Patient-reported outcomes in Primary Spinal Intradural Tumours: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

Primary Spinal Intradural Tumours (PSITs) are rare pathologies that can significantly impact quality of life. This study aimed to review patient reported outcomes (PROs) in PSITs.

METHODS

A systematic search of Pubmed and Embase was performed to identify studies measuring PROs in adults with PSITs. PRO results were categorised as relating to Global, Physical, Social, or Mental health. Outcomes were summarised descriptively.

RESULTS

Following review of 2382 records, 11 studies were eligible for inclusion (737 patients). All studies assessed surgically treated patients. Schwannoma was the commonest pathology (n = 190). 7 studies measured PROs before and after surgery, the remainder assessed only post-operatively. For eight studies, PROs were obtained within 12 months of treatment. 21 PRO measurement tools were used across included studies, of which Euro-Qol-5D (n = 8) and the pain visual/numerical analogue scale (n = 5) were utilised most frequently. Although overall QoL is lower than healthy controls in PSITs, improvements following surgery were found in Extramedullary tumours (EMT) in overall physical, social, and mental health. Similar improvements were not significant across studies of Intramedullary tumours (IMT). Overall QoL and symptom burden was higher in IMT patients than in brain tumour patients. No studies evaluated the effect of chemotherapy or radiotherapy.

CONCLUSION

Patients with PSITs suffer impaired PROs before and after surgery. This is particularly true for IMTs. PRO reporting in PSITs is hindered by a heterogeneity of reporting and varied measurement tools. This calls for the establishment of a standard set of PROs as well as the use of registries.

Tectal Plate Glioma: A Clinical and Radiologic Analysis of Progression and Management in Adults

BACKGROUND

Tectal plate gliomas (TPGs) are a heterogeneous group of uncommon brain tumors. TPGs are considered indolent and are usually managed conservatively but they have the potential to transform into higher-grade tumors. The aims of this study were to investigate the natural history of adult TPG, treatment outcomes, and overall survival.

METHODS

A retrospective cohort analysis was performed of adult patients with TPG between 1993 and 2021. Baseline clinical, radiologic, and management characteristics were collected. The primary outcome was tumor progression, defined as increasing size on radiologic assessment or new gadolinium contrast enhancement. Secondary outcomes included management and mortality.

RESULTS

Thirty-nine patients were included, of whom 23 (52.2%) were men. Median age at diagnosis was 35 years (interquartile range, 27-53). Radiologic tumor progression was observed in 8 patients (20.5%). The 10-year progression-free survival was 72.6% (95% confidence interval [CI], 0.58-0.91). The 10-year overall survival was 86.5% (95% confidence interval, 0.75-1.0). Cerebrospinal fluid diversion procedures were used in 62% of the cohort (n = 24). Seventeen patients (43.6%) underwent at least 1 endoscopic third ventriculostomy, whereas only 6 patients (15.4%) underwent at least 1 ventriculoperitoneal shunt.

CONCLUSIONS

TPG has an overall favorable clinical prognosis, although progression occurs in 1 in 5 patients. Showing accurate factors by which patients with TPG may be risk stratified should be a key area of further research. A follow-up duration of 10 years would be a reasonable window based on the radiologic progression rates in this study; however, larger cohort studies are needed to answer both questions definitively.

Genomic Alterations and the Incidence of Brain Metastases in Advanced and Metastatic NSCLC: A Systematic Review and Meta-Analysis

INTRODUCTION

Brain metastases (BMs) in patients with advanced and metastatic NSCLC are linked to poor prognosis. Identifying genomic alterations associated with BM development could influence screening and determine targeted treatment. We aimed to establish prevalence and incidence in these groups, stratified by genomic alterations.

METHODS

A systematic review and meta-analysis compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were conducted (PROSPERO identification CRD42022315915). Articles published in MEDLINE, EMBASE, and Cochrane Library between January 2000 and May 2022 were included. Prevalence at diagnosis and incidence of new BM per year were obtained, including patients with EGFR, ALK, KRAS, and other alterations. Pooled incidence rates were calculated using random effects models.

RESULTS

A total of 64 unique articles were included (24,784 patients with NSCLC with prevalence data from 45 studies and 9058 patients with NSCLC having incidence data from 40 studies). Pooled BM prevalence at diagnosis was 28.6% (45 studies, 95% confidence interval [CI]: 26.1-31.0), and highest in patients that are ALK-positive (34.9%) or with RET-translocations (32.2%). With a median follow-up of 24 months, the per-year incidence of new BM was 0.13 in the wild-type group (14 studies, 95% CI: 0.11-0.16). Incidence was 0.16 in the EGFR group (16 studies, 95% CI: 0.11-0.21), 0.17 in the ALK group (five studies, 95% CI: 0.10-0.27), 0.10 in the KRAS group (four studies, 95% CI: 0.06-0.17), 0.13 in the ROS1 group (three studies, 95% CI: 0.06-0.28), and 0.12 in the RET group (two studies, 95% CI: 0.08-0.17).

CONCLUSIONS

Comprehensive meta-analysis indicates a higher prevalence and incidence of BM in patients with certain targetable genomic alterations. This supports brain imaging at staging and follow-up, and the need for targeted therapies with brain penetrance.

Beyond the WHO classification of meningioma: using molecular diagnostics to guide management

Meningioma are the most common primary brain tumour. Classically, meningioma are phenotypically grouped using the World Health Organisation (WHO) classification system. However, it is now understood that the WHO approach overfits tumours into three grades, resulting in similarly graded tumours displaying phenotypically distinct behaviour. There is a growing body of research investigating the molecular biology of these tumours, including genomic, transcriptomic, metabolomic, proteomic, and methylomic profiling. Such advancements in molecular profiling of meningioma are providing greater accuracy in prognostication of tumours. Furthermore, a clearer understanding of tumour molecular biology highlights potential targets for pharmacotherapies. Currently, the routine application of in-depth tumour molecular analysis is limited, however as it becomes more widely available it will likely result in improved patient care. This review seeks to explore the important developments in meningioma molecular biology, discussed in the context of their clinical importance.

