Survival of pre-formed zirconia crowns in primary teeth: a prospective practice-based cohort study

BACKGROUND

This study aimed to investigate the (1) survival probabilities of prefabricated zirconia crowns (PZCs) placed on primary teeth and (2) identify demographic and tooth-related factors that might affect survival probability.

METHODS

This study prospectively followed children treated under general anaesthesia by a single practitioner between 2012 and 2020. Demographic variables including the age at treatment, gender and tooth-related variables including FDI tooth number, crown size used and any procedural complications at postoperative reviews were collected.

RESULTS

A total of 155 children involving 319 teeth with PZCs were followed up between 12 and 78 months postoperatively with a mean of 38 months. Of the 319 crowns followed, five failures were observed in three patients requiring extraction. Other procedural complications noted included fracture (n = 3), overhangs (n = 3), internal resorption (n = 5) and 24% of crowns showed signs of radiographic changes on postoperative radiographs when these were taken. Age at treatment, tooth type and need for pulp therapy were not statistically associated with clinical success (P > 0.1).

CONCLUSIONS

PZCs provide an aesthetic and durable solution in the management of children with early childhood caries. This study shows very good clinical success and survival extending up to 78 months for PZCs placed on primary teeth under general anaesthesia.

Children and young people's self-reported experiences of asthma and self-management nursing strategies: An integrative review

AIM

To explore children and young people's (CYP) (5-24 years of age) self-reported experiences of asthma self-management strategies (ASMS) with nursing involvement across various settings.

BACKGROUND

Childhood asthma is an increasingly significant health issue, highlighting the importance of acquiring self-management skills to optimise future health outcomes. Registered nurses play a pivotal role in delivering appropriate, personalized self-management support.

METHODS

This integrative review searched four electronic databases: Cumulated Index to Nursing and Allied Health Literature via Elton B. Stephens Company, Medical Literature Analysis and Retrieval System Online (MEDLINE), Object, View and Interactive Design (OVID), and PubMed, that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis flowchart. Included studies were critically appraised using the Joanna Briggs Institute critical appraisal tools. Braun and Clarks thematic analysis was used to generate themes, and sub-themes.

FINDINGS

Fifteen studies were included for review. Thematic analysis generated three themes being healthy literacy; health and wellbeing; and tools and working together.

CONCLUSIONS

Asthma continues to have negative physical, psychological, and social implications among CYP. CYP are both willing and capable of engaging in ASMS and learning self-management skills, however, continue to have unmet self-management needs.

IMPLICATIONS TO PRACTICE

Strategies must bolster health literacy, improve physical and psychological health, and harness interactive, youth-centric, and informative tools to facilitate communication and decrease the burden of self-management. Applications pose a promising avenue for self-management support. This age group remains under-explored and future research should enable meaningful engagement with CYP to better understand their perspectives and improve strategy success.

Good manufacturing practice production of CD34+ progenitor-derived NK cells for adoptive immunotherapy in acute myeloid leukemia

Allogeneic natural killer (NK) cell-based immunotherapy is a promising, well-tolerated adjuvant therapeutic approach for acute myeloid leukemia (AML). For reproducible NK cell immunotherapy, a homogenous, pure and scalable NK cell product is preferred. Therefore, we developed a good manufacturing practice (GMP)-compliant, cytokine-based ex vivo manufacturing process for generating NK cells from CD34+ hematopoietic stem and progenitor cells (HSPC). This manufacturing process combines amongst others IL15 and IL12 and the aryl hydrocarbon receptor antagonist StemRegenin-1 (SR1) to generate a consistent and active NK cell product that fits the requirements for NK cell immunotherapy well. The cell culture protocol was first optimized to generate NK cells with required expansion and differentiation capacity in GMP-compliant closed system cell culture bags. In addition, phenotype, antitumor potency, proliferative and metabolic capacity were evaluated to characterize the HSPC-NK product. Subsequently, seven batches were manufactured for qualification of the process. All seven runs demonstrated consistent results for proliferation, differentiation and antitumor potency, and preliminary specifications for the investigational medicinal product for early clinical phase trials were set. This GMP-compliant manufacturing process for HSPC-NK cells (named RNK001 cells) is used to produce NK cell batches applied in the clinical trial 'Infusion of ex vivo-generated allogeneic natural killer cells in combination with subcutaneous IL2 in patients with acute myeloid leukemia' approved by the Dutch Ethics Committee (EudraCT 2019-001929-27).

Long term quality of life outcomes following surgical resection alone for benign paediatric intracranial tumours

PURPOSE

Survivors of paediatric intracranial tumours are at increased risk of psychosocial, neuro-developmental, and functional impairment. This study aimed to evaluate long-term health-related quality-of-life (HRQOL) outcomes in patients with benign paediatric brain tumours treated curatively with surgical resection alone.

