Biologic treatment for severe chronic rhinosinusitis with nasal polyps: a systematic review and meta-analysis

BACKGROUND

Chronic rhinosinusitis with nasal polyps is often severe, debilitating and difficult to treat. Biologics that target key inflammatory pathways have the potential to treat this disease; this study aimed to evaluate their effectiveness.

METHODOLOGY

Systematic review and meta-analysis of randomised controlled trials of biologics in chronic rhinosinusitis with nasal polyps. Primary outcomes were extent of disease, objective disease severity and disease-specific quality of life, with outcomes measured at different end-of-treatment timepoints in different studies (range 16-52 weeks).

RESULTS

Eleven trials were identified with 2035 participants. Ten studies reported change in polyp size, estimating a reduction of -1.25 in the treatment group. Six studies reported reduction in Lund-Mackay score where the pooled mean difference was -4.90. Five studies included peak nasal inspiratory flow with a pooled mean difference of 33.54, indicating improved nasal airflow. Seven studies reported change in olfactory score with an overall pooled effect of 6.56 suggesting improved olfaction. The SNOT-22 score in nine studies gave an overall pooled effect of -14.53, indicating improved quality of life.

CONCLUSIONS

Biologics can be effective in treating nasal polyps, with reduction in polyp size and extent of disease, and improved sense of smell and quality of life. There is significant heterogeneity in the outcomes for individual biologics, highlighting the need for further studies.

Amplification of the PLAG-family genes-PLAGL1 and PLAGL2-is a key feature of the novel tumor type CNS embryonal tumor with PLAGL amplification

Pediatric central nervous system (CNS) tumors represent the most common cause of cancer-related death in children aged 0-14 years. They differ from their adult counterparts, showing extensive clinical and molecular heterogeneity as well as a challenging histopathological spectrum that often impairs accurate diagnosis. Here, we use DNA methylation-based CNS tumor classification in combination with copy number, RNA-seq, and ChIP-seq analysis to characterize a newly identified CNS tumor type. In addition, we report histology, patient characteristics, and survival data in this tumor type. We describe a biologically distinct pediatric CNS tumor type (n = 31 cases) that is characterized by focal high-level amplification and resultant overexpression of either PLAGL1 or PLAGL2, and an absence of recurrent genetic alterations characteristic of other pediatric CNS tumor types. Both genes act as transcription factors for a regulatory subset of imprinted genes (IGs), components of the Wnt/β-Catenin pathway, and the potential drug targets RET and CYP2W1, which are also specifically overexpressed in this tumor type. A derived PLAGL-specific gene expression signature indicates dysregulation of imprinting control and differentiation/development. These tumors occurred throughout the neuroaxis including the cerebral hemispheres, cerebellum, and brainstem, and were predominantly composed of primitive embryonal-like cells lacking robust expression of markers of glial or neuronal differentiation (e.g., GFAP, OLIG2, and synaptophysin). Tumors with PLAGL1 amplification were typically diagnosed during adolescence (median age 10.5 years), whereas those with PLAGL2 amplification were diagnosed during early childhood (median age 2 years). The 10-year overall survival was 66% for PLAGL1-amplified tumors, 25% for PLAGL2-amplified tumors, 18% for male patients, and 82% for female patients. In summary, we describe a new type of biologically distinct CNS tumor characterized by PLAGL1/2 amplification that occurs predominantly in infants and toddlers (PLAGL2) or adolescents (PLAGL1) which we consider best classified as a CNS embryonal tumor and which is associated with intermediate survival. The cell of origin and optimal treatment strategies remain to be defined.