Assessing the reporting quality of adult neuro-oncology protocols, abstracts, and trials: Adherence to the SPIRIT and CONSORT statements

Background

Comprehensive and transparent reporting of clinical trial activity is important. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 and Consolidated Standards of Reporting Trials (CONSORT) 2010 statements define the items to be reported in clinical trial protocols and randomized controlled trials, respectively. The aim of this methodological review was to assess the reporting quality of adult neuro-oncology trial protocols and trial result articles.

Methods

Adult primary and secondary brain tumor phase 3 trial protocols and result articles published after the introduction of the SPIRIT 2013 statement, were identified through searches of 4 electronic bibliographic databases. Following extraction of baseline demographic data, the reporting quality of independently included trial protocols and result articles was assessed against the SPIRIT and CONSORT statements respectively. The CONSORT-A checklist, an extension of the CONSORT 2010 statement, was used to specifically assess the abstract accompanying the trial results article. Percentage adherence (standard deviation [SD]) was calculated for each article.

Results

Seven trial protocols, and 36 trial result articles were included. Mean adherence of trial protocols to the SPIRIT statement was 79.4% (SD: 0.11). Mean adherence of trial abstracts to CONSORT-A was 75.3% (SD: 0.12) and trial result articles to CONSORT was 74.5% (SD: 0.10).

Conclusion

The reporting quality of adult neuro-oncology trial protocols and trial result articles requires improvement to ensure comprehensive and transparent communication of planned neuro-oncology clinical trials and results within the literature. Raising awareness by clinical triallists and implementing mandatory evidence of proof of adherence by journals should improve reporting quality.

Health-related quality of life following cranioplasty - a systematic review

Cranioplasty is a neurosurgical procedure that repairs a defect in the skull Coupled with the underlying pathology cranioplasty associated morbidity can have a large impact on patient quality of life, which is often poorly explored. The objective of this systematic review was to identify patient-reported outcomes evaluating health-related quality of life following cranioplasty. The review protocol was registered on PROSPERO (CRD42021251543) and a systematic review was conducted in accordance with the PRISMA statement. PubMed, Embase, CINAHL Plus, and the Cochrane databases were searched from inception to 1 May 2022. All studies reporting HRQoL following cranioplasty were included. Reporting was assessed using the ISOQOL checklist and risk of bias was assessed using the Newcastle-Ottawa Scale or the Johanna-Briggs Institute Scale, as appropriate. A total of 25 studies were included of which 20 were cross-sectional and 2 longitudinal. Most studies utilized study specific questionnaires and Likert scales to assess HRQoL. The studies found a significant improvement in physical functioning, social functioning, cosmetic outcome, and overall HRQoL following cranioplasty. Further longitudinal studies utilising validated measurement tools are required to better understand the effect of cranioplasty at a patient level.

Tranexamic acid use in meningioma surgery - A systematic review and meta-analysis

Tranexamic Acid (TXA) has been used in medical and surgical practice to reduce haemorrhage. The aim of this review was to evaluate the effect of TXA use on intraoperative and postoperative outcomes of meningioma surgery. A systematic review and meta-analysis was conducted in accordance with the PRISMA statement and registered in PROSPERO (CRD42021292157). Six databases were searched up to November 2021 for phase 2-4 control trials or cohort studies, in the English language, examining TXA use during meningioma surgery. Studies ran outside of dedicated neurosurgical departments or centres were excluded. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Random effects meta-analysis were performed to delineate differences in operative and postoperative outcomes. Four studies (281 patients) were included. TXA use significantly reduced intraoperative blood loss (mean difference 315.7 mls [95% confidence interval [CI] -532.8, -98.5]). Factors not affected by TXA use were transfusion requirement (odds ratio = 0.52; 95% CI 0.27, 0.98), operation time (mean difference = -0.2 h; 95% CI -0.8, 0.4), postoperative seizures (Odds Ratio [OR] = 0.88; 95% CI 0.31, 2.53), hospital stay (mean difference = -1.2; 95% CI -3.4, 0.9) and disability after surgery (OR = 0.50; 95% CI 0.23, 1.06). The key limitations of this review were the small sample size, limited data for secondary outcomes and a lack of standardised method for measuring blood loss. TXA use reduces blood loss in meningioma surgery, but not transfusion requirement or postoperative complications. Larger trials are required to investigate the impact of TXA on patient-reported postoperative outcomes.

Volumetric Growth and Growth Curve Analysis of Residual Intracranial Meningioma

BACKGROUND

After meningioma surgery, approximately 1 in 3 patients will have residual tumor that requires ongoing imaging surveillance. The precise volumetric growth rates of these tumors are unknown.

OBJECTIVE

To identify the volumetric growth rates of residual meningioma, growth trajectory, and factors associated with progression.

METHODS

Patients with residual meningioma identified at a tertiary neurosurgery center between 2004 and 2020 were retrospectively reviewed. Tumor volume was measured using manual segmentation, after surgery and at every follow-up MRI scan. Growth rates were ascertained using a linear mixed-effects model and nonlinear regression analysis of growth trajectories. Progression was defined according to the Response Assessment in Neuro-Oncology (RANO) criteria (40% volume increase).

RESULTS

There were 236 patients with residual meningioma. One hundred and thirty-two patients (56.0%) progressed according to the RANO criteria, with 86 patients being conservatively managed (65.2%) after progression. Thirteen patients (5.5%) developed clinical progression. Over a median follow-up of 5.3 years (interquartile range, 3.5-8.6 years), the absolute growth rate was 0.11 cm 3 per year and the relative growth rate 4.3% per year. Factors associated with residual meningioma progression in multivariable Cox regression analysis were skull base location (hazard ratio [HR] 1.60, 95% CI 1.02-2.50) and increasing Ki-67 index (HR 3.43, 95% CI 1.19-9.90). Most meningioma exhibited exponential and logistic growth patterns (median R 2 value 0.84, 95% CI 0.60-0.90).

