Invasive pneumococcal disease serotype 23B1 causing multifocal septic arthritis, myositis and retroperitoneal abscess

We describe a case of a previously healthy unvaccinated man in his 70s who developed penicillin-susceptible bacteraemic invasive pneumococcal disease due to non-vaccine serotype 23B with the unusual manifestations of multifocal myositis, intramuscular abscesses, polyarticular septic arthritis and synovitis. Blood cultures drawn prior to antibiotic therapy and culture of iliopsoas collection were helpful in making the diagnosis. At follow-up, he had persistent hip pain attributed to avascular necrosis of the head of femur, a possible late complication of his pyomyositis.

COVID-19 infection among patients with cancer in Australia from 2020 to 2022: a national multicentre cohort study

Background

The global COVID-19 pandemic disproportionately affected certain populations and its management differed between countries. This national study describes characteristics and outcomes of COVID-19 in patients with cancer in Australia.

Methods

We performed a multicentre cohort study of patients with cancer and COVID-19 from March 2020 to April 2022. Data were analysed to determine varying characteristics between cancer types and changes in outcomes over time. Multivariable analysis was performed to determine risk factors associated with oxygen requirement.

Findings

620 patients with cancer from 15 hospitals had confirmed COVID-19. There were 314/620 (50.6%) male patients, median age 63.5 years (IQR 50-72) and majority had solid organ tumours (392/620, 63.2%). The rate of COVID-19 vaccination (≥1 dose) was 73.4% (455/620). Time from symptom onset to diagnosis was median 1 day (IQR 0-3), patients with haematological malignancy had a longer duration of test positivity. Over the study period, there was a significant decline in COVID-19 severity. Risk factors associated with oxygen requirement included male sex (OR 2.34, 95% CI 1.30-4.20, p = 0.004), age (OR 1.03, 95% CI 1.01-1.06, p = 0.005); not receiving early outpatient therapy (OR 2.78, 95% CI 1.41-5.50, p = 0.003). Diagnosis during the omicron wave was associated with lower odds of oxygen requirement (OR 0.24, 95% CI 0.13-0.43, p < 0.0001).

Interpretation

Outcomes from COVID-19 in patients with cancer in Australia over the pandemic have improved, potentially related to changing viral strain and outpatient therapies.

Funding

This study was supported by research funding from MSD.

Chronic aphasias after left-hemisphere resective surgery

Surgical resection of brain tumours is associated with an increased risk of aphasia. However, relatively little is known about outcomes in the chronic phase (i.e., >6 months). Using voxel-based lesion symptom mapping (VLSM) in 46 patients, we investigated whether chronic language impairments are related to the location of surgical resection, residual tumour characteristics (e.g., peri-resection treatment effects, progressive infiltration, oedema) or both. Approximately 72% of patients scored below the cut-off for aphasia. Action naming and spoken sentence comprehension deficits were associated with lesions in the left anterior temporal and inferior parietal lobes, respectively. Voxel-wise analyses revealed significant associations between ventral language pathways and action naming deficits. Reading impairments were also associated with increasing disconnection of cerebellar pathways. The results indicate chronic post-surgical aphasias reflect a combination of resected tissue and tumour infiltration of language-related white matter tracts, implicating progressive disconnection as the critical mechanism of impairment.

1271 A NOVEL PRESSURE INJURY CARE BUNDLE FOR DEPENDENT PATIENTS WITH PRESSURE INJURIES IN BERMUDA

Introduction

Pressure injury (PI) management is a challenge in dependent patients in acute care wards (ACW) despite standard care (regular pressure relief measures, incontinence management, debridement, optimisation of hydration and nutrition).

Method

A Pressure Injury Care Bundle (PICB), introduced by the Department of Geriatrics, enhanced standard care by diligent and regular interdisciplinary team monitoring of patients with PIs following transfer to Long Term Care (LTC) wards and thus may improve outcomes. The PICB was delivered by multiple PI Nurse Champions with education of all nurse assistants and medical staff into PI aetiology/management. Progress was monitored with weekly PI measurements/photography and Nurse Champion-lead team review of all PIs. Data are presented as mean+/-1SD. After 96+/-103 days in the ACW, the PICB was applied to 30 consecutive patients aged 80+/-14 years, (19(60 %) were female). All had stage 2-4 PIs (present in 25(83%) on admission to ACW). On transfer to LTC wards, all patients had severe physical dependency with a mean Charlson Comorbidity Index of 7+/-3, 27(90%) had palliative needs and 24(80%) were bedfast. Cognitive impairment was present in 22(68%) patients with 12(37%) dying due to advanced dementia. Patients were followed for 116+/-274 days.

Results

PI improvement by &gt;2 stages occurred in 11(36%) patients after a mean of 103 days. Ulcers closed fully after 154+/-48 days in a further 15(50 %) patients. However, new ulcers emerged or preterminal (&lt;21 days prior to death) deterioration occurred in 5(17%) patients, related to severe contractures, preterminal poor nutrition and sarcopenia with 16(54%) patients dying.

Conclusion

These results suggest that an intensive multimodal intervention involving best practice enhanced by PI Nurse Champions and delivered by educated staff with regular PI team progress reviews results in significant improvement/healing of PIs in severely dependent patients with palliative needs. Expansion of the PICB to other wards with prospective evaluation has been planned.