METHODOLOGY

This was a cross-sectional study of patients with benign paediatric intracranial tumours managed with surgery alone between 2000 and 2015. Eligible patients with a minimum of 5-years follow-up after surgery were identified. Validated health-related quality of life (HRQOL) questionnaires were administered: SF-36, QLQ-BN20, QLQ-C30 and PedsQL™.

RESULTS

Twenty-three patients participated (median age at surgery 13 years; range 1-18; 12 male). The most common diagnosis was pilocytic astrocytoma (n = 15). Median time from surgery to participation was 11 years(range 6-19). Fourteen patients achieved A-level qualifications and two obtained an undergraduate degree. Twelve patients were employed, eight were studying and three were unemployed or volunteering. HRQOL outcomes demonstrated significant limitation from social functioning (p = 0.03) and cognitive functioning (p = 0.023) compared to the general population. Patients also experienced higher rates of loss of appetite (p = 0.009) and nausea and vomiting (p = 0.031). Ten patients were under transitional teenager and young-adult (TYA) clinic follow-up. TYA patients achieved higher levels of education (p = 0.014), were more likely to hold a driver's license (p = 0.041) compared to patients not followed-up through these services.

CONCLUSIONS

Childhood brain-tumour survivors have a greater risk of developing psychological, neuro-cognitive and physical impairment. Early comprehensive assessment, specialist healthcare and TYA services are vital to support these patients.

Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation

INTRODUCTION

Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate.

METHODS

A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension.

RESULTS

A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension.

CONCLUSION

In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.

Long Term Quality of Life Outcomes Following Surgical Resection Alone for Benign Paediatric Intracranial Tumours

AIMS

Survivors of paediatric intracranial malignancies are at increased risk of psychosocial, neuro-developmental and functional impairment, important measures of patients’ well-being. This study aimed to evaluate long-term quality of life outcomes (QOL) in patients with benign paediatric brain tumours treated curatively with surgical resection alone.

METHOD

Cross-sectional cohort study of benign paediatric intracranial tumours managed with surgery alone between 2000-2015. Validated QOL questionnaires were administered: SF-36, QLQ-BN20, QLQ-C30 and PedsQLTM.

RESULTS

Twenty-three patients participated (median age at surgery 13 years; range 1-18), twelve were male. The most common diagnosis was pilocytic astrocytoma (n=15). Median time from surgery to participation was 11 years (range 6-19). Fourteen patients achieved A-level qualifications and two obtained an undergraduate degree. Twelve patients were employed, eight were studying and three were unemployed or volunteering. Twelve patients were currently driving. QOL outcomes demonstrated significant limitation from social functioning (p=0.03) and cognitive functioning (p=0.023) compared to the general population norms. Patients also experienced increased loss of appetite (p=0.009) and symptoms of nausea and vomiting (p=0.031). Ten patients were under transitional teenager and young-adult (TYA) clinic follow-up. TYA patients achieved higher levels of education (p=0.014), were more likely to hold a driver’s license (p=0.041) and had improved physical functioning (p=0.005) compared to patients not transitioned through these services.

CONCLUSION

Childhood brain-tumour survivors are particularly vulnerable and at greater risk of developing psychological, neuro-cognitive, socialisation and physical development challenges. Early identification, comprehensive assessment and specialist TYA cancer healthcare input are vital to support these patients and improve their quality of life.

The impact of the COVID-19 lockdown restrictions on orthopaedic trauma admissions in a central academic hospital in Johannesburg

BACKGROUND: The novel coronavirus (SARS-CoV-2), commonly known as Covid-19, has caused a global economic and healthcare crisis. Many countries tried to curb the spread of the virus by implementing various lockdown restrictions to reduce transmission. The Republic of South Africa (RSA) implemented an alcohol ban as one of the lockdown restrictions. The objectives were to describe the effect of the lockdown alert levels and alcohol availability on orthopaedic trauma admissions, compared to the preceding two years. METHODS: A retrospective review of clinical records was conducted. Data included orthopaedic trauma admissions for the five-month period in a facility in Johannesburg from 27 March to 31 August in the years 2018, 2019 and 2020. Lockdown alert levels were categorised according to the Department of Health which included the ban, reintroduction and re-banning of alcohol consumption. Data collected for 2018, 2019 and 2020 included demographics of sex and age, as well as fracture location, open or closed injuries, polytrauma patients and gunshot injuries. RESULTS: Overall, 672, 621 and 465 patients were admitted in 2018, 2019 and 2020, respectively. There was a decrease of 25% of orthopaedic trauma admissions during the five-month lockdown period in 2020 compared to 2019 (p-value = 0.020) and 30% from 2020 compared to 2018 (p-value = 0.010). In 2020, admissions increased by 112% (n = 82) from alert level 4, when alcohol was banned, to alert level 3 (3a), when alcohol was reintroduced. Admissions decreased by 33% (n = 51) from alert level 3 (3a) to alert level 3 (3b), when alcohol was re-banned. Motor vehicle accidents (MVAs) were the commonest cause of admissions in alert level 3 (3a), accounting for 41% (n = 56). Covid-19 tests were positive in 10% (n = 34) of the 346 tests performed on orthopaedic trauma admissions CONCLUSION: Our study showed the decrease in orthopaedic trauma admissions due to the Covid-19 lockdown regulations. Furthermore, our study demonstrated the impact of alcohol availability on orthopaedic trauma admissions in a central academic hospital in Johannesburg. Level of evidence: Level 4.