CONCLUSION

Absolute and relative growth rates of residual meningioma are low, but most meet the RANO criteria for progression. Location and Ki-67 index can be used to stratify adjuvant treatment and surveillance paradigms.

Cranial meningioma with bone involvement: surgical strategies and clinical considerations

BACKGROUND

Intracranial meningioma with bone involvement and primary intraosseous meningioma is uncommon. There is currently no consensus for optimal management. This study aimed to describe the management strategy and outcomes for a 10-year illustrative cohort, and propose an algorithm to aid clinicians in selecting cranioplasty material in such patients.

METHODS

A single-centre, retrospective cohort study (January 2010-August 2021). All adult patients requiring cranial reconstruction due to meningioma with bone involvement or primary intraosseous meningioma were included. Baseline patient and meningioma characteristics, surgical strategy, and surgical morbidity were examined. Descriptive statistics were performed using SPSS v24.0. Data visualisation was performed using R v4.1.0.

RESULTS

Thirty-three patients were identified (mean age 56 years; SD 15) There were 19 females. Twenty-nine patients had secondary bone involvement (88%). Four had primary intraosseous meningioma (12%). Nineteen had gross total resection (GTR; 58%). Thirty had primary 'on-table' cranioplasty (91%). Cranioplasty materials included pre-fabricated polymethyl methacrylate (pPMMA) (n = 12; 36%), titanium mesh (n = 10; 30%), hand-moulded polymethyl methacrylate cement (hPMMA) (n = 4; 12%), pre-fabricated titanium plate (n = 4; 12%), hydroxyapatite (n = 2; 6%), and a single case combining titanium mesh with hPMMA cement (n = 1; 3%). Five patients required reoperation for a postoperative complication (15%).

CONCLUSION

Meningioma with bone involvement and primary intraosseous meningioma often requires cranial reconstruction, but this may not be evident prior to surgical resection. Our experience demonstrates that a wide variety of materials have been used successfully, but that pre-fabricated materials may be associated with fewer postoperative complications. Further research within this population is warranted to identify the most appropriate operative strategy.

Predictors of future haemorrhage from cerebral cavernous malformations: a retrospective cohort study

Cerebral cavernous malformations (CCMs) are commonly diagnosed, with a low reported rate of haemorrhage on long-term follow-up. The identification of factors predictive of future haemorrhage risk would assist in guiding the management of patients with CCM. The aim of this study was to identify variables associated with haemorrhage, and calculate haemorrhage risk in CCM. We conducted a retrospective study of patients diagnosed with a CCM, managed at a specialist tertiary neuroscience centre (2007-2019). The primary outcome was symptomatic haemorrhage, and secondary outcomes were variables associated with increased risk of haemorrhage, using multivariable Cox regression analysis. Included were 545 patients, with 734 confirmed cavernomas. Median age at diagnosis was 47 (interquartile range [IQR] 35-60), with a median follow-up duration after diagnosis of 46 months (IQR 19-85). Of the patients, 15.0% had multiple lesions (N = 82/545). Symptomatic presentation was observed in 52.5% of patients (N = 286/545). The annual haemorrhage rate was 1.00% per lesion-year (25 events in 2512 lesion-years), and higher in those with symptoms at presentation (1.50% per lesion-year, 22 events vs 0.29%, 3 events, P < 0.001). The variables associated with symptomatic haemorrhage were increased size (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.01-1.07, P = 0.004), eloquent location (HR 2.63, 95% CI 1.12-6.16, P = 0.026), and symptomatic haemorrhage at presentation (HR 5.37, 95% CI 2.40-11.99, P < 0.001). This study demonstrated that CCMs have a low haemorrhage rate. Increased size, eloquent location, and haemorrhage at presentation appear to be predictive of a higher risk of haemorrhage, and could be used to stratify management protocols.

Definition and surgical timing in cauda equina syndrome-An updated systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To conduct a systematic review identifying existing definitions of cauda equina syndrome (CES) and time to surgery in the literature for patients with CES.

METHODS

A systematic review was conducted in accordance with the PRISMA statement. Ovid Medline, Embase, CINAHL Plus, and trial registries were searched from October 1st, 2016, to 30th December 2022, and combined with articles identified from a previous systematic review by the same authors (studies published 1990-2016).

RESULTS

A total of 110 studies (52,008 patients) were included. Of these only 16 (14.5%) used established definitions in defining CES, including Fraser criteria (n = 6), British Association of Spine Surgeons (BASS) (n = 5), Gleave and MacFarlane (n = 2), and other (n = 3). Most reported symptoms were urinary dysfunction (n = 44, 40%%), altered sensation in the perianal region (n = 28, 25.5%) and bowel dysfunction (n = 20, 18.2%). Sixty-eight (61.8%) studies included details on time to surgery. There was an increase in percentage of studies defining CES published in the last 5 years compared to ones from 1990-2016 (58.6% vs 77.5.%, P = .045).

CONCLUSIONS

Despite Fraser recommendations, substantial heterogeneity exists in reporting of CES definitions, and a start point for time to surgery, with most authors using self-defined criteria. A consensus is required to define CES and time to surgery, to allow consistency in reporting and study analysis.

Meningioma systematic reviews and meta-analyses: an assessment of reporting and methodological quality

INTRODUCTION

Systematic reviews (SR) and systematic reviews with meta-analysis (SRMA) can constitute the highest level of research evidence. Such evidence syntheses are relied upon heavily to inform the clinical knowledge base and to guide clinical practice for meningioma. This review evaluates the reporting and methodological quality of published meningioma evidence syntheses to date.

METHODS

Eight electronic databases/registries were searched to identify eligible meningioma SRs with and without meta-analysis published between January 1990 and December 2020. Articles concerning spinal meningioma were excluded. Reporting and methodological quality were assessed against the following tools: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2), and Risk Of Bias in Systematic reviews (ROBIS).