EPOS 4 Patients

EPOS2020 is the 4th and most recent version of the European Position Paper on Rhinosinusitis and Nasal Polyps which was first published in 2005. It aims to provide the most up to date scientifically robust information on the topic published in the literature which has been critically analysed by an international group of clinicians drawn from all disciplines dealing with these problems together with patients. The guidelines offer evidence-based recommendations and care pathways for acute and chronic rhinosinusitis in both adults and children. Management of these diseases from the patients' perspective is an important part of EPOS2020. Not only is this included in the main document but, for the first time, we have produced a separate supplement dedicated to and in collaboration with patients, EPOS4Patients, which aims to provide information in an accessible format, to answer frequently asked questions about these diseases and their treatment options as well as including useful patient resources and websites. It has never been more important for patients to be actively involved in their care. Being well informed helps you to make the best decisions together with your doctor.

IMG-13. MRI-BASED RADIOMICS PROGNOSTIC MARKERS OF POSTERIOR FOSSA EPENDYMOMA

PURPOSE

Posterior fossa ependymomas (PFE) are common pediatric brain tumors often assessed with MRI before surgery. Advanced radiomic analysis show promise in stratifying risk and outcome in other pediatric brain tumors. Here, we extracted high-dimensional MRI features to identify prognostic, image-based, radiomics markers of PFE and compared its performance to clinical variables.

METHODS

93 children from five centers (median age=3.3yrs; 59 males; mean PFS=50mos) were included. Tumor volumes were manually contoured on T1-post contrast and T2-weighted MRI for PyRadiomics feature extraction. Features include first-order statistics, size, shape, and texture metrics calculated on the original, log-sigma, and wavelet transformed images. Progression free survival (PFS) served as outcome. 10-fold cross-validation of a LASSO Cox regression was used to predict PFS. Model performance was analyzed and concordance metric (C) was determined using clinical variable (age at diagnosis and sex) only, radiomics only, and radiomics plus clinical variable.

RESULTS

Six radiomic features were selected (all T1): 1 first-order kurtosis (log-sigma) and 5 texture features (3 wavelet, 2 original). This model demonstrated significantly higher performance than a clinical model alone (C: 0.69 vs 0.58, p<0.001). Adding clinical features to the radiomic features didn’t improve prediction (p=0.67). For patients with molecular subtyping (n=48), adding this feature to the clinical plus radiomics models significantly improved performance over clinical features alone (C = 0.79 vs. 0.66, p=0.02). Further validation and model refinement with additional datasets are ongoing.

CONCLUSION

Our pilot study shows potential role for MRI-based radiomics and machine learning for PFE risk stratification and as radiographic biomarkers.

IMG-10. MRI-BASED RADIOMIC PROGNOSTIC MARKERS OF DIFFUSE MIDLINE GLIOMA

BACKGROUND

Diffuse midline gliomas (DMG) are lethal pediatric brain tumors with dismal prognoses. Presently, MRI is the mainstay of disease diagnosis and surveillance. We aimed to identify prognostic image-based radiomics markers of DMG and compare its performance to clinical variables at presentation.

METHODS

104 treatment-naïve DMG MRIs from five centers were used (median age=6.5yrs; 18 males, median OS=11mos). We isolated tumor volumes of T1-post-contrast (T1gad) and T2-weighted (T2) MRI for PyRadiomics high-dimensional feature extraction. 900 features were extracted on each image, including first order statistics, 2D/3D Shape, Gray Level Co-occurrence Matrix, Gray Level Run Length Matrix, Gray Level Size Zone Matrix, Neighboring Gray tone Difference Matrix, and Gray Level Dependence Matrix, as defined by Imaging Biomarker Standardization Initiative. Overall survival (OS) served as outcome. 10-fold cross-validation of LASSO Cox regression was used to predict OS. We analyzed model performance using clinical variable (age at diagnosis and sex) only, radiomics only, and radiomics plus clinical variable. Concordance metric was used to assess the Cox model.

RESULTS

Nine radiomic features were selected from T1gad (2 texture wavelet) and T2 (5 first-order features (1 original, 4 wavelet), 2 texture features (1 wavelet, 1 log-sigma). This model demonstrated significantly higher performance than a clinical model alone (C: 0.68 vs 0.59, p&lt;0.001). Adding clinical features to radiomic features slightly improved prediction, but was not significant (C=0.70, p=0.06).

