chlorine to form chlorinated derivatives of BPA (mono, di, tri and tetra-chlorinated derivatives) or Cl_xBPA.

OBJECTIVE

The aim of this study is to summarize and present the state of knowledge on human toxicological risk assessment of Cl_xBPA.

MATERIALS AND METHODS

A search on Cl_xBPA in the PubMed database was performed based on studies published between 2002 and 2021. Forty-nine studies on chlorinated derivatives of BPA were found. Available information on their sources and levels of exposure, their effects, their possible mechanisms of action and their toxicokinetics data was extracted and presented.

RESULTS

Cl_xBPA have been essentially detected in environmental aqueous media. There is evidence in toxicological and epidemiological studies that Cl_xBPA also have endocrine-disrupting capabilities. These emerging pollutants have been found in human urine, serum, breast milk, adipose and placental tissue and can constitute a risk to human health. However, in vitro and in vivo toxicokinetic data on Cl_xBPA are scarce and do not allow characterization of the disposition kinetics of these compounds.

CONCLUSION

More research to assess their health risks, specifically in vulnerable populations, is needed. Some water chlorination processes are particularly hazardous, and it is important to evaluate their chlorination by-products from a public health perspective.

[Professional profiles and representations of staff members in Burundi health centers: Socio-professional groups with compartmentalizes knowledge]

BACKGROUND

The professional identities, profiles and representations of Burundian health workers remain insufficiently explored. Our twofold objective is to identify the different socio-professional profiles of first-line caregivers and to explore their respective representations of health workers and work.

METHODS

The first study describes the overall population of the 1047 staff members employed in 2014-2015 in 62 health centers. The second is a cross-sectional survey conducted in April 2014. Using IRAMUTEQ© software, we conducted textology analysis of the structure and contents of 911 respondents' representations via 3 free associations with regard to 6 questions on the "good worker" and the "what renders one capable of doing good work".

RESULTS

At the normative level, among all categories of staff, a relational role is a foundation of professional identity, while technical or administrative functions remain marginal. At the positional level, responses differed according to initial qualification level but not as a function of their role with patients or their professional experience. Three socio-professional categories emerged. The most qualified category (one-quarter of the population) consists primarily of male caregivers, with a high turnover rate (4 years) associated with prospects for further training and career development. These persons present the most professionalized representations of the worker and work. The second quarter has an average level of qualification and turnover (10 years), and is mainly composed of female caregivers with limited professional perspectives. This group's representations are less technical and more patient-centered. Finally, the remaining half consists of relatively low-skilled staff members in charge of technical and logistical support, who are likely to spend their entire career in the same center (>20 years). Largely disregarded by the health care system and its funders, they have few opportunities for training or advancement and despite their long experience, maintain profane representations of workers and work.

CONCLUSION

Our results shed light on the predicament of unskilled staff members whose expectations are rarely taken into consideration, even though they represent a significant proportion of the workforce, perform tasks essential to quality of care, and serve as bearers of the memory of their hospital center. These results also highlight the compartmentalization of practices and knowledge between categories of workers and underscore the failure of continuous training strategies targeting the unskilled.

Comparing laparoscopy and laparotomy procedures in the radical hysterectomy surgery for endometrial cancer: a basic review

Gynecological cancers especially endometrial cancer have put a huge burden on health care systems in different societies. In this regard, different studies have evaluated screening, diagnosis and treatments of endometrial cancer. Different survival rates, prognosis and recurrence rates have been reported by variable treatment methods. Laparotomy and laparoscopic radical hysterectomy (RH and LRH) are nowadays two most common surgical methods for endometrial cancer. In this systematic review, we investigated all article comparing two treatment techniques regarding RH and LRH in women with endometrial cancer who were classified as International Federation of Gynecology and Obstetrics (FIGO) stage I to III. Data regarding to blood loss and transfusion rate, operative time, duration of hospital stay, complications as intraoperative and postoperative, mean nodules counts, recurrent rate, adjuvant therapy were collected and analyzed. After reviewing five cohort studies, we indicated that laparoscopic procedures were better than laparotomy for managing endometrial cancer because the duration of hospitalization, blood loss and intraoperative and postoperative complications in laparoscopy procedure were lower than laparotomy procedures.