RESULTS

116 SRs were identified, of which 57 were SRMAs (49.1%). The mean PRISMA score for SRMA was 20.9 out of 27 (SD 3.9, 77.0% PRISMA adherence) and for SR without meta-analysis was 13.8 out of 22 (SD 3.4, 63% PRISMA adherence). Thirty-eight studies (32.8%) achieved greater than 80% adherence to PRISMA. Methodological quality assessment against AMSTAR 2 revealed that 110 (94.8%) studies were of critically low quality. Only 21 studies (18.1%) were judged to have a low risk of bias against ROBIS.

CONCLUSION

The reporting and methodological quality of meningioma evidence syntheses was poor. Established guidelines and critical appraisal tools may be used as an adjunct to aid methodological conduct and reporting of such reviews, in order to improve the validity and transparency of research which may influence clinical practice.

Imaging timing after glioblastoma surgery (INTERVAL-GB): protocol for a UK and Ireland, multicentre retrospective cohort study

INTRODUCTION

Glioblastoma is the most common malignant primary brain tumour with a median overall survival of 12-15 months (range 6-17 months), even with maximal treatment involving debulking neurosurgery and adjuvant concomitant chemoradiotherapy. The use of postoperative imaging to detect progression is of high importance to clinicians and patients, but currently, the optimal follow-up schedule is yet to be defined. It is also unclear how adhering to National Institute for Health and Care Excellence (NICE) guidelines-which are based on general consensus rather than evidence-affects patient outcomes such as progression-free and overall survival. The primary aim of this study is to assess MRI monitoring practice after surgery for glioblastoma, and to evaluate its association with patient outcomes.

METHODS AND ANALYSIS

ImagiNg Timing aftER surgery for glioblastoma: an eVALuation of practice in Great Britain and Ireland is a retrospective multicentre study that will include 450 patients with an operated glioblastoma, treated with any adjuvant therapy regimen in the UK and Ireland. Adult patients ≥18 years diagnosed with glioblastoma and undergoing surgery between 1 August 2018 and 1 February 2019 will be included. Clinical and radiological scanning data will be collected until the date of death or date of last known follow-up. Anonymised data will be uploaded to an online Castor database. Adherence to NICE guidelines and the effect of being concordant with NICE guidelines will be identified using descriptive statistics and Kaplan-Meier survival analysis.

ETHICS AND DISSEMINATION

Each participating centre is required to gain local institutional approval for data collection and sharing. Formal ethical approval is not required since this is a service evaluation. Results of the study will be reported through peer-reviewed presentations and articles, and will be disseminated to participating centres, patients and the public.

External validation of brain arteriovenous malformation haemorrhage scores, AVICH, ICH and R2eD

PURPOSE

To externally validate the arteriovenous malformation-related intracerebral haemorrhage (AVICH), intracerebral haemorrhage (ICH), and novel haemorrhage presentation risk score (R2eD) in brain arteriovenous malformations.

METHODS

Adult patients diagnosed radiologically with an arteriovenous malformation (AVM) at a tertiary neurosurgical centre between 2007 and 2018 were eligible for inclusion. Both the AVICH and ICH scores were calculated for AVM-related symptomatic haemorrhage (SH) and compared against the modified Rankin scale (mRS) at discharge and last follow-up, with unfavourable outcome defined as mRS > 2. R2eD scores were stratified based on presentation with SH. External validity was assessed using Harrel's C-statistic.

RESULTS

Two hundred fifty patients were included. Mean age at diagnosis was 46.2 years [SD = 16.5]). Eighty-seven patients (34.8%) had a SH, with 83 included in the analysis. Unfavourable mRS outcome was seen in 18 (21.6%) patients at discharge and 18 (21.6%) patients at last follow-up. The AVICH score C-statistic was 0.67 (95% confidence interval [CI], 0.53-0.80) at discharge and 0.70 (95% CI, 0.56-0.84) at last follow-up. The ICH score C-statistic was 0.78 (95% CI 0.67-0.88), at discharge and 0.80 (95% CI 0.69-0.91) at last follow-up. The R2eD score C-statistic for predicting AVM haemorrhage was 0.60 (95% CI, 0.53-0.67).

CONCLUSIONS

The AVICH score showed fair-poor performance, while the ICH score showed good-fair performance. The R2eD score demonstrated poor performance, and its clinical utility in predicting AVM haemorrhage remains unclear.

Prevalence and Severity of Temporomandibular Disorders in Rheumatoid Arthritis Patients

Introduction

The temporomandibular joint (TMJ) is an important joint that plays major functions, including dental occlusion, mastication, and facial expressions. Different diseases can affect the TMJ, including chronic inflammatory arthritis. Rheumatoid arthritis (RA) is the most common inflammatory arthritis worldwide associated with TMJ dysfunction. In this study, we assess the prevalence of TMJ among RA patients based on the Fonseca Anamnestic Index.

Methods

Eighty-one patients with rheumatoid arthritis were interviewed by a trained physician to fulfill the Fonseca Anamnestic Index questionnaire. All participants underwent a medical file review to collect their sociodemographic data, RA duration, co-existing comorbidities, and different lab results.

Result

According to the Fonseca score, 29.6% had no temporomandibular disorder (TMD) among RA patients, while 39.5% had mild TMD. Only 6% had severe TMD. The female sex and increased body weight were associated with TMJ disease. 

Conclusion

The majority of rheumatoid arthritis patients (70%) suffer from some degree of temporomandibular joint disorder. 

