Assessment of the quality of online patient information resources for patients considering parastomal hernia treatment

AIM

The aim was to examine the quality of online patient information resources for patients considering parastomal hernia treatment.

METHODS

A Google search was conducted using lay search terms for patient facing sources on parastomal hernia. The quality of the content was assessed using the validated DISCERN instrument. Readability of written content was established using the Flesch-Kincaid score. Sources were also assessed against the essential content and process standards from the National Institute for Health and Care Excellence (NICE) framework for shared decision making support tools. Content analysis was also undertaken to explore what the sources covered and to identify any commonalities across the content.

RESULTS

Fourteen sources were identified and assessed using the identified tools. The mean Flesch-Kincaid reading ease score was 43.61, suggesting that the information was difficult to read. The overall quality of the identified sources was low based on the pooled analysis of the DISCERN and Flesch-Kincaid scores, and when assessed against the criteria in the NICE standards framework for shared decision making tools. Content analysis identified eight categories encompassing 59 codes, which highlighted considerable variation between sources.

CONCLUSIONS

The current information available to patients considering parastomal hernia treatment is of low quality and often does not contain enough information on treatment options for patients to be able to make an informed decision about the best treatment for them. There is a need for high-quality information, ideally co-produced with patients, to provide patients with the necessary information to allow them to make informed decisions about their treatment options when faced with a symptomatic parastomal hernia.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

REGISTRATION

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

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

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

9 MOG associated encephalitis presenting as idiopathic intracranial hypertension

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

Deriving a continuum score for group 3 and 4 medulloblastoma tumor samples analyzed via RNA-sequencing or DNA methylation microarray

Here, we present a protocol for deriving a continuum score for group 3 and 4 medulloblastoma tumor samples analyzed via RNA-sequencing or DNA methylation microarray. We describe steps for utilizing NMF-defined group 3/group 4 metagenes to calculate a continuum score between 0 and 1 that can be projected onto new sample data analyzed via RNA-sequencing. We then detail procedures for reverse engineering a continuum score for samples analyzed via DNA methylation microarray using a random forest classifier.

ARF suppression by MYC but not MYCN confers increased malignancy of aggressive pediatric brain tumors

Medulloblastoma, the most common malignant pediatric brain tumor, often harbors MYC amplifications. Compared to high-grade gliomas, MYC-amplified medulloblastomas often show increased photoreceptor activity and arise in the presence of a functional ARF/p53 suppressor pathway. Here, we generate an immunocompetent transgenic mouse model with regulatable MYC that develop clonal tumors that molecularly resemble photoreceptor-positive Group 3 medulloblastoma. Compared to MYCN-expressing brain tumors driven from the same promoter, pronounced ARF silencing is present in our MYC-expressing model and in human medulloblastoma. While partial Arf suppression causes increased malignancy in MYCN-expressing tumors, complete Arf depletion promotes photoreceptor-negative high-grade glioma formation. Computational models and clinical data further identify drugs targeting MYC-driven tumors with a suppressed but functional ARF pathway. We show that the HSP90 inhibitor, Onalespib, significantly targets MYC-driven but not MYCN-driven tumors in an ARF-dependent manner. The treatment increases cell death in synergy with cisplatin and demonstrates potential for targeting MYC-driven medulloblastoma.

An extradural cyst in a French Bulldog

CASE HISTORY

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

CLINICAL FINDINGS

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

DIAGNOSIS

Extradural cyst.

CLINICAL RELEVANCE

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Loss of ALK hotspot mutations in relapsed neuroblastoma

ALK is the most commonly mutated oncogene in neuroblastoma with increased mutation frequency reported at relapse. Here we report the loss of an ALK mutation in two patients at relapse and a paired neuroblastoma cell line at relapse. ALK detection methods including Sanger sequencing, targeted next-generation sequencing and a new ALK Agena MassARRAY technique were used to detect common hotspot ALK variants in tumors at diagnosis and relapse from two high-risk neuroblastoma patients. Copy number analysis including single nucleotide polymorphism array and array comparative genomic hybridization confirmed adequate tumor cell content in DNA used for mutation testing. Case 1 presented with an ALK F1174L mutation at diagnosis with a variant allele frequency (VAF) ranging between 23.5% and 28.5%, but the mutation was undetectable at relapse. Case 2 presented with an ALK R1257Q mutation at diagnosis (VAF = 39%-47.4%) which decreased to <0.01% at relapse. Segmental chromosomal aberrations were maintained between diagnosis and relapse confirming sufficient tumor cell content for mutation detection. The diagnostic SKNBE1n cell line harbors an ALK F1174S mutation, which was lost in the relapsed SKNBE2c cell line. To our knowledge, these are the first reported cases of loss of ALK mutations at relapse in neuroblastoma in the absence of ALK inhibitor therapy, reflecting intra-tumoral spatial and temporal heterogeneity. As ALK inhibitors are increasingly used in the treatment of refractory/relapsed neuroblastoma, our study highlights the importance of confirming whether an ALK mutation detected at diagnosis is still present in clones leading to relapse.