Screening for cerebrovascular disorder on the basis of family history in asymptomatic children

Background: Cerebrovascular disorders represent a group of uncommon, heterogeneous, and complex conditions in children. We reviewed the screening practice for the detection of cerebrovascular disorder in asymptomatic children referred to our neurovascular service on the basis of a positive family history and parental and/or treating physician concern.Methods: Retrospective case-note review of referrals to our neurovascular service (July 2008-April 2018). Patients were included if the referral was made for screening, on the basis of a positive family history of cerebrovascular disorder. Symptomatic children, those with previous cranial imaging, or children under the care of a clinical geneticist (i.e. due to the child or their relative having HHT or mutations in KRIT1) were not eligible for inclusion.Results: Forty-one children were reviewed, 22 males (Median age 10.7 years, range 0.6-15.6 years). This represented 22% of the total number of referrals over a 10-year period. Twenty-nine children had an MRI/MRA brain. Twenty-eight children were referred due to a family history of intracranial aneurysm and/or subarachnoid haemorrhage, but only two had two first-degree relatives affected. Ten children were referred due to a family history of arteriovenous malformation. Three children were referred due to a family history of stroke. No cerebrovascular disease was detected during the study period (n = 29).Conclusions: Parental and/or physician concern generated a substantial number of referrals but no pathology was detected after screening. Whilst general screening guidance exists for the detection of intracranial aneurysms, consensus guidelines for the screening of children with a positive family history do not, but are required both to guide clinical practice and to assuage parental and/or physician concerns.

BCG-induced protection against Mycobacterium tuberculosis infection: Evidence, mechanisms, and implications for next-generation vaccines

The tuberculosis (TB) vaccine Bacillus Calmette-Guérin (BCG) was introduced 100 years ago, but as it provides insufficient protection against TB disease, especially in adults, new vaccines are being developed and evaluated. The discovery that BCG protects humans from becoming infected with Mycobacterium tuberculosis (Mtb) and not just from progressing to TB disease provides justification for considering Mtb infection as an endpoint in vaccine trials. Such trials would require fewer participants than those with disease as an endpoint. In this review, we first define Mtb infection and disease phenotypes that can be used for mechanistic studies and/or endpoints for vaccine trials. Secondly, we review the evidence for BCG-induced protection against Mtb infection from observational and BCG re-vaccination studies, and discuss limitations and variation of this protection. Thirdly, we review possible underlying mechanisms for BCG efficacy against Mtb infection, including alternative T cell responses, antibody-mediated protection, and innate immune mechanisms, with a specific focus on BCG-induced trained immunity, which involves epigenetic and metabolic reprogramming of innate immune cells. Finally, we discuss the implications for further studies of BCG efficacy against Mtb infection, including for mechanistic research, and their relevance to the design and evaluation of new TB vaccines.

Bariatric Surgery for Congestive Heart Failure Patients Improves Access to Transplantation and Long-term Survival

INTRODUCTION

Obese patients with congestive heart failure (CHF) are often denied access to heart transplantation until they obtain significant weight loss to achieve a certain BMI threshold, often less than 35 kg/m². It is unknown whether the rapid weight loss associated with bariatric surgery leads to improved waitlist placement, and as such improved survival for morbidly obese patients with CHF.

METHODS

A decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with CHF who were deemed ineligible to be waitlisted for heart transplantation unless they achieved a BMI less than 35 kg/m². Life expectancy following medical weight management (MWM), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) was estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m². Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review.

RESULTS

RYGB improved survival compared with both SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 2.1 additional years of life compared with patient's who underwent SG and 7.4 additional years of life compared with MWM. SG patients gained 5.3 years of life compared with MWM.

CONCLUSIONS

When strict waitlist criteria were applied, bariatric surgery improved access to heart transplantation and thereby increased long-term survival compared with MWM. Morbidly obese CHF patients who anticipate need for heart transplantation should be encouraged to pursue surgical weight management strategies, necessitating discussion between bariatric surgeons, cardiologists, and cardiac surgeons for appropriate perioperative risk management.