How should we treat long-standing overt ventriculomegaly in adults (LOVA)? A retrospective cohort study

Long-standing overt ventriculomegaly in adults (LOVA) is a heterogenous group of conditions with differing presentations. Few studies have evaluated success rates of available surgical treatments, or ascertained the natural history. There is a need to assess the efficacy of both endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) as first-line treatments. We conducted a retrospective, single-centre study of adults with LOVA at a tertiary neurosurgery centre in England, UK, aiming to identify presentation, management strategy, and outcome following treatment. A total of 127 patients were included (mean age 48.1 years, 61/127 male). Most patients were symptomatic (73.2%, n = 93/127, median symptom duration 10 months). The most common symptoms were gait ataxia, headache, and cognitive decline (52.8%, 50.4%, and 33.9%, respectively). Fourteen patients had papilloedema. Ninety-one patients (71.7%) underwent surgery (84 ETV, 7 VPS). Over a median follow-up of 33.0 months (interquartile range [IQR] 19.0-65.7), 82.4% had a clinical improvement after surgery, and 81.3% had radiological improvement. Clinical improvement rates were similar between ETV and VP shunt groups (82.1% vs 85.7%, p = 0.812). Surgical complication rates were significantly lower in the ETV group than the VP shunt group (4.8% vs 42.9%, p < 0.001). Of the patients treated surgically, 20 (22.0%) underwent further surgery, with 14 patients improving. This study demonstrates the efficacy of ETV as a first-line treatment for LOVA.

Clinical Outcomes Following Re-Operations for Intracranial Meningioma

Simple Summary

This study investigated patients who underwent more than one operation for a meningioma, a type of brain tumor. Currently, there is little evidence available for this specific patient group. The purpose of this study was to determine if patients had an improvement or deterioration following a second operation for a recurrent meningioma, and to identify any factors that may influence this change. The results demonstrated that following a second operation for meningioma, patients have poorer outcomes. The findings of this study provide supporting information for surgeons and patients, thereby informing decisions related to patient care and re-operation.

Abstract

The outcomes following re-operation for meningioma are poorly described. The aim of this study was to identify risk factors for a performance status outcome following a second operation for a recurrent meningioma. A retrospective, comparative cohort study was conducted. The primary outcome measure was World Health Organization performance. Secondary outcomes were complications, and overall and progression free survival (OS and PFS respectively). Baseline clinical characteristics, tumor details, and operation details were collected. Multivariable binary logistic regression was used to identify risk factors for performance status outcome following a second operation. Between 1988 and 2018, 712 patients had surgery for intracranial meningiomas, 56 (7.9%) of which underwent a second operation for recurrence. Fifteen patients (26.8%) had worsened performance status after the second operation compared to three (5.4%) after the primary procedure (p = 0.002). An increased number of post-operative complications following the second operation was associated with a poorer performance status following that procedure (odds ratio 2.2 [95% CI 1.1–4.6]). The second operation complication rates were higher than after the first surgery (46.4%, n = 26 versus 32.1%, n = 18, p = 0.069). The median OS was 312.0 months (95% CI 257.8–366.2). The median PFS following the first operation was 35.0 months (95% CI 28.9–41.1). Following the second operation, the median PFS was 68.0 months (95% CI 49.1–86.9). The patients undergoing a second operation for meningioma had higher rates of post-operative complications, which is associated with poorer clinical outcomes. The decisions surrounding second operations must be balanced against the surgical risks and should take patient goals into consideration.

P14.71 An assessment of the reporting and methodological quality of meningioma systematic reviews and meta-analyses

BACKGROUND

Systematic reviews and meta-analyses constitute the highest level of research evidence and for a disease with limited clinical trial activity, are often relied upon to help inform clinical practice. This review of reviews evaluates both the reporting & methodological quality of meningioma evidence syntheses.

MATERIAL AND METHODS

Potentially eligible meningioma reviews published between 1st January 1990 and 31st December 2020 were identified from eight electronic databases. Inclusion required the study to meet the Cochrane guideline definition of a systematic review or meta-analysis. Reviews concerning neurofibromatosis type 2, spinal and pediatric meningiomas were excluded. The reporting and methodological quality of articles were assessed against the following modified guidelines: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), A MeaSurement Tool to Assess Systematic Reviews (AMSTAR2) and the Risk of Bias in Systematic Reviews (ROBIS) guidelines.

RESULTS

117 systematic reviews were identified, 57 of which included meta-analysis (48.7%). The number of meningioma systematic reviews published each year has increased with 63 studies (53.9%) published between 01/2018 and 12/2020. A median of 17 studies (IQR 9–29) were included per review. Impact factor of journals publishing a systematic review with or without a meta-analysis was similar (median 2.3 vs 1.8, P=0.397). The mean PRISMA scores for systematic reviews with a meta-analysis was 21.11 (SD 4.1, 78% adherence) and without was 13.89 (SD 3.4, 63% adherence). Twenty-nine systematic reviews with meta-analysis (51%) and 11 without meta-analysis (18%) achieved greater than 80% adherence to PRISMA recommendations. Methodological quality assessment using AMSTAR2 revealed one study (0.9%) as high quality whilst 111 (94.8%) studies were graded as critically low. One hundred and two articles (87.2%) did not utilize a comprehensive search strategy as defined by the AMSTAR2 tool. Ninety-nine studies (84.6%) obtained a high level of concern for potential bias as per the ROBIS assessment. One hundred and eight articles (92.3%) failed to present information that a protocol had been established prior to study commencement and 76 articles (65.0%) did not conduct a risk of bias assessment. Across the three tools, domains relating to the establishment of a protocol prior to review commencement and conducting appropriate risk of bias assessments were frequently low scoring.

CONCLUSION

Overall reporting and methodological quality of meningioma systematic reviews was sub-optimal. Established critical appraisal tools and reporting guidelines should be utilized a priori to assist in producing high-quality systematic reviews.

OS09.7.A Quality of life outcomes in patients with incidental and operated meningiomas: the QUALMS study

BACKGROUND

Long-term Health-Related Quality of Life (HRQoL) is an important measure of patient wellbeing. There is a paucity of studies evaluating HRQoL in meningioma patients.

MATERIAL AND METHODS

Cross-sectional study of adult patients with an incidental or symptomatic intracranial meningioma. Patients with less than 5 years of follow-up, a history of craniospinal radiation or neurofibromatosis type 2 were excluded. HRQoL was evaluated with SF-36, EORTC QLQ-C30 and EORTC QLQ-BN20 questionnaires. Outcome determinants were evaluated using a multi-variable linear regression analysis, adjusted for patient, tumour and treatment characteristics, and duration of follow-up.

