Survivors of infant atypical teratoid/rhabdoid tumors present with severely impaired cognitive functions especially for fluid intelligence and visual processing: data from the German brain tumor studies

BACKGROUND

The contribution of tumor type, multimodal treatment, and other patient-related factors upon long-term cognitive sequelae in infant brain tumor survivors remains undefined. We add our retrospective analysis of neuropsychological and quality of survival (QoS) outcome data of survivors of atypical teratoid/rhabdoid tumors (ATRT) and extracranial malignant rhabdoid tumors of the soft tissues (eMRT) and kidneys (RTK) treated within the same framework. Neuropsychological data from children with ATRT were compared to data from children with non-irradiated low-grade glioma (LGG).

PATIENTS AND METHODS

Following surgery, patients (0-36 months at diagnosis) had received radio-chemotherapy (up to 54 Gy; ATRT: n = 13; eMRT/RTK: n = 7), chemotherapy only (LGG: n = 4; eMRT/RTK: n = 1) or had been observed (LGG: n = 11). Neuropsychological evaluation employing comparable tests was performed at median 6.8 years (ATRT), 6.6 years (eMRT/RTK), and 5.2 years (LGG) post diagnosis.

RESULTS

We detected sequelae in various domains for all tumor types. Group comparison showed impairments, specifically in fluid intelligence (p = .041; d = 1.11) and visual processing (p = .001; d = 2.09) in ATRT patients when compared to LGG patients. Results for psychomotor speed and attention abilities were significantly below the norm for both groups (p < .001-.019; d = 0.79-1.90). Diagnosis predicted impairments of cognitive outcome, while sex- and age-related variables did not. QoS outcome for all rhabdoid patients displayed impairments mainly in social (p = .008; d = 0.74) and school functioning (p = .048; d = 0.67), as well as lower overall scores in psychosocial functioning (p = .023; d = 0.78) and quality of life (p = .006; d = 0.79) compared to healthy controls.

CONCLUSION

Survivors of infant ATRT experience various late effects in cognition and QoS following multimodal treatment, while infant LGG patients without radiotherapy demonstrated comparable impairments in psychomotor and attention abilities. Early onset and multimodal treatment of rhabdoid tumors require close monitoring of neuropsychological and QoS sequelae.

ATRT-02. Neuropsychological function in infant atypical teratoid/rhabdoid tumor versus low-grade glioma survivors reflects tumor malignancy and multimodal treatment

BACKGROUND: Therapy of infants with brain tumors predisposes these patients to increased risks for cognitive sequelae, especially following radiotherapy. Neuropsychological outcome gains importance for those 40-60% of patients with an atypical teratoid/rhabdoid tumor (ATRT) who survive beyond 2 years. Still, reports on cognitive late-effects in children with ATRT are scarce compared to other pediatric brain tumor groups. We analyzed neuropsychological outcome for long-term ATRT-survivors registered in EU-RHAB and infant low-grade glioma (LGG) survivors from the SIOP-LGG 2004-study and LGG-registry. PATIENTS+METHODS: Age at diagnosis of both cohorts was 0-36 months. ATRT-patients (n=13) treated with up to 54Gy radiotherapy (median age 22 months (±7.1)) were evaluated with the “ATRT-Neuropsychology” tool based on SIOPE-BTG QoS-Group recommendations at median 6.8 years (±2.8) after diagnosis. LGG-patients (n=15) treated without radiotherapy (4/15 with chemotherapy) were analyzed with the German “Neuropsychological-Basic-Diagnostic” tool 5.2 years (±0.6) post-diagnosis. RESULTS: The ATRT- vs. LGG-cohorts were comparable for median age at diagnosis, sex-ratio and tumor-localization, though they differed slightly in median age at assessment (9.5/7.2 years (±2.5/1.1)). Results of age-appropriate tests showed increased impairments for ATRT-patients in fluid intelligence (FI) (p=.006, d=1.214) and in visual-spatial processing (VSP) (p<.001, d=2.233) compared to LGG-patients. The median for neuropsychological test results of ATRT-patients spanned from considerably below the normal to the lower normal range (median=65-90), while results of LGG-patients were mostly in the lower normal range (median=83-103). Results for psychomotor speed abilities (PMS) were distinctly below the norm for both patient groups (p=.002-.007). CONCLUSION: Infant ATRT- and LGG-patients develop significant impairments in PMS abilities following multimodal treatment. Long-term survivors of ATRT suffer from additional FI and VSP deficits. Our data suggest that high malignancy requiring multimodal treatment determines the inferior cognitive outcome for the ATRT-cohort. Long-term neuropsychological monitoring (and treatment options) should be implemented as standard of care in ATRT- and LGG-trials.