CONCLUSION

Our pilot study shows a potential role for MRI-based radiomics and machine learning for DMG risk stratification and as image-based biomarkers for clinical therapy trials.

Impact of the rise of artificial intelligence in radiology: What do radiologists think?

PURPOSE

The purpose of this study was to assess the perception, knowledge, wishes and expectations of a sample of French radiologists towards the rise of artificial intelligence (AI) in radiology.

MATERIAL AND METHOD

A general data protection regulation-compliant electronic survey was sent by e-mail to the 617 radiologists registered in the French departments of Nord and Pas-de-Calais (93 radiology residents and 524 senior radiologists), from both public and private institutions. The survey included 42 questions focusing on AI in radiology, and data were collected between January 16^th and January 31^st, 2019. The answers were analyzed together by a senior radiologist and a radiology resident.

RESULTS

A total of 70 radiology residents and 200 senior radiologists participated to the survey, which corresponded to a response rate of 43.8% (270/617). One hundred ninety-eight radiologists (198/270; 73.3%) estimated they had received insufficient previous information on AI. Two hundred and fifty-five respondents (255/270; 94.4%) would consider attending a generic continuous medical education in this field and 187 (187/270; 69.3%) a technically advanced training on AI. Two hundred and fourteen respondents (214/270; 79.3%) thought that AI will have a positive impact on their future practice. The highest expectations were the lowering of imaging-related medical errors (219/270; 81%), followed by the lowering of the interpretation time of each examination (201/270; 74.4%) and the increase in the time spent with patients (141/270; 52.2%).

CONCLUSION

While respondents had the feeling of receiving insufficient previous information on AI, they are willing to improve their knowledge and technical skills on this field. They share an optimistic view and think that AI will have a positive impact on their future practice. A lower risk of imaging-related medical errors and an increase in the time spent with patients are among their main expectations.

Multinodular and vacuolating neuronal tumors in epilepsy: dysplasia or neoplasia?

Multinodular and vacuolating neuronal tumor (MVNT) is a new pattern of neuronal tumour included in the recently revised WHO 2016 classification of tumors of the CNS. There are 15 reports in the literature to date. They are typically associated with late onset epilepsy and a neoplastic vs. malformative biology has been questioned. We present a series of ten cases and compare their pathological and genetic features to better characterized epilepsy‐associated malformations including focal cortical dysplasia type II (FCDII) and low‐grade epilepsy‐associated tumors (LEAT). Clinical and neuroradiology data were reviewed and a broad immunohistochemistry panel was applied to explore neuronal and glial differentiation, interneuronal populations, mTOR pathway activation and neurodegenerative changes. Next generation sequencing was performed for targeted multi‐gene analysis to identify mutations common to epilepsy lesions including FCDII and LEAT. All of the surgical cases in this series presented with seizures, and were located in the temporal lobe. There was a lack of any progressive changes on serial pre‐operative MRI and a mean age at surgery of 45 years. The vacuolated cells of the lesion expressed mature neuronal markers (neurofilament/SMI32, MAP2, synaptophysin). Prominent labelling of the lesional cells for developmentally regulated proteins (OTX1, TBR1, SOX2, MAP1b, CD34, GFAPδ) and oligodendroglial lineage markers (OLIG2, SMI94) was observed. No mutations were detected in the mTOR pathway genes, BRAF, FGFR1 or MYB. Clinical, pathological and genetic data could indicate that MVNT aligns more with a malformative lesion than a true neoplasm with origin from a progenitor neuro‐glial cell type showing aberrant maturation.