RESULTS

699 patients were invited to participate and 246 responded: 118 (48%) had an incidental meningioma. Mean age at diagnosis was 56.8 years (SD=13) and 81% were female. Median time from diagnosis to completion of questionnaire was 8.5 years (IQR 6.8–11.5). During follow-up, 158 patients (64.2%) had at least one operation for their meningioma and 47 patients (19.1%) had radiotherapy. Of those operated, 126 (79.7%) had WHO grade 1 and 24 (15.2%) had grade 2 meningiomas. Compared to normative population values, meningioma patients reported a worse SF-36 general health score (mean 61.9 vs 56.5, P=0.003) but a similar QLQ-C30 global health score (mean 62.3 vs 65.8, P=0.039), worse SF-36 and QLQ-C30 physical functioning scores (mean 74.1 vs 64.6, P&lt;0.001 and mean 81.8 vs 76.5, P=0.007) and similar SF-36 and QLQ-C30 emotional health scores (mean 72.2 vs 70.9, P=0.367 and mean 71.0 vs 71.9, P=0.960). QLQ-C30 cognitive functioning was worse (mean 80.5 vs 71.4, P&lt;0.001). Compared to the meningioma literature, QLQ-BN20 seizure burden was similar (mean 2.0 vs 1.6, P=0.760). A worse performance status at diagnosis was associated with an inferior QLQ-C30 global health score (β-coefficient=-4.9 [95% CI -9.1-(-)0.6] P=0.024). Number of surgeries was significantly associated with a worse QLQ-C30 cognitive functioning score (β-coefficient=-7.0 [95% CI -13.2-(-)0.9], P=0.025). Anti-epileptic drug use was associated with a significantly worse QLQ-C30 emotional health score (β-coefficient=-10.9 [95% CI -21.7-(-)0.01], P=0.050).

CONCLUSION

Meningioma patients have long-term HRQoL impairments affecting their physical and cognitive functions. An understanding that multiple surgeries affects cognitive function, and the need for anti-epileptic drugs equate to poorer emotional health, could help target appropriate therapies and support in the future.

P14.66 Re-operation for recurrent meningioma - are we helping patients?

BACKGROUND

Meningioma is the commonest primary brain tumour. Despite surgery, meningiomas can recur. Surgery is usually the first line treatment for recurrent meningioma. The aim was to determine the risk factors associated with clinical outcomes (performance status, morbidity, mortality, recurrence) following re-operation for recurrence of intracranial meningioma.

MATERIAL AND METHODS

Retrospective cohort study (1998–2018). Eligible patients had reoperation for local recurrence of a previously operated meningioma. Collected data included baseline clinical and imaging characteristic. Primary outcome measure was performance status after each reoperation. Secondary outcome measures were medical and surgical morbidity, recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Fifty-eight patients were eligible (37 female, mean age at 1st re-operation 56.1 years (SD=11.6)). Eleven patients (19.6%) had 2 re-operations and 3 patients (5.4%) had 3 re-operations. Median follow up was 128.5 months (IQR=73–194.5). Median time to 1st recurrence and 1st re-operation were 36.5 (IQR=24.3–81.0) and 43.8 months (IQR=20.3–103.4), respectively. Fifteen patients (26.8%) had worse performance status after 1st reoperation, compared to 5.4% (n=3) after the primary operation. Complication rate was 32.1% (n=18) after the primary operation compared to 48.2% (n=27) after 1st reoperation. At primary operation, there were 29 (51.8%) grade 1, 24 (42.9%) grade 2, and 1 (1.8%) grade 3 tumours. Median RFS after first re-operation was 36.5 months (95% CI 29.3–43.9). Median OS was 312 months (95 % CI 257.8–366.2). Increased number of post-operative complications were a risk factor for worsened performance status following reoperation (OR 2.2 [95% CI 1.1–4.6], P=0.029).

CONCLUSION

Re-operation is associated with a worse performance status and increased risk of complications. Re-operating meningiomas for radiological recurrence without symptoms increases patient morbidity. Shared-care management decision should be made with patients when considering operating for radiological recurrence only.

P14.02 The Natural History of a Residual Intracranial Meningioma- Volumetric Growth and Predictors of Progression

BACKGROUND

Resection of meningioma leaves residual solid tumour in ~25% of patients. Selection for further treatment and follow-up strategy may benefit from knowledge of volumetric growth and associated prognostic factors.

MATERIAL AND METHODS

Growth rates were assessed using a linear mixed effects model, in a retrospective adult cohort that underwent subtotal resection of meningioma (2004–2018). Endpoints were re-treatment, end of follow-up or death. Cox regression analysis was used to identify prognostic factors for progression, defined using the Response Assessment in Neuro-Oncology (RANO) volumetric criteria.

RESULTS

236 patients were included. Mean age at surgery was 56.3 years (SD=13.7) and 73.7% were female. WHO grades were 1 (n=195, 82.6%), 2 (n=40, 16.9%) and 3 (n=1, 0.5%). Adjuvant fractionated radiotherapy (fRT) was administered to 34 patients (14.4%), with no propensity towards higher WHO grade or residual volume. Median pre-operative meningioma and post-operative residual volumes were 34.0cm3 (IQR 16.0–63.0) and 2.0cm3 (IQR 0.8–5.2), respectively. Median follow-up was 64 months (IQR 42–104). Median absolute growth rate (AGR) and relative growth rate (RGR) were 0.1cm3/year and 4.3%/year, respectively. According to RANO criteria, 132 (55.9%) patients progressed, of which 13 (9.8%) developed symptoms. Median progression-free survival was 56 months (95% CI 43.1–69.0). Multivariable analysis identified adjuvant fRT (HR 1.7, [95% CI 1.0–2.8], P=0.046), skull base location (HR 1.5, [95% CI 1.0–2.4], P=0.047) and Ki-67 index (HR 3.7 [95% CI 1.3–10.8], P=0.017) as prognostic factors for volumetric progression. WHO grade was not significant (HR 1.0, [95% CI 0.5–1.7], P=0.905). Forty-nine patients who progressed (37.1%) underwent further treatment: fRT (n=19), re-operation (n=15), Stereotactic radiosurgery (SRS) (n=10) and surgery+adjuvant fRT (n=5). Of those, 8 (16.3%) progressed further (after re-operation [n=6] and SRS [n=2]). Seven were treated with a 2nd re-operation (n=3), fRT (n=3), and SRS (n=1). One patient progressed after a 2nd reoperation and was treated with SRS, after which they remained stable. Median survival was not reached. 5- and 10-year overall survival (OS) was 96% and 86% respectively.