Orbito-cranial schwannoma-a multicentre experience

OBJECTIVES

To describe the features, management approaches, and outcomes of orbito-cranial schwannomas.

METHODS

Retrospective review of ten patients with orbito-cranial schwannomas managed in six orbital services over 22 years. Data collected included demographics, presenting features, neuroimaging characteristics, histology, management approach, complications, and outcomes.

RESULTS

Mean age of the patients was 41.4 ± 19.9 years, and 6 (60%) were females. The majority presented with proptosis (90%), limited extraocular motility (80%), eyelid swelling (60%), and optic neuropathy (60%). Most lesions (80%) involved the entire anterior-posterior span of the orbit, with both intra- and extraconal involvement. All tumours involved the orbital apex, the superior orbital fissure, and extended at least to the cavernous sinus. Surgical resection was performed for all. Seven (70%) of the tumours were completely or subtotally resected combining an intracapsular approach by an orbital-neurosurgical collaboration, with no recurrence on postoperative follow-up (6-186 months). Three underwent tumour debulking. Of these, two remained stable on follow-up (6-34 months) and one showed progression of the residual tumour over 9 years (cellular schwannoma on histology) necessitating stereotactic radiotherapy (SRT) for local control. Adjuncts to the orbito-cranial resection included perioperative frozen section (n = 5), endoscopic transorbital approach (n = 2), and image-guided navigation (n = 1). Post-surgical adjuvant SRT was used in three subjects.

CONCLUSIONS

These results highlight the possibility of successful surgical control in complex orbito-cranial schwannomas. A combined neurosurgical/orbital approach with consideration of an intracapsular resection is recommended. Recurrence may not occur with subtotal excision and observation may be reasonable. Adjunctive SRT for progression or residual tumour can be considered.

199 A NOVEL PRESSURE INJURY CARE BUNDLE FOR DEPENDENT PATIENTS WITH PRESSURE INJURIES IN BERMUDA

Background

Pressure Injury (PI) management is challenging for dependent patients in Acute Care Wards (ACW) despite standard care (regular pressure relief measures, incontinence management, debridement, optimisation of hydration and nutrition). A Pressure Injury Care Bundle (PICB), introduced by the Department of Geriatrics, enhanced standard care by diligent and regular interdisciplinary team monitoring of patients with PIs following transfer to Long-Term Care (LTC) wards and thus may improve outcomes.

Methods

The PICB was delivered by multiple PI Nurse Champions with education of all nurse assistants and medical staff into PI aetiology/management. Progress was monitored with weekly PI measurements/photography and Nurse Champion-lead team review of all PIs. Data are presented as mean+/-1SD.

After 96+/-103 days in the ACW, the PICB was applied to 30 consecutive patients aged 80+/-14 years, (60 % female; 19/30). All had stage 2-4 PIs (present in 83% on admission to ACW). On transfer to LTC wards, all had severe physical dependency with mean Charlson Comorbidity Index of 7+/-3, 27(90%) had palliative needs and 24(80%) were bedfast. Cognitive impairment was present in 22(68%) patients with 12(37%) dying due to advanced dementia. Patients were followed for 116+/-274 days.

Results

PI improvement by &gt;2 stages occurred in 11(36%) patients after a mean of 103 days. Ulcers closed fully after 154+/-48 days in a further 15(50 %) patients. However, new ulcers emerged or preterminal (&lt;21 days prior to death) deterioration occurred in 5(17%) patients, related to severe contractures, preterminal poor nutrition and sarcopenia with 16(54%) patients dying.

Conclusion

These results suggest an intensive multimodal intervention involving best practice enhanced by PI Nurse Champions and delivered by educated staff with regular PI team progress reviews results in significant improvement/healing of PIs in severely dependent patients with palliative needs. Expansion of the PICB to other wards with prospective evaluation is planned.

A comparison of macular ganglion cell and retinal nerve fibre layer optical coherence tomographic parameters as predictors of visual outcomes of surgery for pituitary tumours

PURPOSE

The prognostic value of optical coherence tomography (OCT) of the macular ganglion cell layer (mGGL) versus peripapillary retinal nerve fibre layers (pRNFL) following chiasmal decompression is unclear. This study is the largest comparison of the two parameters to date and aims to clarify how their performance as covariates compare in predictive models of long-term visual outcomes following pituitary or parasellar tumour surgical resection.

METHODS

This was a prospective, two-year, longitudinal cohort study in a single centre tertiary hospital setting. Participants with MRI evidence of pituitary or parasellar tumour compression of the optic chiasm who underwent surgical decompression, were enrolled. Associations between pre-operative OCT parameters and long-term visual outcomes were assessed using multivariable generalised linear mixed models and an age matched normative database.

RESULTS

Final analysis included 216 eyes of 108 participants with a mean age (standard deviation) of 51.6 (17.04) years, of whom 58 (49%) were female. The superior inner mGCL was the best predictor of long-term visual field recovery, with an area under the curve of 0.90, a sensitivity of 80%, specificity of 88%, positive predictive value of 86%, and negative predictive value of 83%.

CONCLUSION

mGCL performed better in predicting long-term visual field recovery post-pituitary or parasellar surgical resection. The superior inner mGCL was the best specific measure which may provide clinical utility in pre-operative counselling. In this study we clarify previously variable comparisons of mGCL and pRNFL parameters in post-operative predictive modelling.