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

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

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

Funding Acknowledgements

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

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

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

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

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

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

MEDB-43. Development of a bioinformatics pipeline for identification of differential DNA methylation events associated with medulloblastoma relapse

Relapsed medulloblastoma (rMB) is treatment-resistant and fatal in ~95% of cases. The epigenetic features of rMB, and any role as drivers of disease relapse/treatment-resistance have yet to be investigated. We therefore developed a pipeline to identify differentially methylated CpGs (DM-CpGs) and regions (DMRs) in a paired-rMB cohort. Our paired-rMB cohort (n=61, relapsed tumours matched with diagnosis counterparts) with available Illumina Methylation 450K/850K microarray data was processed in R-Studio. The packages Limma and DMRcate were used to perform a paired differential methylation analysis on a filtered selection of array probes (n=335,767), identifying DM-CpGs and DMRs with a 5% FDR. DMRs were further retained if they had a maximum-Δβ of >0.2 and correlated with locus-specific gene expression in a separate paired DNA-methylation array/RNA-seq cohort from medulloblastoma diagnosis samples (n=202). Finally, we created univariable Cox models to assess the prognostic potential of DM-CpGs/DMRs in an independent survival cohort of medulloblastoma diagnosis samples (n=498). Across the paired-rMB cohort, there were few significant differential methylation events initially identified at relapse (n=258 DM-CpGs, n=32 DMRs). Upon sub-analysis by molecular group, MB_Group4 (n=18 pairs) alone yielded significant findings (n=189 DM-CpGs, n=26 DMRs). Most changes involved hypermethylation events detected at relapse. Multiple DM-CpGs identified at relapse were prognostic for both overall and event-free survival when assessed in our independent cohort (n=22 whole cohort, n=13 Group 4, BH-adjusted p<0.05). When applying the DMR filters, only the MB_Group4 DMRs passed the Δβ filter (n=18/26), with few correlating with gene expression (n=2, p<0.001), and none demonstrating prognostic significance. This pipeline facilitates exploration of the clinical relevance of epigenome-wide changes in a paired-rMB cohort. We highlight the potential prognostic significance of DM-CpGs, and future work will explore the potential functional role of candidate-genes associated with our DMRs, as novel drivers of rMB.

PATH-06. Molecular subgrouping of medulloblastoma via low-depth whole genome bisulfite sequencing

INTRODUCTION: International consensus recognises four molecular subgroups of medulloblastoma, each with distinct molecular features and clinical outcomes. Assigning molecular subgroup is typically achieved via the Illumina DNA methylation microarray. Given the rapidly-expanding WGS capacity in healthcare institutions, there is an unmet need to develop platform-independent, sequence-based subgrouping assays. Whole genome bisulfite sequencing (WGBS) enables the assessment of genome-wide methylation status at single-base resolution. To date, its routine application for subgroup assignment has been limited, due to high economic cost and sample input requirements. Currently, no optimised pipeline exists that is tailored to handle samples sequenced at low-pass (i.e., <10x depth). METHODOLOGY: Two datasets were utilised; 36 newly sequenced low-depth (10x) and 42 publicly available high-depth (30x) WGBS medulloblastoma samples (n=34), alongside cerebellar control samples (n=8), all with matched DNA methylation microarray data. We applied imputation to low-pass WGBS data, assessed inter-platform correlation and identified molecular subgroups by directly integrating WGBS sample data with pre-existing array-trained models. We developed machine learning WGBS-based classifiers and compared performance against microarray. We optimised reference-free aneuploidy detection with low-pass WGBS and assessed concordance with microarray-derived aneuploidy calls. RESULTS: We optimised a pipeline for processing, QC, and analysis of low-pass WGBS data, suitable for routine molecular subgrouping and reference-free aneuploidy assessment that achieves 96% sensitivity compared to microarray approaches. A pilot study of the suitability of FFPE was promising, and we demonstrate that WGBS data can be integrated into existing array-trained models with high assignment probabilities. Also, WGBS-derived classifier performance measures exceeded microarray-derived classifiers. CONCLUSION: We describe a platform-independent WGBS assay for molecular subgrouping of medulloblastoma. It performs equivalently to array-based methods at increasingly comparable cost ($400 vs $580) and provides a proof-of-concept for routine clinical adoption using standard WGS technology. Finally, the full methylome enabled elucidation of additional biological heterogeneity that has hitherto been inaccessible.