CONCLUSION

Growth rates of a residual meningioma vary with a dichotomy observed in progression rates. Half of patients with a residual meningioma showed radiological progression requiring multiple treatment to control the tumour. The other half demonstrate a more indolent course. Skull base location and higher Ki67 are important prognostic factors for progression and therefore, should be considered to stratify patients for adjuvant radiotherapy.

Neurosurgery activity levels in the United Kingdom and republic of Ireland during the first wave of the covid-19 pandemic - a retrospective cross-sectional cohort study

The impact of Covid-19 on surgical patients worldwide has been substantial. In the United Kingdom (UK) and the Republic of Ireland (RoI), the first wave of the pandemic occurred in March 2020. The aims of this study were to: (1) evaluate the volume of neurosurgical operative activity levels, Covid-19 infection rate and mortality rate in April 2020 with a retrospective cross-sectional cohort study conducted across 16 UK and RoI neurosurgical centres, and (2) compare patient outcomes in a single institution in April-June 2020 with a comparative cohort in 2019. Across the UK and RoI, 818 patients were included. There were 594 emergency and 224 elective operations. The incidence rate of Covid-19 infection was 2.6% (21/818). The overall mortality rate in patients with a Covid-19 infection was 28.6% (6/21). In the single centre cohort analysis, an overall reduction in neurosurgical operative activity by 65% was observed between 2020 (n = 304) and 2019 (n = 868). The current and future impact on UK neurosurgical operative activity has implications for service delivery and neurosurgical training.

Volumetric growth of residual meningioma - A systematic review

Surgical resection of meningioma leaves residual solid tumour in over 25% of patients. Selection for further treatment and follow-up strategy may benefit from knowledge of volumetric growth and factors associated with re-growth. The aim of this review was to evaluate volumetric growth and variables associated with growth in patients that underwent incomplete resection of a meningioma without the use of adjuvant radiotherapy. A systematic review was conducted in accordance with the PRISMA statement and registered a priori with PROSPERO (registration number: CRD42020177052). Six databases were searched up to May 2020. Full text articles analysing volumetric growth rates in at least 10 patients who had residual meningioma after surgery were assessed. Four single-centre, retrospective studies totalling 238 patients were included, of which 99% of meningioma were WHO grade 1. The absolute tumour growth rate ranged from 0.09 to 4.94 cm³ per year. The relative growth rate ranged from 5.11 to 14.18% per year. Varying methods of volumetric assessment and definitions of growth impeded pooled analysis. Pre-operative and residual tumour volume, and hyperintensity on T2 weighted MRI were identified as variables associated with residual meningioma growth, however this was inconsistent across studies. Risk of bias was high in all studies. Radiological regrowth occurred in 42-67% of cases. Our review identified that volumetric growth of residual meningioma is scarcely reported. Sufficiently powered studies are required to delineate volumetric growth and prognostic factors to stratify management.

Data Mining and Fusion of Unobtrusive Sensing Solutions for Indoor Activity Recognition

This paper proposes the fusion of data from unobtrusive sensing solutions for the recognition and classification of activities in home environments. The ability to recognize and classify activities can help in the objective monitoring of health and wellness trends in ageing adults. While the use of video and stereo cameras for monitoring activities provides an adequate insight, the privacy of users is not fully protected (i.e., users can easily be recognized from the images). Another concern is that widely used wearable sensors, such as accelerometers, have some disadvantages, such as limited battery life, adoption issues and wearability. This study investigates the use of low-cost thermal sensing solutions capable of generating distinct thermal blobs with timestamps to recognize the activities of study participants. More than 11,000 thermal blobs were recorded from 10 healthy participants with two thermal sensors placed in a laboratory kitchen: (i) one mounted on the ceiling, and (ii) the other positioned on a mini tripod stand in the corner of the room. Furthermore, data from the ceiling thermal sensor were fused with data gleaned from the lateral thermal sensor. Contact sensors were used at each stage as the gold standard for timestamp approximation during data acquisition, which allowed the attainment of: (i) the time at which each activity took place, (ii) the type of activity performed, and (iii) the location of each participant. Experimental results demonstrated successful cluster-based activity recognition and classification with an average regression co-efficient of 0.95 for tested clusters and features. Also, an average accuracy of 95% was obtained for data mining models such as k-nearest neighbor, logistic regression, neural network and random forest on Evaluation Test.Clinical Relevance-This study presents an unobtrusive (i.e., privacy-friendly) solution for activity recognition and classification, for the purposes of profiling trends in health and wellbeing.

Acute Esophageal Necrosis Associated With Methicillin-Resistant Staphylococcus Aureus Septicemia: A Case Report

Acute esophageal necrosis (AEN) is a multifactorial disease with a predilection for elderly male patients with multiple medical problems, including mainly hypoperfusion and malnutrition. The diagnosis is confirmed by biopsy, and AEN is managed conservatively by controlling the underlying illness. We report a case of a 65-year-old man with malnutrition, heart failure secondary to ischemic heart disease, infection with methicillin-resistant Staphylococcus aureus septicemia, and positive herpes simplex serology, who developed upper gastrointestinal (GI) bleeding. Endoscopy confirmed AEN, and he was managed conservatively with antacids, hydration, and antibiotics.