Consensus core clinical data elements for meningiomas

BACKGROUND

With increasing molecular analyses of meningiomas, there is a need to harmonize language used to capture clinical data across centers to ensure that molecular alterations are appropriately linked to clinical variables of interest. Here the International Consortium on Meningiomas presents a set of core and supplemental meningioma-specific Common Data Elements (CDEs) to facilitate comparative and pooled analyses.

METHODS

The generation of CDEs followed the four-phase process similar to other National Institute of Neurological Disorders and Stroke (NINDS) CDE projects: discovery, internal validation, external validation, and distribution.

RESULTS

The CDEs were organized into patient- and tumor-level modules. In total, 17 core CDEs (10 patient-level and 7-tumour-level) as well as 14 supplemental CDEs (7 patient-level and 7 tumour-level) were defined and described. These CDEs are now made publicly available for dissemination and adoption.

CONCLUSIONS

CDEs provide a framework for discussion in the neuro-oncology community that will facilitate data sharing for collaborative research projects and aid in developing a common language for comparative and pooled analyses. The meningioma-specific CDEs presented here are intended to be dynamic parameters that evolve with time and The Consortium welcomes international feedback for further refinement and implementation of these CDEs.

Melanoma brain metastases that progress on BRAF-MEK inhibitors demonstrate resistance to ipilimumab-nivolumab that is associated with the Innate PD-1 Resistance Signature (IPRES)

Background

Melanoma brain metastases (MBMs) are a challenging clinical problem with high morbidity and mortality. Although first-line dabrafenib–trametinib and ipilimumab–nivolumab have similar intracranial response rates (50%–55%), central nervous system (CNS) resistance to BRAF-MEK inhibitors (BRAF-MEKi) usually occurs around 6 months, and durable responses are only seen with combination immunotherapy. We sought to investigate the utility of ipilimumab–nivolumab after MBM progression on BRAF-MEKi and identify mechanisms of resistance.

Methods

Patients who received first-line ipilimumab–nivolumab for MBMs or second/third line ipilimumab–nivolumab for intracranial metastases with BRAF^V600 mutations with prior progression on BRAF-MEKi and MRI brain staging from March 1, 2015 to June 30, 2018 were included. Modified intracranial RECIST was used to assess response. Formalin-fixed paraffin-embedded samples of BRAF^V600 mutant MBMs that were naïve to systemic treatment (n=18) or excised after progression on BRAF-MEKi (n=14) underwent whole transcriptome sequencing. Comparative analyses of MBMs naïve to systemic treatment versus BRAF-MEKi progression were performed.

Results

Twenty-five and 30 patients who received first and second/third line ipilimumab–nivolumab, were included respectively. Median sum of MBM diameters was 13 and 20.5 mm for the first and second/third line ipilimumab–nivolumab groups, respectively. Intracranial response rate was 75.0% (12/16), and median progression-free survival (PFS) was 41.6 months for first-line ipilimumab–nivolumab. Efficacy of second/third line ipilimumab-nivolumab after BRAF-MEKi progression was poor with an intracranial response rate of 4.8% (1/21) and median PFS of 1.3 months. Given the poor activity of ipilimumab–nivolumab after BRAF-MEKi MBM progression, we performed whole transcriptome sequencing to identify mechanisms of drug resistance. We identified a set of 178 differentially expressed genes (DEGs) between naïve and MBMs with progression on BRAF-MEKi treatment (p value <0.05, false discovery rate (FDR) <0.1). No distinct pathways were identified from gene set enrichment analyses using Kyoto Encyclopedia of Genes and Genomes, Gene Ontogeny or Hallmark libraries; however, enrichment of DEG from the Innate Anti-PD1 Resistance Signature (IPRES) was identified (p value=0.007, FDR=0.03).

Conclusions

Second-line ipilimumab–nivolumab for MBMs after BRAF-MEKi progression has poor activity. MBMs that are resistant to BRAF-MEKi that also conferred resistance to second-line ipilimumab–nivolumab showed enrichment of the IPRES gene signature.

A normative database of A-scan data using the Heidelberg Spectralis Spectral Domain Optical Coherence Tomography machine

Purpose

To develop the first normative database of macular and circumpapillary scans with reference values at the level of the A-scan using the Heidelberg Spectralis Optical Coherence Tomography (OCT) machine.

Methods

This study is a retrospective cross sectional analysis of macular and circumpapillary OCT scans of healthy individuals. All participants had a full ophthalmic examination, including best corrected visual acuity, intraocular pressure, biomicroscopy, posterior segment examination and OCT scan. The volume and thickness of each of the nine Early Treatment Diabetic Retinopathy zones at the macula were analysed for the total retinal thickness, retinal nerve fibre layer (RNFL), ganglion cell layer (GCL) and inner plexiform layer (IPL). The thickness of the circumpapillary RNFL was analysed at the disc. Associations between age, gender, refractive error and OCT measurements were explored. De-identified A-scans were extracted from the OCT machine as separate tab-separated text file and made available according to the data sharing statement.