Brain malformations and cognitive performance in spina bifida

AIM

To systematically characterize radiological features of patients with spina bifida, their relationship to cognitive function, and differences between spina bifida aperta (SBA) and spina bifida occulta (SBO).

METHOD

In a retrospective study of 265 patients (117 females, 148 males; median age at imaging 11y, range 1-47y; SBA n=206, SBO n=59), the radiological phenotype was assessed through magnetic resonance imaging (MRI) (SBA n=171, SBO n=59). In 126 patients (SBA n=116, SBO n=10) Kaufman Assessment Battery for Children (KABC) or Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV) and Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV) were performed.

RESULTS

Patients with spina bifida show numerous brain malformations, always present for SBA but rarely for SBO. The most frequent brain malformations in SBA included abnormal corpus callosum (69%), hypoplastic pons (50%), and hypoplastic mesencephalon (20%). Cognitive total IQ scores were below average in 44% (KABC) to 49% (WISC-IV) of children with SBA, while almost all children with SBO scored at least average. Stenogyria (p=0.006), pons (p=0.003), and mesencephalon hypoplasia (p=0.01) correlated with lower total IQ score and verbal comprehension. Various brain malformations correlate significantly with several cognitive domains, while lesion level only correlates with processing speed.

INTERPRETATION

IQ scores were significantly lower in patients with SBA than in patients with SBO. Verbal competence, perceptual reasoning, and working memory were significantly impaired for SBA and correlated with stenogyria and abnormalities of the midbrain and corpus callosum.

WHAT THIS PAPER ADDS

Brain malformations occur more frequently in spina bifida aperta (SBA) than in spina bifida occulta (SBO). Cognitive impairment is less frequent in SBO. Hydrocephalus, stenogyria, midbrain, and corpus callosum abnormalities are associated with lower cognitive function. Difference in prognosis in SBO versus SBA can alter prenatal counselling.

Vectorial calibration of superconducting magnets with a quantum magnetic sensor

Cryogenic vector magnet systems make it possible to study the anisotropic magnetic properties of materials without mechanically rotating the sample but by electrically tilting and turning the magnetic field. Vector magnetic fields generated inside superconducting vector magnets are generally measured with three Hall sensors. These three probes must be calibrated over a range of temperatures, and the temperature-dependent calibrations cannot be easily carried out inside an already magnetized superconducting magnet because of remaining magnetic fields. A single magnetometer based on an ensemble of nitrogen vacancy (NV) centers in diamond is proposed to overcome these limitations. The quenching of the photoluminescence intensity emitted by NV centers can determine the field in the remanent state of the solenoids and allows an easy and fast canceling of the residual magnetic field. Once the field is reset to zero, the calibration of this magnetometer can be performed in situ by a single measurement of an optically detected magnetic resonance spectrum. Thereby, these magnetometers do not require any additional temperature-dependent calibrations outside the magnet and offer the possibility to measure vector magnetic fields in three dimensions with a single sensor. Its axial alignment is given by the crystal structure of the diamond host, which increases the accuracy of the field orientation measured with this sensor, compared to the classical arrangement of three Hall sensors. It is foreseeable that the magnetometer described here has the potential to be applied in various fields in the future, such as the characterization of ferromagnetic core solenoids or other magnetic arrangements.