Melanoma in congenital melanocytic naevi

Congenital melanocytic naevi (CMN) are a known risk factor for melanoma, with the greatest risk currently thought to be in childhood. There has been controversy over the years about the incidence of melanoma, and therefore over the clinical management of CMN, due partly to the difficulties of histological diagnosis and partly to publishing bias towards cases of malignancy. Large cohort studies have demonstrated that melanoma risk in childhood is related to the severity of the congenital phenotype. New understanding of the genetics of CMN offers the possibility of improvement in diagnosis of melanoma, identification of those at highest risk, and new treatment options. We review the world literature and our centre's experience over the last 25 years, including the molecular characteristics of melanoma in these patients and new melanoma incidence and outcome data from our prospective cohort. Management strategies are proposed for presentation of suspected melanoma of the skin and the central nervous system in patients with CMN, including use of oral mitogen-activated protein kinase kinase inhibitors in NRAS-mutated tumours.

The need for an objective measure in septorhinoplasty surgery: are we any closer to finding an answer?

OBJECTIVES

To assess the reliability of nasal inspiratory peak flow (NIPF) in providing a clinically accurate objective measure following functional septorhinoplasty by comparing it to the validated disease-specific quality-of-life questionnaire, SNOT-22. Studies so far have demonstrated poor correlation between bilateral NIPF and symptom-specific nasal questionnaires following septorhinoplasty.

DESIGN

To perform a prospective comparative analysis between NIPF and the validated disease-specific quality-of-life questionnaire SNOT-22 and to determine whether a correlation exists following septorhinoplasty surgery.

SETTING

The Royal National Throat Nose and Ear Hospital, London.

PARTICIPANTS

A total of 122 patients (78 males, 44 females; mean age 33.5 ± 12.2 years) were recruited from the senior authors rhinology clinic and underwent functional septorhinoplasty surgery.

MAIN OUTCOME MEASURES

Preoperative and postoperative nasal inspiratory peak flow (NIPF) measurements were performed in addition to the completion of three subjective quality-of-life and symptom assessment tool questionnaires; Sinonasal Outcome Test 22 (SNOT-22), Nasal Obstruction Symptom Evaluation (NOSE) and Visual Analogue Scale (VAS: 0-10).

RESULTS

The mean preoperative NIPF was 88.2 L/min, and the postoperative value was 101.6 L/min and showed a significant improvement following surgery (P = 0.0064). The mean total SNOT-22 score improved significantly from 48.6 to 26.6 (P < 0.0001); the NOSE score from 14.1 to 6.6 (P < 0.0001); and the Visual Analogue Scale (VAS) blockage score from 6.9 to 3.2 (P < 0.0001). All individual domains assessed showed improvements postoperatively, but no correlation was found between the NIPF and SNOT-22 score. Equally, we did not find a correlation between NIPF and the symptom-specific NOSE questionnaire and the nasal blockage domain on the Visual Analogue Scale (VAS) scale.

CONCLUSION

We have demonstrated that NIPF does not correlate with the SNOT-22 disease-specific questionnaire, although both outcomes significantly improve postoperatively. At present, we are still lacking a clinically accurate objective measure of nasal function for the evaluation of patients undergoing septorhinoplasty surgery.

Outcomes in open structure septorhinoplasty

OBJECTIVES

This study assessed the patient-related outcome measures and complications of post-open structure septorhinoplasty. It also investigated the factors associated with the need for revision surgery.

METHODS

We prospectively reviewed the case notes of patients who underwent septorhinoplasty performed by a single rhinologist at our institute between August 2011 and August 2013. Patient satisfaction was assessed using the Rhinoplasty Outcomes Evaluation (ROE) tool.

RESULTS

A total of 120 patients were included with a mean follow-up time of 28.2 months. Eight patients (6.7%) required revision nasal surgery. There was a significant increase in the mean post-operative ROE score of all patients who underwent surgery (19.5 ± 9.41 vs. 68.4 ± 23.7,p < 0.001). The rate of revision surgery was significantly higher in patients with complex surgeries (3/12 vs. 5/108, p = 0.03). There were higher rates of nasal tip deformity surgery and augmentation surgery in the revision surgery group compared to the primary surgery group: 8/17 vs. 20/103, p = 0.03 for nasal tip and 10/17 vs. 27/103, p = 0.01 for augmentation.