Results

Two-hundred eyes from 146 participants were included of which 69 (47%) were female. The mean age (SD) was 48.52 (17.52). Participants were evenly distributed across four age groups and represented nine broad ethnic groups in proportions comparable to the local distribution. All the macular scans were 20° x 20° (5.9 mm x 5.9 mm), with a total scan density between 12,800 and 49,152 A-scans. The peripapillary scans were all 12° (3.5 mm), at a scan density of 768 A-scans. The mean retinal, GCL and IPL volumes were significantly greater in males than females. Mean peripapillary RNFL thickness did not differ significantly between males and females. Age and total retinal volume (r = –0.2561, P = 0.0003), GCL volume (–0.2911, P < 0.0001) and IPL volume (–0.3194, P < 0.0001) were negatively correlated. The IPL had the strongest three significant negatively associated segments; superior inner IPL (r = –0.3444, P < 0.0001), nasal outer IPL (r = –0.3217, P < 0.0001) and inferior inner IPL (r = –0.3179, P < 0.0001). The temporal inner macular RNFL showed a statistically significant positive correlation (r = 0.1929, P = 0.0062) with age. The only significant association between age and thickness at the peripapillary disc scan was the superior temporal sector (r = –0.1910, P = 0.0067). All retinal layers were negatively correlated for refractive error, except for the central RNFL which was positively correlated (r = 0.1426, P = 0.044).

Conclusion

This study provides a normative database of macular and circumpapillary scans with reference values at the level of the A-scan using the Heidelberg Spectralis Optical Coherence Tomography (OCT) machine.

BIOM-49. SERUM microRNA IS A PROGNOSTIC AND POST-OPERATIVE MONITORING BIOMARKER IN GLIOMA

Although magnetic resonance imaging (MRI) provides accurate anatomical and spatial details regarding gliomas, it is not reliable at predicting biological behaviour and is confounded by problems such as pseudo-progression. A circulating biomarker has potential to improve predictions of glioma outcomes and identify tumor progression post treatment, however no such biomarker is currently available. We aimed to discover a microRNA (miRNA) serum biomarker for longitudinal monitoring of glioma patients as well as identify miRNAs that are predictive of survival outcomes. To investigate this a prospectively collected cohort of 91 gliomas and 17 healthy controls underwent pre- and post-operative serum miRNA profiling using the next-generation sequencing platform Nanostring®. Differentially expressed miRNAs were discovered using a machine learning random forest analysis. Candidate miRNAs were then assessed by droplet digital PCR in 11 patients with multiple follow-up samples and compared to tumor volume based on MRI. A lasso-regression model was used to identify candidate miRNAs from pre-operative serum that were associated with both progression-free and overall survival. We identified a 9-gene miRNA signature that could distinguish between glioma and healthy controls with 99.8% accuracy. From this signature, we identified two miRNAs that demonstrated dynamic changes which correlated closely with tumor volume in both LGG and GBM. Importantly, miRNA levels did not increase in two cases of pseudo-progression, indicating the potential utility of this test in guiding treatment decisions. Additionally, altered expressions of 6 miRNAs were found to be associated with overall and progression-free survival and were incorporated in a predictive model with already known survival factors. In conclusion, we have identified a highly accurate 9-miRNA signature associated with glioma serum and observed specific miRNAs that both correlated with tumor volume over long-term follow up and were predictive of survival. These results support a large prospective validation study of serum miRNA biomarkers in glioma.

NCOG-55. HARMONIZING LANGUAGE TO MAXIMIZE IMPACT: AN UPDATE ON COMMON DATA ELEMENTS FOR MENINGIOMA AND REVIEW OF CLINICAL TRIALS IN MENINGIOMA

BACKGROUND

With increasing studies reporting on the molecular profiling of meningiomas, there is a need to harmonize language used to capture clinical data across centers to ensure that molecular alterations are appropriately linked to clinical variables of interest. Here the International Consortium on Meningiomas presents a final set of core and supplemental meningioma-specific Common Data Elements (CDEs) to facilitate comparative and pooled analyses.

METHODS

The generation of CDEs followed the four-phase process similar to other National Institute of Neurological Disorders and Stroke (NINDS) CDE projects: development/discovery based on data from published and ongoing meningioma trials, internal validation, external validation including presentation of our data form at the Society for Neuro-Oncology previously, and distribution.

RESULTS

We developed a set of CDEs organized into patient- and tumor-level modules. In total, the Consortium identified 16 core CDEs (9 patient-level and 7-tumour-level) e.g. age at index surgery, diagnosis of neurofibromatosis, prior chemotherapy or radiation, tumor location, extent of resection, recurrence, etc. An additional 15 supplemental CDEs were defined and described (8 patient-level and 7 tumour-level) e.g. race, cause of death, multiple tumors, tumor size, Simpson grade, second intervention, etc. These CDES are now made publicly available for dissemination and adoption. We also present a narrative review and analysis of recent and ongoing meningioma trials.

CONCLUSIONS

These CDEs provide a framework for discussion in the neuro-oncology community that will facilitating data sharing for collaborative research projects and aid in developing a common language for comparative and pooled analyses. The CDEs are intended to be dynamic parameters that evolve with time and The Consortium welcomes international feedback for further refinement and implementation of these CDEs.