Platelet-rich plasma or extracorporeal shockwave therapy for plantar fasciitis

BACKGROUND

Plantar fasciitis is a common cause of plantar pain which is prevalent among adults. Conservative tractions, invasive injections, shock therapies and also surgical procedures are known as beneficial methods in non-responsive cases. Here we evaluated and compared the injection of platelet rich plasma (PRP) and usage of extracorporeal shockwave therapy (ESWT) in pain reduction in patients with chronic plantar fasciitis.

METHODS

This is a randomized clinical trial that was performed in 2017-2020 on patients with chronic plantar fasciitis who did not respond to conservative therapies. A total number of 110 patients with plantar fasciitis were entered based on inclusion and exclusion criteria. Patients were then divided into two groups. The pain of patients was measured using visual analogue scale (VAS) before interventions. The first group underwent PRP injections while the second group underwent ESWT using Shock Master 500. Patients were visited 2, 4, 8, 12, 16, and 24 weeks after interventions and the pain scores were noted using VAS.

RESULTS

Data of 104 patients were analyzed. Initial VAS scores of patients were also analyzed. These data indicated no significant differences between the pains of patients before interventions (P = 0.413). Pain evaluations in 2, 4, 8, 12, 16, and 24 weeks after interventions with controlling age and sex showed significantly reduced VAS scores in both groups after interventions (P = 0.002). We should also note that pain in the PRP group reduced more than ESWT group and this difference was also significant (P = 0.001).

CONCLUSION

Here we showed that PRP injections and ESWT are both beneficial in pain amelioration in patients with chronic plantar fasciitis. We also indicated that PRP injections were associated with better pain reduction results compared to ESWT.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Encephalopathy and seizure activity in a COVID-19 well controlled HIV patient

A 41-year-old male with a history of well controlled HIV presented with confusion and was found to have COVID-19. Lumbar puncture was negative. He had worsening encephalopathy with tonic-clonic seizure requiring intubation. He was treated with hydroxychloroquine and azithromycin with improvement in mental status back to baseline after 6 days.

Electron-phonon dynamics in 2D carbon based-hybrids XC (X = Si, Ge, Sn)

The effect of the presence of electron-phonon (e-ph) coupling in the SiC, GeC and SnC hybrids is studied in the framework of the ab initio perturbation theory. The electronic bang gap thermal dependence reveals a normal monotonic decrease in the SiC and GeC semiconductors, whereas SnC exhibits an anomalous behavior. The electron line widths were evaluated and the contributions of acoustic and optical phonon modes to the imaginary part of the self-energy were determined. It has been found that the e-ph scattering rates are globally controlled by the out-of-plane acoustic transverse mode ZA in SiC while both ZA and ZO are overriding in GeC. In SnC, the out-of-plane transverse optical mode ZO is the most dominant. The relaxation lifetime of the photo-excited electrons shows that the thermalization of the hot carrier occurs at 90 fs, 100 fs and 120 fs in SiC, GeC and SnC, respectively. The present study properly describes the subpicosecond time scale after sunlight illumination using an approach that requires no empirical data. The results make the investigated structures suitable for providing low cost and high-performance optical communication and monitoring applications using 2D materials.