Injury patterns of patients with upper limb and hand trauma sustained during the COVID-19 pandemic lockdown in the UK: a retrospective cohort study

This work aimed to identify the lead causes of upper limb injury presenting to a busy hand and major trauma unit during the UK COVID-19 domestic lockdown period, in comparison to a cohort from the same period one year previously. Hand and upper limb injuries presenting to the host organization during a pre-lockdown period (23rd March 2019–11th May 2019) and the formal UK lockdown period (23rd March 2020–11th May 2020) were compared, using data collated from the host institution’s hand surgery database. The UK lockdown period was associated with a 52% fall in the number of patients presenting to the service with hand and upper limb injuries (589 pre-lockdown vs. 284 during lockdown). There was a significant increase in the proportion of injuries due to machinery use during lockdown (38, 6.5% pre-lockdown vs. 33, 11.6% during lockdown, P = 0.009), other etiologies were consistent. The proportion requiring surgical management were similar (n = 272, 46.2% pre-lockdown vs. n = 138, 48.6% during lockdown, P = 0.50). The proportion requiring overnight admission fell (n = 94, 16.0% pre-lockdown vs. 29, 10.2% during lockdown, P = 0.022). COVID-19 related lockdown in the UK resulted in a reduction in the presenting numbers of hand related injuries; however almost half of these patients still required surgery. These data may be of use to other hand surgery centers for resource planning during future lockdown periods, and for injury prevention strategies in the post-COVID-19 world.

Patient-Reported Outcomes Following Lumbar Decompression Surgery: A Review of 2699 Cases

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Despite numerous advances in the technology and techniques available to spinal surgeons, lumbar decompression remains the mainstay of degenerative lumbar spine surgery. It has proven efficacy in trials, but only limited evidence of advantage over conservative management in large scale systematic reviews. We collated data from a large surgically managed cohort to evaluate the patient-reported outcomes.

METHODS

We performed a retrospective analysis of a prospectively populated database. Patient demographics, surgical details, and patient outcomes (Spine Tango core outcome measures index [COMI]-Low Back) were collected for 2699 lumbar decompression surgeries.

RESULTS

Lumbar decompression was shown to be successful at improving leg pain (mean improvement in visual analogue scale [VAS] at 3 months = 4) and to a lesser extent, back pain (mean improvement in VAS at 3 months = 2.61). Mean improvement in COMI score was 3.15 for all-comers. Minimal clinically important improvement (MCID) in COMI score (-2 points) was achieved in 73% of patients by 2-year follow-up. Primary surgery was more effective than redo surgery: odds ratio 0.547 (95% CI 0.408-0.733, P < .001). The benefits across all outcomes were maintained for the 2-year follow-up period. Patients can be classified according to their outcome as "early responders"; achieving MCID by 3 months (61% primary vs 41% redo), "late responders"; achieving MCID by 2 years (15% vs 20%) or nonresponders (24% vs 39%).

CONCLUSIONS

Lumbar decompression is effective in improving quality of life in appropriately selected patients. Patient-reported outcome measures collected routinely and collated within a registry are a powerful tool for assessing the efficacy of lumbar spine interventions and allow accurate counseling of patients perioperatively.

Loneliness and Facebook use: the role of social comparison and rumination

There is conflicting evidence as to whether Facebook, one of the most popular social networking sites, either promotes social connectedness or contributes to the rising prevalence of loneliness. This study aimed to understand the association between Facebook use and loneliness. Two hundred and fourteen active Facebook users (M_age = 35.65; 80.8% female) completed a cross-sectional questionnaire measuring the nature of their Facebook use, how frequently they ruminate, the tendency to compare themselves to their Facebook friends, and upward and downward social comparison. The results showed that rumination and upward social comparison on Facebook were significantly associated with loneliness. The type of activity users engaged in when using Facebook was not significant. The study therefore demonstrates that Facebook users who ruminate and compare themselves to their perceived superiors on Facebook are more likely to experience loneliness. Suggested solutions include raising awareness and using algorithms on Facebook to deliver targeted interventions.

SURG-12. PAEDIATRIC BRAIN TUMOUR SURGERY: HOW CAN WE REPORT OUR SURGICAL OUTCOMES AND OPERATIVE MORBIDITY?

OBJECTIVE

Our objective was to quantify resection outcomes and operative morbidity in paediatric brain tumour surgery using existing scales, assessing their applicability.

METHODS

We investigated morbidity using the Clavien-Dindo (CD) scale and the Drake classification. All paediatric patients receiving a biopsy or craniotomy for an intracranial tumour in a single tertiary paediatric neurosurgery centre between January 2008 and December 2018 were studied. Complications up to day 30 post op were graded.