CONCLUSIONS

Open structure septorhinoplasty significantly increased the ROE score. Our rate of revision surgery, 6.7%, was lower than the average rate of 10%-18% reported in the literature. The rate of revision surgery was higher in cases judged pre-operatively to be more complex.

Abstract LB-201: MYC and TP53 defects interact at medulloblastoma relapse to define rapidly progressive disease and can be targeted therapeutically

Disease recurrence following multi-modal therapy is the single most adverse event in medulloblastoma (MB). Currently &gt;90% of relapsing patients die, accounting for ∼10% of childhood cancer deaths. MB is heterogeneous at diagnosis, comprising four molecular subgroups with distinct clinicopathological and molecular features and outcomes. The relevance of these features at relapse is unknown, making characterisation, modelling and targeted therapy of relapse biology essential to improve outcomes. However, relapsed MBs are not routinely biopsied in clinical practice.

We undertook a first comprehensive investigation of the molecular, clinical and pathological features of 29 relapsed MBs and paired tumour samples taken at diagnosis, including the assessment of features with established significance at diagnosis (e.g. chromosome 17 and TP53 pathway status, MYC family (MYC, MYCN) gene amplification, polyploidy, CTNNB1 mutation and molecular subgroup status). Molecular subgroup was concordant at diagnosis and relapse, however evidence of alteration of all other features examined was found in relapsed tumours, with the majority of changes (30/44) representing acquired high-risk events. Most notably, MYC family gene amplifications and TP53 pathway defects commonly emerged in combination at relapse following conventional multimodal treatment (P=0.02, 7/22, 32%) and predicted rapid progression to death (P=0.016).

These observations suggested aberrant activation of MYC family genes synergizes with TP53 inactivation in the genesis of biologically aggressive MB. To investigate any such relationship, we examined Trp53 status in our transgenic mouse model of spontaneously-arising MYCN-driven MB (GTML; Glt1-tTA/TRE-MYCN-Luc). Somatic Trp53 mutations were found in 83% of tumors (n=10/12). Direct modelling of this interaction in GTML/Trp53KI/KI mice dramatically enhanced MB formation with 100% penetrance (43/43, median survival 47 days) in GTML/Trp53KI/KI versus 6% (3/50) in GTML; P&lt;0.0001), faithfully mimicked clinicopathological characteristics of TP53-MYC family gene-associated relapsed human tumors, and validated the essential role of TP53 in potentiating the growth of MYCN-driven MB. Finally, therapeutic inhibition of Aurora-A kinase using MLN8237 in these tumours, and in derived neurospheres in vitro, promoted degradation of MYCN, reduced tumor growth and prolonged survival.

In summary, while subgroup status remains stable, MBs display altered molecular, pathological and clinical features at relapse, and the emergence of combined TP53-MYC family gene defects is common following conventional therapy. Their association with rapid demise, coupled with their biological validation as driving and therapeutically exploitable events in a novel mouse MB model, strongly support further investigation and routine biopsy of relapse disease to drive future individualised therapeutic strategies.

Citation Format: Rebecca M. Hill, Sanne Kuijper, Janet Lindsey, Ed C. Schwalbe, Karen Barker, Jessica Boult, Daniel Williamson, Zai Ahmad, Albert Hallsworth, Sarra Ryan, Evon Poon, Simon Robinson, Ruth Ruddle, Florence Raynaud, Louise Howell, Colin Kwok, Abhijit Joshi, Sarah Nicholson, Stephen Crosier, Stephen Wharton, Tom Jacques, Keith Robson, Antony Michalski, Darren Hargrave, Barry Pizer, Simon Bailey, Fredrik J. Swartling, Kevin Petrie, William A. Weiss, Louis Chesler, Steve Clifford. MYC and TP53 defects interact at medulloblastoma relapse to define rapidly progressive disease and can be targeted therapeutically. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-201. doi:10.1158/1538-7445.AM2014-LB-201

Outcomes in Open Structure Septorhinoplasty

Objectives:

The aim of our study was to look at patient related outcome measures and complications post–open structure septorhinoplasty performed by the same experienced rhinologist and to look at any factors associated with increased risk for requirement of revision surgery.