Time series analysis of ambient air-temperature during the period 1970-2016 over Sydney, Australia

Providing evidence of potential changes in the climate has become increasingly important as it is the first step towards adopting mitigation and adaptation measures and planning for urban resilience. In this study a statistical analysis of the ambient air temperature time series over Sydney, Australia during 1970-2016 has been carried out with the aim to investigate potential changes towards higher temperatures. The dataset has been statistically analyzed using different techniques, concluding that the investigation should be performed on a monthly basis. A persistence analysis was conducted using different statistical approaches to investigate the dependence between consecutive monthly and daily ambient air temperature values. A trend analysis of the ambient air temperature and degree days time series has been conducted using linear regression to estimate the linear trend (slope) and its statistical significance (using a Student-t-test) and the Kendall-Mann test to identify the time at which the tendency starts to occur as well as the time after which it becomes statistically significant.

Adrenal gland hemangioma: A rare case of the incidentaloma: Case report

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Adrenal gland hemangioma is an extremely rare benign vascular tumor.

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It is frequently discovered as incidental radiological findings in abdominal imaging performed for various reasons.

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The preoperative diagnosis is very difficult, generally CT and MR imaging are useful for the diagnosis of hemangioma.

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In front of an adrenal mass discovered incidentally there are several factors to consider: the tumor size, its secreting character or not, imaging data suggestive of malignancy and complications.

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These factors help in determining which incidental adrenal masses should be excised.

Bakground

Adrenal glands hemangiomas are rare, benign and non-functional tumors. They are often discovered as incidentalomas either during imaging or autopsies. Nearly 70 cases were reported in the literature.

Case report

We report a case of a non-functional adrenal hemangioma (AH) that was incidentally found on abdominal ultra sonography (US) during the routine control of diabetes of a 58 year-old man. Imaging with US and Computed tomography (CT) showed an heterogeneous and partially calcified 6 cm tumor of the right adrenal gland. The mass was surgically excised and the histological examination concluded to an adrenal haemangioma.

Conclusion

Although rare, AH should be included in the differential diagnosis of the adrenal neoplasmas.

Development of the New Zealand White Rabbit Eye: I. Pre- and Postnatal Development of Eye Tunics

The New Zealand white (NZW) rabbit has been and is right now regularly utilized in ophthalmic surgery evaluation. Inside NZW rabbit eye, the visibility of ocular structures throughout surgical procedure is fantastic. Younger rabbits are used in different ages for the evaluation of ophthalmic surgery. Complete studies of ocular development in the NZW rabbits have not been reported previously. The aim of the present investigation was to describe the major landmarks and the time course of the pre- and post-natal development of the complete eye tunics of the NZW rabbit to give a superb model as well as a fruitful area for further ophthalmological investigations. Serial histological sections of NZW rabbit prenatal (E13-E28) and post-natal (P1-P14) stages were examined, respectively. The eye of the NZW rabbit developed in a similar manner to that of the human and domestic animals eyes; the principal differences were at the time of occurrence of certain developmental events, absence of pigmentation which represent an exploited benefit for ophthalmic surgery, remarkable Bowman's membrane at E25, poor developed ciliary stroma and juvenile retinal layer until P9. In human, the basic morphogenetic processes of the development of eye tunics are completed towards the end of the first half of gestation period. However, the latter represents the beginning stage of the development of eye tunics in the rabbit. Thus, allowing various extensive ophthalmic researches to be performed.

Abstract P5-16-16: Role of tumor microenvironment, as assessed by breast MRI background parenchymal enhancement (BPE), in modulating response to neoadjuvant chemotherapy in young women with localized breast cancer

Background:

Neoadjuvant chemotherapy (NACT) is generally established as a therapeutic option for selected high-risk patients with localized breast cancer, including triple negative breast cancer (TNBC). On a patient level, achievement of pathologic complete response (pCR) at the time of surgery is associated with improved long-term outcomes and is considered to be a surrogate marker. Response to NACT is a complex phenomenon dependent on both host and tumor characteristics. While tumor characteristics, such as receptors and tumor grade, have been well studied as predictors of pCR, host characteristics to predict pCR have been less well studied. Background parenchymal enhancement (BPE) is an imaging characteristic that reflects the normal enhancement of the fibroglandular tissue on breast MRI, and could potentially modulate response to NACT by influencing the tumor microenvironment and vasculature. The aim of this study was to explore the ability of baseline BPE to predict pCR in a cohort of young women with localized breast cancer.