RESULTS

There were 459 operations: 92 biopsies and 367 craniotomies comprising 166 infratentorial and 292 supratentorial tumours. Median age was 9 years (56% male). The surgical goal was achieved or exceeded in 94% of cases. Thirty-day mortality was 1.31% with all deaths related to disease and none to surgical complications. The overall CD score was 1 in 10.9% of cases, 2 in 18.9%, 3A in 1.7%, 3B in 11.8%, and 4 in 1.1%. There was no operative morbidity in 54% of cases. Using the Drake classification, meningitis was seen in 3.92% of cases, seizures in 3.92%, neurological deficit (that persisted at 30 days) in 8.5%, CSF leak in 5.01%, wound infection in 1.96%, haemorrhage 1.75 %, shunt infection in 1.53%, shunt block in 0.65%, medical complications in 2.4%, and others in 3.05%.

CONCLUSIONS

This is the largest series presenting morbidity from paediatric brain tumour surgery, and the first to validate the CD scale. Our morbidity on the Drake scale was comparable with other series. There is a need to develop improved tools to quantify morbidity in this high-risk specialty.

Reflecting on success in trauma research: experiences from the SGCNS and SIR studies

The inclusion of British Service Personnel (SP) lacking capacity into research studies from the point of injury through to medium-term rehabilitation had not previously been undertaken until work to support operations in Afghanistan (2001-2014). The Surgeon General's Casualty Nutrition Study and the Steroids and Immunity from Injury through to Rehabilitation Study sought to address the nutrition, endocrine and immune responses in a military patient cohort. A fundamental part of research is to feedback to patients, their relatives and ward staff on data collection and outcomes, and how future research may be improved to better support both injured SP and trauma patients in the UK. This paper will provide an experiential view on the delivery, operations and infrastructure requirements that should be considered when developing military research at a role-3 facility, before, during and after a study.

OP0234 MBS2320, A NOVEL SELECTIVE MODULATOR OF IMMUNE METABOLISM, IN PATIENTS WITH SEVERE RHEUMATOID ARTHRITIS: SAFETY, TOLERABILITY AND EFFICACY RESULTS OF A PHASE 2 STUDY

Background:

Despite the availability of several treatment options for Rheumatoid Arthritis (RA), many patients are classed as ‘non-responders’ who show little or no improvement. Hence, there remains a need for new therapies with a differentiated mechanism of action, to be used alone or in combination. MBS2320 is a selective modulator of immune metabolism displaying distinctive dual pharmacology: strong anti-inflammatory activity as well as a broader spectrum of osteoprotection than TNFα inhibition in preclinical models1.

Objectives:

To evaluate the safety, tolerability and efficacy of MBS2320 in patients receiving a stable dose of methotrexate (MTX).

Methods:

Patients with active RA on a stable dose of MTX were randomised 2:1 to receive MBS2320 (80mg) or matching placebo once daily for 4 weeks. Subject to a satisfactory safety and tolerability assessment, patients were escalated to a dose of 120 mg qd or remained on 80 mg qd for a further 8 weeks. Safety, efficacy, pharmacokinetics and pharmacodynamics were evaluated.

Results:

121 patients were randomised (Safety analysis set) to MBS2320 or matching placebo and 96 completed the study. Sixteen subjects were excluded from the efficacy analysis set due to evidence of poor compliance or absence of efficacy evaluations. Enrolled patients were mostly female (86.8%), white and with a mean (range) age at baseline (BL) of 52 (19-69) years.

The study population had hard-to-treat, severe, active and erosive disease as indicated by high BL DAS28-CRP and DAS28-ESR, low Week-12 placebo ACR50 and DAS28-CRP responder rates (2.5% and 5% respectively) and a low ratio of synovitis-to-erosion volume despite treatment with DMARD(s).

There were no serious treatment emergent adverse events (TEAEs). 15 patients (19%) randomised to MBS2320 withdrew due to TEAEs, predominantly of nausea. TEAEs were typically reported soon after dosing, were mostly mild in severity and resolved without treatment. Onset of TEAEs reduced as the study proceeded.

Gastrointestinal disorders were the most frequently reported TEAEs (all causalities) with a higher incidence in patients receiving MBS2320 (68.8%) than placebo (14.6%). Nausea was most frequently reported during Week 1 (27.3% patients). Asthenia and/or fatigue was reported more frequently in the MBS2320 treatment group (23.8% patients) than with placebo (7.3% patients), with the majority being considered related to study drug. Infections were more frequently reported by patients receiving placebo (22.0%) than those receiving MBS2320 (12.5%). There were no clinically relevant treatment-related trends in the biochemistry, haematology, urinalysis, vital signs or ECG data.