Exploration of the uptake of asymptomatic COVID-19 lateral flow testing in Birmingham, UK: survey and qualitative research

AIM

To examine public perspectives on lateral flow testing (LFT) for COVID-19.

DESIGN

Online survey with nested semi-structured interviews.

SETTING

Birmingham, UK.

PARTICIPANTS

220 Birmingham residents, 21 of whom took part in an interview.

RESULTS

Fifty-six per cent of respondents had taken an LFT. Reasons for not testing included adherence to other government COVID-19 guidance, having had a vaccination and not thinking LFTs were accurate. In 16% of households with children nobody, including children, was testing. In households where children were testing, their parents or other adults were often not. Those who were testing and eligible for workplace and school testing were more likely to be testing twice weekly. In other settings, respondents were more likely to be testing on a one-off or ad hoc basis. Approximately half of respondents said that they were likely to visit friends and family after a negative test result and 10% that they were unlikely to self-isolate following a positive test result. In interviews, participants who were testing described the peace of mind that testing afforded them prior to activities or interactions with family and friends, including those they considered to be vulnerable. Interviewees who were not testing described concerns about test accuracy and also cited a lack of face-to-face interaction with others precluding the need to test. Participants were often testing flexibly according to circumstances and perceived risk of COVID-19 transmission.

CONCLUSIONS

While some choose not to test, others are doing so in order to provide peace of mind to engage in personal interactions they might otherwise have avoided. This peace of mind may be a necessary pre-requisite for some to more fully re-engage in pre-pandemic activities. Despite clear concerns about test accuracy among those not testing, those who are testing held generally positive attitudes towards the continued use of LFTs.

Laser-induced ultrasound transmitters for large-volume ultrasound tomography

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

Funding Acknowledgements

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

Background/Introduction

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

Purpose

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

Methods

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

Results

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

Conclusion

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

OMIC-06. MOLECULAR SUBGROUPING OF MEDULLOBLASTOMA VIA LOW-DEPTH WHOLE GENOME BISULFITE SEQUENCING

Introduction

International consensus recognises four molecular subgroups of medulloblastoma, each with distinct molecular features and clinical outcomes. The current gold-standard for subgroup assignment is DNA methylation microarray. There is an unmet need to develop platform-independent subgrouping assays which are both non-proprietary and compatible with rapidly-expanding WGS capacity in healthcare. Whole Genome Bisulfite Sequencing (WGBS) enables the assessment of genome-wide methylation status at single-base resolution. Previously, WGBS adoption has been limited by cost and sample quality/quantity requirements. Its application for routine detection of medulloblastoma subgroups has not previously been reported.

Methodology

Two datasets were utilised; 36 newly-sequenced low-depth (10x coverage) and 34 publicly-available high-depth (30x) WGBS medulloblastomas, all with matched DNA methylation microarray data. We compared platform concordance and identified molecular subgroups. Machine-learning WGBS-based subgroup classifiers were optimised and compared between platforms. Aneuploidy and mutation detection using WGBS was optimised and compared to microarray-derived estimates where possible. Finally, comprehensive subgroup-specific DNA methylation signatures were identified.

Results

We optimised a pipeline for processing, quality control and analysis of low-depth WGBS data, suitable for routine molecular subgrouping and aneuploidy assessment. We demonstrated the suitability of fresh-frozen and FFPE DNA for WGBS, and, using downsampling, showed that subgroup calling is robust at coverages as low as 2x. We identified differentially methylated regions that, due to poor representation, could not be detected using methylation microarrays. Molecular subgroups of medulloblastoma assigned using WGBS were concordant with array-based definitions, and WGBS-derived classifier performance measures exceeded microarray-derived classifiers.

Conclusion

We describe a platform-independent assay for molecular subgrouping of medulloblastoma using WGBS. It performs equivalently to current array-based methods at comparable cost ($405 vs $596) and provides a proof-of-concept for its routine clinical adoption using standard WGS technology. Finally, the full methylome enabled elucidation of additional biological heterogeneity that has hitherto been inaccessible.