Methods:

Retrospective review of case notes of all patients who underwent septorhinoplasty at the same institute, performed by the same rhinologist, between January 2009 and February 2013. Assessment of patient satisfaction was made using the Rhinoplasty Outcomes Evaluation (ROE) tool.

Results:

One hundred seventy patients were included in the study, with mean follow-up of 28.2 months. The most common complication was residual deformity (10/170, 5.9%). Eleven patients required further revision nasal surgery (11/170, 6.5%). There was a statistically significant increase in the ROE scores pre- and postoperatively in all patients undergoing surgery (19.5 ± 9.41 vs 68.4 ± 23.7, P < .001). There was a statistically significantly higher rate of revision surgery in patients who had complex surgery (4/16 vs 7/154, P = .01), a higher rate of nasal tip deformity in the revision surgery group compared with the primary surgery group (10/24 vs 29/146, P = .03), and a higher rate of augmentation surgery in the revision surgery group compared with the primary surgery group (13/24 vs 40/146, P =.02).

Conclusions:

Open structure septorhinoplasty results in a significant increase in patient satisfaction. Our rate of revision surgery is lower than the average reported in the literature. The rate of revision surgery is higher in cases judged to be more complex preoperatively.

Pitfalls of operative management of secondary post-tonsillectomy haemorrhage--a case report

INTRODUCTION

The authors present a potential complication associated with the surgical management of post-tonsillectomy haemorrhage using absorbable cellulose haemostatic dressings. The article discusses the deficiencies of our current understanding of how best to manage this common and potentially life-threatening ENT emergency.

CASE REPORT

A 40-year-old man presented to Accident-and-Emergency with a post-tonsillectomy haemorrhage on the 7th postoperative day. The bleeding was managed surgically, with suturing of the faucial pillars incorporating a piece of Surgicel into the closure. Two days later the patient experienced an episode of partial airway obstruction, due to a piece of dislodged haemostatic material, owing to failure of the closure. The techniques used in the operative management of post-tonsillectomy bleeding are not formally evaluated or discussed in the current literature, and in some cases are unreliable or even potentially hazardous. Further discussion, research, and formulation of a more stepwise approach would be of considerable benefit.

Attitudes towards and evaluation of medical emergency teams: a survey of trainees in intensive care medicine

A survey was conducted to explore the perception of intensive care registrars on the impact of activities outside the intensive care unit (ICU), particularly in medical emergency teams, on their training and the care of patients. An anonymous mail-out survey was sent to 356 trainees registered with the Joint Faculty of Intensive Care Medicine, half of whom were determined to be involved in ICU duties. No patients were involved and respondents participated voluntarily. The main outcome measures were barriers and predictors of satisfaction with ICU training. One-hundred-and-thirty-six (38%) trainees responded. Seventy-eight percent had participated in a medical emergency team, of whom 99% of respondents stated the medical emergency team included an ICU registrar but rarely (3%) an ICU consultant. Sixty-six percent of respondents reported that medical emergency team involvement had a positive effect on training but 77% reported little or no supervision of team duties. While trainees did not believe they spent too much time performing medical emergency team duties, the time spent on medical emergency teams at night, when ICU staffing levels are at their lowest, was the same as during the day. Serious concern was expressed about the negative impact of medical emergency team activities on their ability to care for ICU patients and the additional stress on ICU medical and nursing staff Overall, ICU trainees regarded participation in a medical emergency team as positive on training and on patient care in wards, but other results have resource implications for the provision of clinical emergency response systems, care of patients in ICUs and the training of the future intensive care workforce.