Methods:

A retrospective chart review was conducted of women ages 40 and under with stage II-III breast cancer treated with NACT at our institution from 2004 – 2014. Demographic, clinical, and pathological variables were extracted from the medical records. The primary outcome was achievement of pCR, defined as ypT0/is ypN0, after NACT. BPE pattern in the contralateral breast was obtained from pre-treatment breast MRI reports if available and otherwise was retrospectively determined by a breast radiologist blinded to patient outcomes. BPE was dichotomized as low (minimum and mild) vs. high (moderate and marked). Logistic regression was used for statistical analysis.

Results:

A total of 69 patients ages 40 and under received NACT for localized breast cancer during the study period and had available pre-treatment breast MRI images. Median age at diagnosis was 36 (range 27-40). The majority of patients had grade 3 (65.2%), ER+/HER2- (60.9%) tumors while 24.6% had TNBC. Among pre-treatment breast MRIs, 42 (60.9%) patients had minimum or mild BPE and 27 (39.1%) patients had moderate or marked BPE. The overall pCR rate was 39%. After controlling for tumor grade, ER status, HER2 status, clinical stage, and type of NACT, high baseline BPE was associated with a trend towards higher odds of achieving pCR compared to low BPE (OR = 1.49, 95% CI 0.47–4.71), though statistical significance was not reached (p = 0.50). When stratified by ER status, the relationship was stronger among the ER+ subset (OR 1.8, p = 0.49) compared to the ER- subset (OR 1.3, p = 0.78).

Conclusions:

A statistically significant association between high baseline BPE and achievement of pCR was not found in this limited sample size, but a trend towards higher pCR rates, particularly with ER+ tumors, was seen. While tumor factors have traditionally been used to predict pCR, BPE is a readily available MRI imaging characteristic that reflects the tumor microenvironment and may be useful in building a model that incorporates tumor factors along with host factors to develop personalized NACT regimens for young women with breast cancer.

Citation Format: Spring L, Rutledge G, Yala A, Haddad S, Specht M, Moy B, Barzilay R, Lehman C, Bardia A. Role of tumor microenvironment, as assessed by breast MRI background parenchymal enhancement (BPE), in modulating response to neoadjuvant chemotherapy in young women with localized breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-16-16.

COMT Val(158) Met genotype is associated with reward learning: a replication study and meta-analysis

Identifying mechanisms through which individual differences in reward learning emerge offers an opportunity to understand both a fundamental form of adaptive responding as well as etiological pathways through which aberrant reward learning may contribute to maladaptive behaviors and psychopathology. One candidate mechanism through which individual differences in reward learning may emerge is variability in dopaminergic reinforcement signaling. A common functional polymorphism within the catechol-O-methyl transferase gene (COMT; rs4680, Val(158) Met) has been linked to reward learning, where homozygosity for the Met allele (linked to heightened prefrontal dopamine function and decreased dopamine synthesis in the midbrain) has been associated with relatively increased reward learning. Here, we used a probabilistic reward learning task to asses response bias, a behavioral form of reward learning, across three separate samples that were combined for analyses (age: 21.80 ± 3.95; n = 392; 268 female; European-American: n = 208). We replicate prior reports that COMT rs4680 Met allele homozygosity is associated with increased reward learning in European-American participants (β = 0.20, t = 2.75, P < 0.01; ΔR(2) = 0.04). Moreover, a meta-analysis of 4 studies, including the current one, confirmed the association between COMT rs4680 genotype and reward learning (95% CI -0.11 to -0.03; z = 3.2; P < 0.01). These results suggest that variability in dopamine signaling associated with COMT rs4680 influences individual differences in reward which may potentially contribute to psychopathology characterized by reward dysfunction.