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

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

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

Background

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

Objective

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

Search strategy

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

Selection criteria

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

Data collection and analysis

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

Main results

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

Conclusions

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

Tweetable abstract

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

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

Phylogenomic Classification and Biosynthetic Potential of the Fossil Fuel-Biodesulfurizing Rhodococcus Strain IGTS8

Rhodococcus strain IGTS8 is the most extensively studied model bacterium for biodesulfurization of fossil fuels via the non–destructive sulfur–specific 4S pathway. This strain was initially assigned to Rhodococcus rhodochrous and later to Rhodococcus erythropolis thus making its taxonomic status debatable and reflecting the limited resolution of methods available at the time. In this study, phylogenomic analyses of the whole genome sequences of strain IGTS8 and closely related rhodococci showed that R. erythropolis and Rhodococcus qingshengii are very closely related species, that Rhodococcus strain IGTS8 is a R. qingshengii strain and that several strains identified as R. erythropolis should be re-classified as R. qingshengii. The genomes of strains assigned to these species contain potentially novel biosynthetic gene clusters showing that members of these taxa should be given greater importance in the search for new antimicrobials and other industrially important biomolecules. The plasmid-borne dsz operon encoding fossil fuel desulfurization enzymes was present in R. qingshengii IGTS8 and R. erythropolis XP suggesting that it might be transferable between members of these species.

Typology of modifications to peer support work for adults with mental health problems: systematic review

BACKGROUND

Peer support work roles are being implemented internationally, and increasingly in lower-resource settings. However, there is no framework to inform what types of modifications are needed to address local contextual and cultural aspects.

AIMS

To conduct a systematic review identifying a typology of modifications to peer support work for adults with mental health problems.

METHOD

We systematically reviewed the peer support literature following PRISMA guidelines for systematic reviews (registered on PROSPERO (International Prospective Register of Systematic Reviews) on 24 July 2018: CRD42018094832). All study designs were eligible and studies were selected according to the stated eligibility criteria and analysed with standardised critical appraisal tools. A narrative synthesis was conducted to identify types of, and rationales for modifications.

RESULTS

A total of 15 300 unique studies were identified, from which 39 studies were included with only one from a low-resource setting. Six types of modifications were identified: role expectations; initial training; type of contact; role extension; workplace support for peer support workers; and recruitment. Five rationales for modifications were identified: to provide best possible peer support; to best meet service user needs; to meet organisational needs, to maximise role clarity; and to address socioeconomic issues.

CONCLUSIONS

Peer support work is modified in both pre-planned and unplanned ways when implemented. Considering each identified modification as a candidate change will lead to a more systematic consideration of whether and how to modify peer support in different settings. Future evaluative research of modifiable versus non-modifiable components of peer support work is needed to understand the modifications needed for implementation among different mental health systems and cultural settings.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

A systematic review of influences on implementation of peer support work for adults with mental health problems

PURPOSE

The evidence base for peer support work in mental health is established, yet implementation remains a challenge. The aim of this systematic review was to identify influences which facilitate or are barriers to implementation of mental health peer support work.

METHODS

Data sources comprised online databases (n = 11), journal table of contents (n = 2), conference proceedings (n = 18), peer support websites (n = 2), expert consultation (n = 38) and forward and backward citation tracking. Publications were included if they reported on implementation facilitators or barriers for formal face-to-face peer support work with adults with a mental health problem, and were available in English, French, German, Hebrew, Luganda, Spanish or Swahili. Data were analysed using narrative synthesis. A six-site international survey [Germany (2 sites), India, Israel, Tanzania, Uganda] using a measure based on the strongest influences was conducted. The review protocol was pre-registered (Prospero: CRD42018094838).

RESULTS

The search strategy identified 5813 publications, of which 53 were included. Fourteen implementation influences were identified, notably organisational culture (reported by 53% of papers), training (42%) and role definition (40%). Ratings on a measure using these influences demonstrated preliminary evidence for the convergent and discriminant validity of the identified influences.

CONCLUSION

The identified influences provide a guide to implementation of peer support. For services developing a peer support service, organisational culture including role support (training, role clarity, resourcing and access to a peer network) and staff attitudes need to be considered. The identified influences provide a theory base to prepare research sites for implementing peer support worker interventions.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Objectives

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

Design

Single centre, retrospective, radiological review.

Subjects

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

Methods

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

Results

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

Conclusions

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk factors for surgical site infections in neurosurgery

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

Objectives

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

Design

Retrospective cohort study.

Subjects

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

Methods

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

Results

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

Conclusions

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