Early Onset, Long Illness Duration, Epilepsy Type, and Polypharmacy Have an Adverse Effect on Psychosocial Outcome in Children with Epilepsy

Epilepsy is often associated with psychosocial comorbidity and this can be more disabling than the seizure activity. Still, these associated conditions are often underdiagnosed and therefore not sufficiently treated. We studied a large pediatric cohort of 371 patients with epilepsy to identify factors associated with negative outcome. We found that patients with early-onset epilepsy, epilepsy of known etiology, and polypharmacy were the most likely to display cognitive impairment. Behavioral problems were particularly prevalent in patients with an epilepsy duration ≥ 5 years. Similarly, early-onset epilepsy, long illness duration, epilepsy of known etiology, and polypharmacy had an adverse effect on school placement and/or social contact. With polypharmacy being the only potentially modifiable factor, it is important to balance between benefits and adverse effects of antiepileptic drugs and consider alternative therapy options in selected patients such as epilepsy surgery, vagal nerve stimulation, and ketogenic diet early-on.

Comparison of Assay Kits for Unconjugated Estriol Shows that Expressing Results as Multiples of the Median Causes Unacceptable Variation in Calculated Risk Factors for Down Syndrome

We compared the performance of two methods for assaying unconjugated estriol in serum: the modified Amerlex third-trimester RIA kit, as used in seminal papers on unconjugated estriol in Down syndrome screening, and the new optimized Amerlex-M second-trimester kit. The significant difference between the results of each assay could cause unacceptable changes in the detection rate and false-positive rate of Down syndrome screening programs, especially if previously published values for estriol are used in the risk calculation. It is not possible to define new calculation parameters for every assay kit because new parameters will need to be defined every time kit changes occur, which would require a large collection of samples from Down syndrome pregnancies for standardization. Possible solutions to this problem are discussed.

The Multiple Sclerosis Inventory of Cognition for Adolescents (MUSICADO): A brief screening instrument to assess cognitive dysfunction, fatigue and loss of health-related quality of life in pediatric-onset multiple sclerosis

OBJECTIVE

Screening for cognitive impairment (CI), fatigue and also Health-related quality of life (HRQoL) in patients with pediatric-onset multiple sclerosis (POMS) is of utmost importance in clinical practice. The aim of this study was to establish a new and validated pediatric screening tool "MUSICADO" that is easy to use and time economical.

METHODS

106 patients with POMS aged 12-18 years and 210 healthy controls (HCs) stratified for age and education underwent neuropsychological testing including a screening test "Multiple Sclerosis Inventory of Cognition" for adults and 8 standardized cognitive tests and established scales to assess fatigue and HRQoL.

RESULTS

The phonemic verbal fluency task (RWT "s-words"), the Trail Making Test A (TMT-A), and the Digit Span Forward discriminated significantly between patients and HCs (p = 0.000, respectively) and showed the highest proportion of test failure in patients (24.5%, 17.9%; 15.1%, respectively). Therefore, they were put together to form the cognitive part of the "MUSICADO". After applying a scoring algorithm with balanced weighting of the subtests and age and education correction and a cut-off score for impairment, 35.8% of patients were categorized to be cognitively impaired (specificity: 88.6%). Fatigue was detected in 37.1% of the patients (specificity: 94.0%) and loss of HRQoL in 41.8% (specificity 95.7%) with the screening version, respectively.

CONCLUSION

The MUSICADO is a newly designed brief and easy to use screening test to help to early identify CI, fatigue, and loss of HRQoL in patients with POMS as cut scores are provided for all three items. Further studies will have to show its usability in independent samples of patients with POMS.

Recurrent occipital dermatofibrosarcoma protuberans tackled with wide local excision: A case report and current management

Dermatofibrosarcoma protuberans (DFSP) is a slowgrowing, locally invasive tumour of the dermis. It commonly presents in the trunks and proximal extremities but is seen to a lesser extent in the head and neck regions. We present a case report of a recurrent DFSP in a 48-year-old Iban woman at the occipital region. The patient underwent wide local excision and removal of outer table of cranium, dressing followed by split thickness skin graft. Histopathological examination confirmed dermatofibrosarcoma protuberans with clear lateral surgical margins and a deep margin of 0.5mm. She is currently undergoing radiotherapy and is planned for 50Grey 25cycles.

Hierarchically structured carbon and silica by chemical foaming

Foamed organic/silica hybrid materials are synthesized via cationic polymerization of organic carbonates with twin monomers. They are converted into hierarchically structured carbon and silica.