Higher ACR20 response rates were observed in patients receiving MBS2320 versus those receiving placebo at all time points and increased with time. At Week 12, ACR50 response rates with MBS2320 treatment were increased by >4-fold compared with placebo (11.6% vs 2.5%). Greater mean reductions from baseline in DAS28-CRP were also observed in patients receiving MBS2320 versus those receiving placebo at Week 12 (-18.6% vs -8.4%). DAS28-CRP responder rates were more than doubled with MBS2320 treatment compared to placebo (5% vs 14%). These changes were mirrored by improvements in tender joint counts, reduced hsCRP and improvements in Patient Reported Outcomes of pain VAS, Patients’ and Clinicians‘ Global Assessments of Disease Activity and Patients‘ Global Impression of Change.

Conclusion:

MBS2320 was generally well tolerated for up to 12 weeks in this RA study population. Nausea was the most common TEAE, was generally mild in severity and resolved without treatment. In this population of patients with hard-to-treat, severe, active, erosive disease MBS2320 showed evidence of a clinical benefit on both ACR20 responses and DAS28-CRP.

References:

[1]Patel et al, Ann Rheum Dis, 78, S2, 2019, A228

Acknowledgments:

Louise Jopling, Ian Anderson, Ian Gourley, Devenini Damayanthi,

Disclosure of Interests:

Lisa Patel Shareholder of: Istesso Ltd, Employee of: Istesso Ltd, Laurence Skillern Consultant of: Istesso Ltd, Martyn Foster Shareholder of: Istesso Ltd, Consultant of: Istesso Ltd, Andy Gray Shareholder of: Istesso Ltd, Consultant of: Istesso Ltd, Richard Leff Consultant of: Istesso Ltd, Sam Williams Shareholder of: Istesso Ltd, Employee of: Istesso Ltd

Dysregulation of the actin scavenging system and inhibition of DNase activity following severe thermal injury

Background

Circulating cell‐free DNA (cfDNA) is not found in healthy subjects, but is readily detected after thermal injury and may contribute to the risk of multiple organ failure. The hypothesis was that a postburn reduction in DNase protein/enzyme activity could contribute to the increase in cfDNA following thermal injury.

Methods

Patients with severe burns covering at least 15 per cent of total body surface area were recruited to a prospective cohort study within 24 h of injury. Blood samples were collected from the day of injury for 12 months.

Results

Analysis of blood samples from 64 patients revealed a significant reduction in DNase activity on days 1–28 after injury, compared with healthy controls. DNase protein levels were not affected, suggesting the presence of an enzyme inhibitor. Further analysis revealed that actin (an inhibitor of DNase) was present in serum samples from patients but not those from controls, and concentrations of the actin scavenging proteins gelsolin and vitamin D‐binding protein were significantly reduced after burn injury. In a pilot study of ten military patients with polytrauma, administration of blood products resulted in an increase in DNase activity and gelsolin levels.

Conclusion

The results of this study suggest a novel biological mechanism for the accumulation of cfDNA following thermal injury by which high levels of actin released by damaged tissue cause a reduction in DNase activity. Restoration of the actin scavenging system could therefore restore DNase activity, and reduce the risk of cfDNA‐induced host tissue damage and thrombosis.

P96 Screening for cerebrovascular pathology on the basis of positive family history in the paediatric population

Objectives

Neurovascular disorders are uncommon, complex conditions in children. We reviewed the screening practice and outcome of children referred to the neurovascular service on the basis of positive family history.

Design

Retrospective review of prospectively maintained database.

Subjects

Children referred to the neurovascular service on the basis of family history, for screening at our hospital.

Methods

We retrospectively examined our database between July 2008 and April 2018 for the reasons for referral, family history, investigations performed, and the outcome of the screening process.

Results

44 children were reviewed (23 male, median age 10). Thirty-one children had an MRI/MRA brain. One child subsequently had uncomplicated digital subtraction angiography. Thirty children were referred due to a family history of subarachnoid haemorrhage, of which 17 had a single first-degree relative, and two had two first-degree relatives. Nine children were referred with a family history of arteriovenous malformation, (2 were associated with hereditary haemorrhagic telangiectasia). Five children were discussed due to a family history of non-specific haemorrhagic stroke. Seven children had a history of headache, (4 were prescribed Pizotifen for migraine). No neurovascular pathology was detected following screening within our cohort.

Conclusions

A consensus screening policy does not exist but is required both to guide clinical practice and to assuage parental or patient concerns. We will survey UK paediatric centres to commence this process.

TP1-10 Non tumour brain biopsies in alder hey paediatric neurosurgery

Objectives

To review the utility of non-tumour brain biopsies in Alder Hey Children’s NHS Foundation Trust Paediatric Neurosurgery Department.

Methods

Operative records were searched for ‘biopsy’. Case notes were reviewed for referral source, histology, surgical complication and outcome. Tumour, epilepsy and non-brain biopsy cases were excluded.