Potential biomarkers and challenges in glioma diagnosis, therapy and prognosis

Gliomas are the most common central nervous system malignancies and present with significant morbidity and mortality. Treatment modalities are currently limited to surgical resection, chemotherapy and radiotherapy. Increases in survival rate over the previous decades are negligible, further pinpointing an unmet clinical need in this field. There is a continual struggle with the development of effective glioma diagnostics and therapeutics, largely due to a multitude of factors, including the presence of the blood–brain barrier and significant intertumoural and intratumoural heterogeneity. Importantly, there is a lack of reliable biomarkers for glioma, particularly in aiding tumour subtyping and measuring response to therapy. There is a need for biomarkers that would both overcome the complexity of the disease and allow for a minimally invasive means of detection and analysis. This is a comprehensive review evaluating the potential of current cellular, proteomic and molecular biomarker candidates for glioma. Significant hurdles faced in glioma diagnostics and therapy are also discussed here.

EPID-31. EFFICIENT STUDY OF SURGICALLY TREATED MENINGIOMA THROUGH CLINICAL DATA STANDARDIZATION

With increasing epidemiological and biological studies on meningiomas, standardized clinical data capture will be necessary to interpret results across studies and to translate them to clinical practice. To meet this need for consistent clinical data capture, the International Consortium on Meningioma, has developed a set of common data elements (CDEs), to be used across clinical and biological research. Building from terminology used in clinical practice and ongoing studies, we used a consensus-of-experts approach to arrive at a set of standardized and vetted data elements. Areas of focus include patient characteristics, patient history, radiological and intra-operative description, histological diagnosis and molecular testing, non-surgical interventions, and surveillance. These data elements are implemented in Research Electronic Data Capture (REDCap) forms. With REDCap implementation, components of the CDE set can be selected and instituted in a local REDCap instance for efficient study start-up. The scope of the current CDE set focuses on surgically treated meningioma. However, modular forms provide flexibility and to allow the scope to be expanded to include non-surgically treated meningioma. Dissemination plans are underway to introduce the CDEs to neuro-oncology researchers and clinicians through publication and presentations, where feedback will be solicited. Adoption of CDEs for research will improve consistency and interpretability across studies, expediting research in this frequently occurring tumor.

Solid non-enhancing cerebellar pilocytic astrocytoma case report

Pilocytic astrocytomas (PA) are slow-growing low-grade gliomas, commonly diagnosed as cerebellar tumors among the pediatric and adolescent population. Characteristic neuroradiologic findings in PA include a cystic mass with enhancing solid nodule. While uncommon radiologic features of PA, including non-enhancing cystic tumors, have been previously described, we present a unique case of a patient with a non-enhancing solid cerebellar PA. The main clinical, radiologic, and pathologic findings are discussed and the relevant literature reviewed. To our knowledge, this is the first reported patient with these radiologic features of PA, highlighting the need for awareness of uncommon presentations when discussing differential diagnosis and pre-operative planning for cerebellar tumors in the relevant age group.

Intraparenchymal infratentorial ependymoma

Ependymomas are glial series tumours that can occur throughout the neural axis, usually in close proximity to the ventricles or central canal. While the fourth ventricle is a common location for ependymoma, we present a rare case of an entirely intraparenchymal infratentorial tumour, remote from the ventricular surface, and discuss the imaging characteristics that may suggest the diagnosis. The histological features, which remain identical despite the varied morphology of intraventricular versus intraparenchymal tumours, are also considered.

Multidisciplinary rehabilitation after primary brain tumour treatment

BACKGROUND

Brain tumours can cause significant disability, which may be amenable to multidisciplinary rehabilitation. However, the evidence base for this is unclear. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews [2013, Issue 1, Art. No. CD009509] on 'Multidisciplinary rehabilitation after primary brain tumour treatment'.

OBJECTIVES

To assess the effectiveness of multidisciplinary rehabilitation in people after primary brain tumour treatment, especially the types of approaches that are effective (settings, intensity).

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library up to Issue 12 of 12, 2014), MEDLINE (1950 to January week 2, 2015), EMBASE (1980 to January week 2, 2015), PEDro (1985 to January week 2 2015), and LILACS (1982 to January week 2, 2015). We checked the bibliographies of papers we identified and contacted the authors and known experts in the field to seek published and unpublished trials.

SELECTION CRITERIA

Controlled clinical trials (randomised and non-randomised clinical trials) that compared multidisciplinary rehabilitation in primary brain tumour with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary rehabilitation in different settings or at different levels of intensity.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed study quality, extracted data, and performed a 'best evidence ' synthesis based on methodological quality.

MAIN RESULTS

We did not identify any studies for inclusion in the previous version of this review. For this update, the literature search identified one low-quality controlled clinical trial involving 106 participants. The findings from this study suggest 'low-level' evidence to support high-intensity ambulatory (outpatient) multidisciplinary rehabilitation in reducing short- and long-term motor disability (continence, mobility and locomotion, cognition), when compared with standard outpatient care. We found improvement in some domains of disability (continence, communication) and psychosocial gains were maintained at six months follow-up. We found no evidence for improvement in overall participation (quality of life and societal relationship). No adverse events were reported as a result of multidisciplinary rehabilitation. We found no evidence for improvement in quality of life or cost-effectiveness of rehabilitation. It was also not possible to suggest best 'dose' of therapy.