Simplified read schemes for krypton tagging velocimetry in N2 and air

The background and results for two simplified read schemes for krypton tagging velocimetry (KTV) are presented. The first scheme utilizes the excitation/re-excitation approach found in the literature but replaces the pulsed dye laser used for the re-excitation step with a continuous wave, narrowband laser diode. The second scheme is a single-laser setup with no read laser where the fluorescence of the tagged Kr is imaged at successive times. Results are presented and compared to historical data for experiments performed in 99%N₂/1% Kr and 95% air/5% Kr underexpanded jets. The approach with the laser diode has a higher signal, while the single-laser approach yields more consistent results. Both schemes maintain an SNR comparable to that in the literature, but with a simpler setup that enables future high-repetition rate KTV experiments.

Application of lemongrass oil in vapour phase for the effective control of anthracnose of 'Sekaki' papaya

AIMS

To evaluate the potential use of lemongrass essential oil vapour as an alternative for synthetic fungicides in controlling anthracnose of papaya.

METHODS AND RESULTS

Lemongrass oil used in the study was characterized using gas chromatography-flame ionization detection (GC-FID) before it was tested against anthracnose of papaya in vitro and in vivo. The GC-FID analysis showed that geranial (45·6%) and neral (34·3%) were the major components in lemongrass oil. In vitro study revealed that lemongrass oil vapour at all concentrations tested (33, 66, 132, 264 and 528 μl l(-1) ) suppressed the mycelial growth and conidial germination of Colletotrichum gloeosporioides. For the in vivo study, 'Sekaki' papaya were exposed to lemongrass oil fumigation (0, 7, 14, 28 μl l(-1) ) for 18 h and at room temperature for 9 days. Lemongrass oil vapour at the concentration of 28 μl l(-1) was most effective against anthracnose of artificially inoculated papaya fruit while quality parameters of papaya were not significantly altered.

CONCLUSIONS

This suggests that lemongrass oil vapour can control anthracnose disease development on papaya without affecting its natural ripening process.

SIGNIFICANCE AND IMPACT OF THE STUDY

The potential practical application of this technology can reduce reliance on synthetic fungicides for the control of postharvest diseases in papaya.

Prophylactic efficacy of recombinant IL-12, clindamycin alone or in combination against experimental reactivated toxoplasmosis

Reactivation of experimental chronic toxoplasmosis was induced by daily i.m. injection of 0.1 ml hydrocortisone acetate (25 mg/ml) per mouse. Administration of clindamycin (5 mg/kg orally), rIL-12 (0.25 microg i.p.) or combination of both was done once weekly for 3 months course starting 2 days post suppression. The prophylactic effect was assessed by determination of both survival rate and brain cyst counts with histopathological examination of brain sections at different time points post suppression besides the influence of these drug regimens on interferon gamma (IFN-delta) production. All immunocompromised untreated mice exhibited increased brain cyst burdens and reduced IFN-delta production and died due to toxoplasmic encephalitis. Neither clindamycin nor rIL-12 prevented reactivation of chronic infection, however, the slight prolongation of survival was observed. Simultaneous administration of clindamycin and rIL-12 resulted in prevention of reactivation in 73.3% of the mice till the end of the experiment. The combination regimen produced significant higher levels of IFN-delta than either drug alone suggesting that both rIL-12 and clindamycin can act additively or synergistically to prevent reactivation of chronic infection with T. gondii most probably through enhancement of IFN-delta production.

PAH-DNA adducts in a petrol refinery in Egypt

Epidemiological surveys in occupationally exposed populations postulate that long-term exposure to polycyclic aromatic hydrocarbons (PAHs) is carcinogenic. We studied the ability of PAHs to induce the formation of adducts in the DNA of white blood cells of petrol refinery workers exposed at the workplace. Our study included a random sample of 56 workers exposed to PAHs and 37 non-exposed workers. In the univariate analysis, the DNA adduct level of PAH-exposed workers (42.22 +/- 45.11) was significantly increased (P < 0.05) compared with that in the non-exposed group (20.90 +/- 22.56). However, we could not identify either current smoking or absence of glutathione S-transferase class Mu as possible risk factors for DNA adducts. Linear regression analysis identified degree of exposure to PAHs as the only DNA adducts risk factor. Further research with a larger sample size is under investigation to identify the DNA adduct levels and relationship between the different types of PAHs.

Responses of larval Chrysomyia albiceps (Wiedemann) to light

Investigations into the phototactic behaviour of Chyrsomyia albiceps led to the following results: (a) The phototactic behaviour of the third instar fresh larvae had moved away from the light within 50 sec. (96%). (b) Fatigued larvae moved across the division line several times and took more time to travel away from light.

Supercontinuum generated by six-photon mixing

We obtain the shape, phase, and spectral distribution of an ultrafast pulse propagating in a chi((5)) medium (six-photon mixing). The calculation is performed in the plane-wave approximation for a dispersionless medium but with self-steepening present.

Interference pattern of the supercontinuum generated by self-phase modulation

We compute the interference pattern generated by a plane-wave self-phase-modulated ultrafast pulse. For high intensities, the presence of the amplitude-phase time shift in this signal generates fringe position shifts. We also compute the Fourier transform of the interferometric intensity distribution and relate its range to the functions that determine the supercontinuum spectral extents and frequency shift.

Male attitudes towards family planning in Khartoum, Sudan

In a 1982 survey of 250 men living in Khartoum, knowledge of, attitudes towards and use of contraception among Sudanese men were explored. Particular attention was given to attitudes towards male and female sterilization. Although most of the men expressed a desire to have large families, several findings suggest that they felt that they may have to be satisfied with a lower number for economic reasons. Three-fifths of the men with wives of reproductive age wished to use family planning services now but only about one-fifth were currently using an effective method. Almost 60% of the men were interested in learning more about female sterilization and about 50%, more about male sterilization. In general, attitudes towards family planning were more favourable than previously believed by providers of these services. Only 2·8% of these men had obtained services from a family planning clinic, suggesting that the demand currently exceeds the supply.