Results

83 ‘biopsy’ cases were identified between 2008 and 2017. 31 tumour, 5 epilepsy, 2 infections and 28 non brain/other biopsies were excluded. 17 brain biopsies for non-tumour causes were seen. 15 patients were referred by neurology, 2 by rheumatology. 14 underwent a craniotomy/mini-craniotomy, 3 had burrholes.4 biopsies were non diagnostic, 2 were abnormal but inconclusive for diagnosis. Diagnoses included: 3 demyelinating lesions, 2 normal brain tissue, 1 neurosarcoidosis, 1 autoimmune encephalitis, 1 definite Rasmussen’s Encephalitis, 1 possible Rasmussen’s Encephalitis, 1 systemic lupus erythematosus associated CNS vasculitis, 1 inflammatory infiltrate (secondary to hydrocephalus/ventriculitis), 1 patient developed a late wound infection. No other surgical morbidities/mortalities were recorded. 11 of these cases had a change in management or the treating team were reassured due to the result of the biopsy (i.e. were able to start immunomodulatory drugs in the absence of infection).

Conclusions

65% of brain biopsies were diagnostic. 71% of biopsies either changed management or reassured the treating team about a line of management. The procedure is low risk with 0.06% morbidity and 0% mortality.

P98 A decade of primary tumours of the spine in the paediatric population

Objectives

Primary spinal tumours in children are rare and poorly understood; we review 10 years of surgical experience.

Design

Retrospective review of prospectively maintained database.

Subjects

Children receiving surgical management of primary spinal tumours in a single, tertiary paediatric neurosurgery centre.

Methods

Operations for primary spinal tumours were abstracted from our prospectively maintained surgical database and supplemented with data from case notes, operative records, and imaging studies.

Results

Between 2008 and 2017, 37 procedures were performed on 29 patients (19 male; Median age 7.5 years, IQR 2–11.25). 28 had their primary procedure in our unit: 21 excisions, and 7 biopsies (of which 5 proceeded to further surgery). Tumours were classified as extradural (10), intradural extramedullary (3), intradural intramedullary (11) or bony (4). Tumours were found at the following levels: Cervical (8; 29%), Cervicothoracic (2; 7.1%), Thoracic (10; 36%), Thoracolumbar (3; 11%), Lumbar (2; 7.1%), Lumbosacral (2; 7.1%) and Sacral (1; 3.6%). Histology comprised: Pilocytic Astrocytoma (6), Other Astrocytoma (4), Schwannoma (3), Ewing Sarcoma (2), Langerhans cell histiocytosis (2), Lymphoma (2), Neurofibroma (2), and others (7) including one Myxopapillary Ependymoma.

Conclusions

The rarity and heterogeneity of paediatric spinal tumours makes treatment challenging. We propose a national online registry including a tissue bank, and invite collaboration with other units.

Use of intravenous immunoglobulin for the treatment of autoimmune encephalitis: audit of the NHS experience

Objectives

The treatments of limbic and other autoimmune encephalitis include immunosuppression, symptomatic treatment, and in the case of paraneoplastic syndromes, appropriate therapy for underlying neoplasms. When immunotherapy is considered, intravenous immunoglobulin is one option for treatment, either alone or in combination with corticosteroids. To date, however, evidence for the use of intravenous immunoglobulin in this context comes from case series/expert reviews as no controlled trials have been performed. We aimed to analyse the NHS England Database of intravenous immunoglobulin usage, which was designed to log use and guide procurement, to explore usage and therapeutic effect of intravenous immunoglobulin in autoimmune encephalitis in England.

Design

We conducted a retrospective audit and review of the NHS England Database on intravenous immunoglobulin use.

Setting

NHS England Database of intravenous immunoglobulin use which covers secondary and tertiary care prescribing and use of intravenous immunoglobulin for all patients in hospitals in England.

Participants

Hospital in-patients with confirmed or suspected autoimmune/limbic encephalitis between September 2010 and January 2017.

Results

A total of 625 patients who were 18 years of age or older were treated with intravenous immunoglobulin for autoimmune encephalitis, of whom 398 were determined as having 'highly likely' or 'definite' autoimmune/limbic encephalitis. Ninety-six percent were treated with a single course of intravenous immunoglobulin. The availability and accuracy of reporting of outcomes was very poor, with complete data only available in 27% of all cases.

Conclusions

This is the first review of data from this unique national database. Whilst there was evidence for clinical improvement in many cases of patients treated with intravenous immunoglobulin, the quality of outcome data was generally inadequate. Methods to improve quality, accuracy and completeness of reporting are crucial to maximise the potential value of this resource as an auditing tool.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Circumferential intradural meningioma of the thoracic spinal cord

BACKGROUND AND CONTEXT

There are very few reported cases of a meningioma circumferentially surrounding the spinal cord. To date, this entity has only been described at the conus medullaris and in the cervical cord. Herewith, the authors describe a case of an intradural extramedullary meningioma that completely encircled the thoracic spinal cord.