AUTHORS' CONCLUSIONS

Since the last version of this review, one new study has been identified for inclusion. The best evidence to date comes from this CCT, which provides low quality evidence that higher intensity ambulatory (outpatient) multidisciplinary rehabilitation reduces short- and long-term disability in people with brain tumour compared with standard outpatient care. Our conclusions are tentative at best, given gaps in current research in this area. Although the strength of evidence has increased with the identification of a new controlled clinical trial in this updated review, further research is needed into appropriate and robust study designs; outcome measurement; caregiver needs; evaluation of optimal settings; type, intensity, duration of therapy; and cost-effectiveness of multidisciplinary rehabilitation in the brain tumour population.

First interim analysis of a randomised trial of whole brain radiotherapy in melanoma brain metastases confirms high data quality

Background

Brain metastases are a common cause of death in patients with melanoma. The role of adjuvant whole brain radiotherapy (WBRT) following local treatment of intracranial melanoma metastases is controversial. The Australian and New Zealand Melanoma Trials Group (ANZMTG) and the Trans-Tasman Radiation Oncology Group (TROG) are leading the first ever single histology randomised trial investigating this question. The primary endpoint is distant intracranial failure on magnetic resonance imaging (MRI) within twelve months of randomisation. The first planned interim analysis was performed twelve months after randomisation of the 100^th patient. The analysis was an opportunity to review completeness of the trial data to date.

Methods

All data received up to the end of twelve months after randomisation of the 100th patient was reviewed.

Results

Review of pathology reports confirmed that all 100 patients had stage IV melanoma and were appropriately entered into the study. Of the 47 distant intracranial events, 34 occurred in isolation (i.e. only distant failure was identified), whilst 13 were accompanied by local failure. Data review showed compliance with the protocol mandated MRI schedule and accuracy of intracranial failure reporting was very high. The Quality of Life (QoL) component of the study achieved a 91% completion rate. For the neurocognitive function (NCF) assessments, a high completion rate was maintained throughout the 12 month period. Where assessments were not performed at expected time points, valid reasons were noted. Radiotherapy quality was high. Of 50 patients who received WBRT, 32 were reviewed as per protocol design and there was only one major variation out of 308 data points reviewed (0.3%). There were minimal trial related adverse events (AEs) and no serious adverse events (SAEs). Pre-specified protocol stopping rules were not met.

Conclusions

The Data Safety Monitoring Committee (DSMC) recommended the trial continue recruitment after reviewing the unblinded data. The data provision and quality to date indicates that a reliable outcome will be obtained when the final analysis is performed. Accrual is ongoing with 156 out of 200 patients randomised to date (26^th November 2014).

Effectiveness of integrated multidisciplinary rehabilitation in primary brain cancer survivors in an Australian community cohort: a controlled clinical trial

OBJECTIVE

To evaluate effectiveness of a multidisciplinary rehabilitation program for persons following definitive primary brain tumour treatment in a community cohort.

METHODS

The brain tumour (glioma) survivors (n = 106) were allocated either to the treatment group (n = 53) (intensive ambulatory multidisciplinary rehabilitation), or the waitlist control group (n = 53). The primary outcome - Functional Independence Measure (FIM), measured 'Activity' limitation; secondary measures included Depression, Anxiety Stress Scale, Perceived Impact Problem Profile and Cancer Rehabilitation Evaluation System. Assessments were at baseline, 3 and 6 months after program completion.

RESULTS

Participants were predominantly women (56%), with mean age 51 years (standard deviation 13.6) and median time since diagnosis of 2.1 years. Intention-to-treat analysis showed a significant difference between groups at 3-month in favour of multidisciplinary rehabilitation program in FIM motor subscales: 'self-care', 'sphincter', 'locomotion', 'mobility'(p < 0.01 for all); and FIM 'communication' (p < 0.01) and 'psychosocial' subscales (p < 0.05), with small to moderate effect size (r = 0.2-0.4). At 6-month follow-up, significant improvement in the treatment group was maintained only for FIM 'sphincter', 'communication' and 'cognition' subscales (p < 0.01 for all). No difference between groups was noted in other subscales.

CONCLUSIONS

brain tumour survivors can improve function with multidisciplinary rehabilitation, with some gains maintained up to 6 months. Evidence for specific interventions in the 'blackbox' of rehabilitation is needed.

Improving care for pediatric diabetic ketoacidosis

OBJECTIVE

We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures.

METHODS

Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets.

RESULTS

Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations.

CONCLUSIONS

Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities.

Socio-demographic factors and their impact on the number of resections for patients with recurrent glioblastoma

Glioblastoma multiforme (GBM) is the most aggressive malignant brain tumour. Having a second or subsequent operation at recurrence may be a positive prognostic factor for survival. Recent studies suggest that socio-demographic variables may influence survival, raising the question whether surgical care differs based on these variables. We examined the relationship between selected socio-demographic variables and the number of repeat operations undergone by patients with recurrent GBM. Data from all patients diagnosed with GBM between 2001 and 2011 was obtained from a clinical database maintained across two institutions (one public, one private). The clinical and socio-demographic factors for patients who received one operation were compared to those who had two or more operations, using chi-squared analyses to determine statistical differences between groups. Socioeconomic status was measured using the Index of Relative Socioeconomic Advantage and Disadvantage scores. Of 553 patients, 449 (81%) had one operation and 104 (19%) had ≥2 operations. Patients who had ≥2 operations were significantly younger (median 55 years versus 64 years, p<0.001), less likely to have multifocal (p=0.043) or bilateral (p=0.037) disease and more likely to have initial macroscopic resection (p=0.006), than those who had only one operation. Socioeconomic status did not significantly differ between the groups (p=0.31). Similarly, there was no significant difference between the number of operations in patients from regional versus city residence and public versus private hospital. This is reassuring as it suggests similar surgical management options are available for patients regardless of socio-demographic background.