Normothermic Ex Vivo Kidney Perfusion Following Static Cold Storage-Brief, Intermediate, or Prolonged Perfusion for Optimal Renal Graft Reconditioning?

Normothermic ex vivo kidney perfusion (NEVKP) demonstrated superior results compared to hypothermic storage in donation after circulatory death (DCD) kidney transplantation. It is unknown whether an optimal perfusion time exists following hypothermic storage to allow for the recovery of renal grafts from cold ischemic injury. In a porcine model of DCD kidney autotransplantation, the impact of initial static cold storage (SCS) (8 h) followed by various periods of NEVKP recovery was investigated: group A, 8 hSCS only (control); group B, 8 hSCS + 1 hNEVKP (brief NEVKP); group C, 8 hSCS + 8 hNEVKP (intermediate NEVKP); and group D, 8 hSCS + 16 hNEVKP (prolonged NEVKP). All grafts were preserved and transplanted successfully. One animal in group D was sacrificed and excluded by postoperative day 3 due to hind limb paralysis, but demonstrated good renal function. Postoperative graft assessment during 8 days' follow-up demonstrated lowest levels of peak serum creatinine for intermediate (C) and prolonged (D) NEVKP (p = 0.027). Histological assessment on day 8 demonstrated a significant difference in tubular injury (p = 0.001), with highest values for group B. These results suggest that longer periods of NEVKP following SCS are feasible and safe for postponing surgical transplant procedure and superior to brief NEVKP, reducing the damage caused during cold ischemic storage of renal grafts.

Management of neglected ACL avulsion fractures: a case series and systematic review

INTRODUCTION

Neglected tibial eminence avulsion fractures of the anterior cruciate ligament (ACL) are uncommonly seen in modern times, but are fairly common due to a missed diagnosis/mismanagement in developing countries.

OBJECTIVES

To determine the outcomes after open reduction and internal fixation of late presenting ACL avulsion fractures, and to review the literature for similar cases, in an attempt to evaluate the ideal surgical management in this unique scenario.

STUDY DESIGN

Retrospective observational study and systematic review MATERIALS: The study included 10 male and 2 female cases (mean age 29.9 years). Patients were assessed for the pre-operative knee range-of-motion (ROM), flexion deformity and stability; functional assessment was conducted using the Lysholm scale, both pre and post-operatively. Open reduction and internal fixation with two partially threaded screws (via a mini anterior approach) was performed in all 12 cases. All patients were clinically followed up for a minimum duration of 12 months. We searched PubMed, Embase and Cochrane databases from the period of inception to January 15, 2017 for similar case series/reports involving management of chronic/neglected ACL avulsion fractures and systematically reviewed these studies following standard PRISMA guidelines.

RESULTS

The median duration of presentation after injury was 12 months (range 3 to 312 months; mean 45.3 months). The mean follow-up duration was 24.1 months (range 12-48 months). All patients achieved normal knee extension except one patient who had a residual 5° flexion contracture. On physical examination, Lachman and pivot-shift tests were negative in all but 1 patient. No case required ACL reconstruction, and the fractures united radiologically within 12 weeks; all patients regained former activity levels.

DISCUSSION

Eleven published studies, mainly case reports, reported on the management of chronic/neglected ACL avulsion fractures. Arthroscopic suture/wire fixation, arthroscopic debridement of avulsed fragment and open reduction, internal fixation (ORIF) with screws are the described techniques for this uncommon entity. However, anatomic reduction of ACL avulsion fractures is difficult arthroscopically as crater depth assessment and repositioning of the avulsed fragment become a problem; the avulsed fragment may also hypertrophy, and some contractures in ACL may develop. A mini-open procedure does not add to the morbidity, overcomes reduction obstacles and allows easy fixation with screws, and can be done even in centers that do not have arthroscopic experience. The key point is accurate reduction and rigid fixation, ensuring no impingement on full extension CONCLUSIONS: Mini-open fixation allows accurate, anatomic reduction and stable fixation with screws, and should be the preferred method of fixation for late presenting ACL avulsion fractures; embedding the fragment deep into the crater or size reduction are key to preventing extension deficits.