CASE REPORT

A 40-year-old woman with progressive numbness of the lower limbs and spasticity of gait following a fall presented to our hospital. Magnetic resonance imaging of the spine demonstrated an abnormality at T6-T7 completely encircling the spinal cord. The patient underwent a T6-T8 laminectomy and subtotal resection of the intradural partially calcified lesion. Resection of the anterolateral portion was not feasible. Histology revealed psammomatous meningioma (WHO Grade 1). The patient recovered well and was discharged with improved gait but some residual numbness of her feet and right hemithorax.

CONCLUSION

This is the first reported case of an intradural extramedullary meningioma completely encircling the thoracic spinal cord. Achieving complete resection of this circumferential meningioma was not possible via a posterior approach. The optimum management of this condition is unknown; clearly, achieving symptomatic relief with adequate cord decompression is paramount; however, the long-term outcome and risk of recurrence in these cases, given their rarity and the difficulties in achieving complete resection, is unknown.

Primary cerebral histiocytic sarcoma in childhood: a case report of protracted survival and review of the literature

INTRODUCTION

Histiocytic sarcoma (HS) of the central nervous system (CNS) is exceptionally rare in pediatric patients, historically associated with an exceptionally poor prognosis. Here, the authors present a novel case of protracted progression-free survival following surgical excision, radiotherapy and temozolomide.

CASE REPORT

A 15-year-old Caucasian girl presented with a two-month history of headache, diplopia, vomiting, lethargy, weight loss and neurocognitive deterioration without gross neurological deficit on physical examination. Magnetic resonance imaging (MRI) of the brain identified a 5.8 × 4.7 × 4.0 cm lesion in the right frontal lobe with associated mass effect and no dissemination. Following two surgical procedures, gross total resection was achieved. Histology and immunohistochemistry confirmed HS, with strong CD163 staining. After focal radiotherapy with concomitant temozolomide, and a further seven cycles of temozolomide, the patient made an excellent recovery and is recurrence free without neurological deficit, 23 months following presentation.

CONCLUSION

To the authors' knowledge, this is the first incidence of a prolonged, functionally preserved and recurrence-free outcome following a diagnosis of HS within the CNS of a pediatric patient. We suggest early diagnosis prior to dissemination and complete surgical resection as an essential treatment goal in this rare disease.

Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation

Extremity injuries define the surgical burden of recent conflicts. Current literature is inconclusive when assessing the merits of limb salvage over amputation. The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to equivalent outcomes for unilateral trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 and 2010, as described in a previously published series, were contacted. Consenting individuals conducted a brief telephone interview and were asked to complete a SF-36 questionnaire. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation between 2004 and 2010. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria. Telephone follow-up and SF-36 questionnaire data was available for 30 patients (61%). The median follow-up was 4 years (49 months, IQR 39-63). Ten of the 30 patients required revision surgery, three of which involved conversion from initial fixation to a circular frame for non- or mal-union. Twenty-two of the 30 patients (73%) recovered sufficiently to complete an age-standardised basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35-54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores between the limb salvage and amputation groups (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.

The effects and effectiveness of electromotive drug administration and chemohyperthermia for treating non-muscle invasive bladder cancer

INTRODUCTION

Preliminary studies show that device assisted intravesical therapies appear more effective than passive diffusion intravesical therapy for the treatment of non-muscle invasive bladder cancer (NMIBC) in specific settings, and phase III studies are now being conducted. Consequently, we have undertaken a non-systematic review with the objective of describing the scientific basis and mechanisms of action of electromotive drug administration (EMDA) and chemohyperthermia (CHT).

METHODS

PubMed, ClinicalTrials.gov and the Cochrane Library were searched to source evidence for this non-systematic review. Randomised controlled trials, systematic reviews and meta-analyses were evaluated. Publications regarding the scientific basis and mechanisms of action of EMDA and CHT were identified, as well as clinical studies to date.

RESULTS

EMDA takes advantage of three phenomena: iontophoresis, electro-osmosis and electroporation. It has been found to reduce recurrence rates in NMIBC patients and has been proposed as an addition or alternative to bacillus Calmette-Guérin (BCG) therapy in the treatment of high risk NMIBC. CHT improves the efficacy of mitomycin C by three mechanisms: tumour cell cytotoxicity, altered tumour blood flow and localised immune responses. Fewer studies have been conducted with CHT than with EMDA but they have demonstrated utility for increasing disease-free survival, especially in patients who have previously failed BCG therapy.

CONCLUSIONS

It is anticipated that EMDA and CHT will play important roles in the management of NMIBC in the future. Techniques of delivery should be standardised, and there is a need for more randomised controlled trials to evaluate the benefits of the treatments alongside quality of life and cost-effectiveness.