Multidisciplinary rehabilitation after primary brain tumour treatment

BACKGROUND

Brain tumours can cause significant disability, which may be amenable to multidisciplinary rehabilitation. However, the evidence base for this is unclear.

OBJECTIVES

To assess the effectiveness of multidisciplinary rehabilitation in adults after primary brain tumour treatment, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialized Register (March week 2, 2012), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 3, 2012), MEDLINE (1966 to March week 2, 2012), EMBASE (1980 to March week 2, 2012), PEDro (1982 to March 2012) and LILACS (1982 to March week 2, 2012). We checked the bibliographies of papers identified and contacted the authors and known experts in the field to seek published and unpublished trials.

SELECTION CRITERIA

Controlled clinical trials (randomised and non-randomised clinical trials) that compared multidisciplinary rehabilitation in primary brain tumour with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary rehabilitation in different settings or at different levels of intensity.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed study quality, extracted data and performed a 'best evidence' synthesis based on methodological quality.

MAIN RESULTS

No randomised controlled trials (RCTs) or controlled clinical trials (CCTs) were identified.

AUTHORS' CONCLUSIONS

No RCTs or CCTs were available for synthesis of 'best evidence' for multidisciplinary rehabilitation after treatment for brain tumour patients. However, this does not suggest the ineffectiveness of multidisciplinary rehabilitation but rather highlights the challenges in trial design and rigour, outcome measurement and complexities of care in this population. For completeness of literature, 12 observational studies (with high risk of bias) involving patients with brain tumours were included. These studies provided 'very low level' evidence suggesting that multidisciplinary rehabilitation (inpatient, home-based) may improve functional outcomes, and ambulatory programmes (outpatient and home-based) may improve vocation and quality of life. These conclusions are tentative at best, given gaps in current research in this area. Further research is needed into appropriate and robust study designs, outcome measurement, caregiver needs, evaluation of optimal settings, type, intensity, duration of therapy, and cost-effectiveness of multidisciplinary rehabilitation in the brain tumour population.

Glioma patterns of care in Victoria from 1998–2000

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Background: The management of Gliomas is complex and requires a multidisciplinary approach. The care of such patients (pts) may be variable. The State of Victoria has a population of approximately 4 million people and over 300 new glioma cases diagnosed annually. Methods: This was a retrospective cohort study conducted by surveying doctors involved in managing incident adult glioma cases identified from the population based Victorian Cancer Registry during 1998–2000. The survey was conducted in 2004–5 obtaining at least four years follow-up data on all pts. Results: 828 pts were considered eligible for this study. 264 pts (32%) were aged over 70 years and 92 (11%) were aged over 80 years. 105 (13%) did not have a histologic diagnosis and 473 (57%) had glioblastoma multiforme (GBM). Complete macroscopic resection was performed in 209 pts (25%). Of all pts with a glioma, 612 (74%) and 326 (54%) were referred at initial diagnosis for consideration of radiotherapy and chemotherapy respectively. In 473 pts with GBM, 406 (86%) and 147 (31%) pts were initially referred for consideration of radiotherapy and chemotherapy respectively. Only 39 pts(5%) were enrolled on a clinical trial. The median survival for pts with a GBM was 7.4 months with a 3% five-year survival. Conclusions: This is one of the largest ever-reported glioma management surveys. Much of the patient demographics and approach to treatment were expected and represent a reasonable “standard of care”. Importantly, this study emphasises the elderly nature of this patient population and identifies areas of concern including: absence of histologic diagnosis, lack of multi-disciplinary care and low clinical trial enrolment.

No significant financial relationships to disclose.

Electrical cardioversion of emergency department patients with atrial fibrillation

STUDY OBJECTIVE

Electrical cardioversion of emergency department (ED) patients with atrial fibrillation has not been well investigated. The objective of this study is to identify the outcomes and complications associated with ED electrical cardioversion of patients with atrial fibrillation.

METHODS

This retrospective health records survey investigated a consecutive cohort of ED patients with atrial fibrillation who underwent electrical cardioversion in 4 EDs during a 42-month period. Trained personnel reviewed medical records for demographic characteristics, clinical descriptors, medical interventions, complications, and ED return visits within 7 days. Data were analyzed using descriptive statistics.

RESULTS

The study population consisted of 388 patients (mean age 61 years; range 20 to 93 years). Duration of atrial fibrillation was less than 48 hours in 99% of the cohort. Electrical cardioversion was successful in 332 (86%) patients. Twenty-eight complications were noted in 25 electrical cardioversion encounters: 22 attributed to procedural sedation and analgesia and 6 attributed to electrical cardioversion. Three hundred thirty-three (86%) patients were discharged to home from the ED: 301 after electrical cardioversion success and 32 with electrical cardioversion failure. Thirty-nine patients (10%) returned to the ED within 7 days, 25 of these patients (6% of successful electrical cardioversion patients) returned because of relapse of atrial fibrillation.