Can local infiltration analgesia increase satisfaction in postoperative short-term pain control in total knee arthroplasty?

BACKGROUND

One of the major challenges to total knee arthroplasty (TKA) is optimal pain control. Effective analgesia is capital in fast-track surgery programs to allow patient's early functional outcomes.

OBJECTIVES

Compare length of stay (LOS) short-term pain control, and patients' satisfaction at 1 month between local infiltration analgesia (LIA) combined with femoral nerve block (FNB) and FNB only in patients undergoing TKA.

PATIENTS AND METHODS

Two hundred and fifty-four patients were included in a randomized prospective study and distributed in two groups. The first group received an intraoperative LIA (150 mL mixture of ropivacaine 2.0 mg/mL + ketorolac 30 mg + adrenaline 10 μg/mL) combined to an FNB. The control group had only an FNB. Demographical data and visual analog scale (VAS) score were obtained preoperatively, at 36 h after surgery and at the 15-day follow-up. Patients' satisfaction at 1 month was also evaluated. Statistical analysis data was performed.

RESULTS

No differences in demographical data and preoperative VAS score were observed between both groups. LIA group had a lower VAS score at 36 h after surgery (1.34 ± 1.31 vs. 3.68 ± 1.932 in the control group, p = 0.00), but these differences were not maintained at the 15-day follow-up (4.51 ± 1.889 vs. 4.11 ± 1.940 in the control group, p > 0.05). LOS and patients' satisfaction were comparable between groups. Patients with LIA had no additional complications.

CONCLUSIONS

LIA is a safe adjuvant to FNB to reduce perioperative pain during the first 36 h after TKA. Its effects wean with time, but do cover the first crucial hours of rehabilitation in a fast-track program. LIA seems don't modify postoperative course nor patient's satisfaction at short-term follow-up. The final impact of LIA on surgical outcome is still to be determined.

Should lower limb fractures be treated surgically in patients with chronic spinal injuries? Experience in a reference centre

OBJECTIVE

To report the outcomes of surgical treatment of lower limb fractures in patients with chronic spinal cord injuries.

MATERIAL AND METHOD

A total of 37 lower limb fractures were treated from 2003 to 2010, of which 25 fractures were treated surgically and 12 orthopaedically.

RESULTS

Patients of the surgical group had better clinical results, range of motion, bone consolidation, and less pressure ulcers and radiological misalignment. No differences were detected between groups in terms of pain, hospital stay, and medical complications.

DISCUSSION

There is no currently consensus regarding the management of lower limb fractures in patients with chronic spinal cord injuries, but the trend has been conservative treatment due to the high rate of complications in surgical treatment.

CONCLUSIONS

Chronic spinal cord injuries patients with lower limb fractures who are treated surgically achieved a more reliable consolidation, practically a free range of motion, low rate of cutaneous complications, and pain associated with the fracture. This allows a quick return to the previous standard of living, and should be considered as an alternative to orthopaedic treatment in these patients.

Learning from defects using a comprehensive management system for incident reports in critical care

Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICU-related incident reports increased from 20 to 36 incidents per 1000 patient days (P=0.01). After implementing the CMS, there was an increase in reporting 'no harm' from 14.2 to 28.1 incidents per 1000 patient days (P<0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1-Q3: 26-212] versus 13 days [Q1-Q3: 6-25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety.

Congenital neuroblastoma presenting with paraplegia following spinal puncture in a neonate. Case report and review of the literature

Neuroblastoma is the most common intraspinal solid tumor of childhood. Neurological deterioration due to an intratumoral hemorrhage following a spinal puncture is extremely rare. We report on the case of a 23-day-old neonate who was admitted to our institution for the onset of a paraplegia following a diagnostic lumbar puncture. The MRI showed an epidural tumor with massive intratumoral hemorrhage. Operatively and with histologic confirmation, the mass was determined to be a neuroblastoma. Following surgery, neurological function improved.