CONCLUSION

In this multicenter cohort, selected ED patients with atrial fibrillation had high rates of electrical cardioversion success, infrequent hospital admission, and few immediate and short-term complications.

Heparan sulphate sulphotransferase expression in mice and Caenorhabditis elegans

Heparan sulphate (HS) acts as a multifunctional cell regulator, with specific sulphated saccharide sequences designed for selective interactions with many proteins. Functionally, these interactions result in regulation of the protein activities, and there is growing evidence that cells can dynamically alter the structure of HS sequences that they display. HS biosynthesis involves the action of a complex set of enzymes with polymerase, epimerase and sulphotransferase (ST) activities. In higher organisms, multiple isoforms of STs decorate the nascent HS chains with specific patterns of sulphation that confer selective biological functions. The study of HSSTs in model organisms provides a valuable opportunity to examine the expression of these enzymes in relation to the structure and activities of the HS produced. Here we describe that, in mice, there are stage-specific combinations of HSST isoenzymes that underlie the synthesis of different HS species at different times in the developing brain. This differential expression of HSSTs results in the synthesis of structurally variant HS species that form functional signalling complexes with specific fibroblast growth factors and their receptors. Regulated synthesis of specific HS species could be a mechanism for the regulation of proliferation and differentiation in the developing brain. We also describe evidence that a Caenorhabditis elegans orthologue of the mammalian 2OST enzyme, called HST-2, is essential for the normal development of this nematode. Together, these studies emphasize the importance of HSSTs in the biosynthesis of functionally variant HS proteoglycans, and demonstrate the importance of these complex regulatory molecules in developmental processes.

Sequencing of 3-O sulfate containing heparin decasaccharides with a partial antithrombin III binding site

Heparin- and heparan sulfate-like glycosaminoglycans (HLGAGs) represent an important class of molecules that interact with and modulate the activity of growth factors, enzymes, and morphogens. Of the many biological functions for this class of molecules, one of its most important functions is its interaction with antithrombin III (AT-III). AT-III binding to a specific heparin pentasaccharide sequence, containing an unusual 3-O sulfate on a N-sulfated, 6-O sulfated glucosamine, increases 1,000-fold AT-III's ability to inhibit specific proteases in the coagulation cascade. In this manner, HLGAGs play an important biological and pharmacological role in the modulation of blood clotting. Recently, a sequencing methodology was developed to further structure-function relationships of this important class of molecules. This methodology combines a property-encoded nomenclature scheme to handle the large information content (properties) of HLGAGs, with matrix-assisted laser desorption ionization MS and enzymatic and chemical degradation as experimental constraints to rapidly sequence picomole quantities of HLGAG oligosaccharides. Using the above property-encoded nomenclature-matrix-assisted laser desorption ionization approach, we found that the sequence of the decasaccharide used in this study is DeltaU(2S)H(NS,6S)I(2S)H(NS, 6S)I(2S)H(NS,6S)IH(NAc,6S)GH(NS,3S,6S) (+/-DDD4-7). We confirmed our results by using integral glycan sequencing and one-dimensional proton NMR. Furthermore, we show that this approach is flexible and is able to derive sequence information on an oligosaccharide mixture. Thus, this methodology will make possible both the analysis of other unusual sequences in HLGAGs with important biological activity as well as provide the basis for the structural analysis of these pharamacologically important group of heparin/heparan sulfates.

Proximal tubular basement membrane width in insulin-dependent diabetes mellitus

Although glomerular structure has been studied, careful evaluation of tubular basement membrane (TBM) structure in diabetes in humans has not been done. We measured proximal TBM width, glomerular basement membrane (GBM) width, mesangial fractional volume [Vv(Mes/glom)], mesangial matrix fractional volume [Vv(MM/glom)], and cortical interstitial fractional volume [Vv(Int/cortex)] in 35 insulin-dependent diabetic (IDDM) patients and 20 controls. The patients' mean age was 28 +/- 10 years (X +/- SD) and IDDM duration was 17 +/- 8 years. Twenty-five patients were normoalbuminuric, four microalbuminuric, and six had overt proteinuria. Tubular basement membrane and GBM widths were measured by the orthogonal intercept method and mesangial and interstitial parameters by point counting. The TBM width was 915 +/- 320 nm in IDDM patients and 558 +/- 116 nm in controls (P = 0.0005); the TBM width was also increased in normoalbuminuric patients (849 +/- 297 nm, P = 0.0005). The TBM width was strongly directly related to GBM width (r = 0.67, P < 0.001), Vv(Mes/glom) (r = 0.52, P < 0.01), and Vv(MM/glom) (r = 0.61, P < 0.001), but only weakly to Vv(Int/cortex) (r = 0.29, NS). The TBM width (r = 0.65, P < 0.001) and GBM width (r = 0.65, P < 0.001) were strongly related to hemoglobin A1C (HbA1C), while the Vv(Mes/glom) (r = 0.35, P < 0.05) and Vv(Int/cortex) (r = 0.30, NS) were only weakly related to HbA1C. Thus, increased proximal TBM width is an integral component of early nephropathology in IDDM patients. This study suggests that the metabolic disturbances of diabetes are strong determinants of the constellation of structural abnormalities occurring in human diabetic nephropathy.