Iodine induced thyrotoxicosis following povidine-iodine dressings: a case report

A 40-year-old woman was admitted to the intensive care unit after a radical resection of a recurrent abdominal malignancy. Her postoperative course was complicated by sepsis requiring numerous abdominal operations with the abdomen being left open for drainage and dressings. Use of povidone-iodine soaked abdominal packs to reduce secondary infection led to development of thyrotoxicosis, which resolved following the cessation of the iodine dressings. A high index of suspicion is needed for the diagnosis of this condition in intensive care patients as the usual haemodynamic signs of thyrotoxicosis may be misinterpreted as being caused by sepsis.

Cervical spine clearance in Australian intensive care units

OBJECTIVE

Rigid or semi-rigid collar and spine board related complications may be causes of significant morbidity in intubated polytraumatised patients. As the process quantifying cervical spine injuries is controversial, exclusion of cervical spinal injuries (cervical spine clearance) can be delayed, thereby increasing complications associated with spinal cord immobilisation. We examined current practices in Australian ICUs by survey.

METHODS

The intensive care unit or trauma services director and the senior nursing unit manager from 17 units within designated Australian trauma centres were surveyed separately by telephone. The presence of a written protocol for cervical spine clearance including radiological and clinical criteria, time goals for clearance, immobilisation methods and formal surveillance of collar related complications were assessed using a standardised questionnaire.

RESULTS

All states and territories were represented. Of those services surveyed, only 50% had a written protocol, 50% had no specific time goal for cervical spinal clearance and the method of clearance ranged from plain cervical spine X-rays only to routine use of MRI. Immobilisation methods also varied, including use of rigid (hard) or soft collars with 71% having no formal surveillance of collar-related complications. Despite these results, 65% were satisfied with their approach to cervical spine clearance.

CONCLUSIONS

There is no standardised approach to the clearance of the cervical spine in intubated trauma patients in Australian intensive care units. In addition, morbidity from current practices and the true incidence of cervical spine injuries remains unknown. We recommend use of a written protocol and formal documentation of collar related complications. A standardised approach to radiological and clinical clearance of cervical spine injuries, which is practical, yet safe, remains a subject for future risk-benefit analysis.

Does neostigmine increase gastric emptying in the critically ill?--results of a pilot study

OBJECTIVE

Based on the successful use of neostigmine for the treatment of acute colonic pseudo-obstruction, we hypothesised that neostigmine would increase gastric emptying and improve tolerance to enteral feeding in the critically ill patient.

METHODS

Eleven patients intolerant of enteral feeds due to high gastric aspirates, were randomised to receive a 'study infusion' consisting of either neostigmine (0.4 mg/hr) or 0.9% saline. If, after 12 hours the patient was deemed intolerant of the nasogastric feed, the rate of the 'study infusion' was doubled. Those who remained intolerant after 24 hours of the 'study infusion' were 'crossed-over' and continued on the other infusion for a further 24 hours. Gastric emptying was assessed in each group before and after the infusion by measuring the hourly rates of feed "absorption" [(delivery rate + returned aspirates) - total aspirates] and paracetamol absorption using the area under a time-concentration curve at 120 minutes (AUC120). Differences within and between groups were analysed using Students t test and one-way analysis of variance.

RESULTS

Six patients received neostigmine first and 5 received the placebo first. Four of the 6 patients receiving the neostigmine first compared with all of those receiving placebo first required to be 'crossed-over' to the other infusion. While the hourly rates of feed "absorption" were greater for patients receiving neostigmine than for placebo, these differences did not achieve statistical significance. The mean paracetamol AUC120 for all patients who received neostigmine was 3996 mg/min/L while that for placebo was 1929 mg/min/L (p = 0.21).

CONCLUSIONS

These data suggest that while neostigmine may have a positive effect on gastric emptying and enteral feed absorption in critically ill patients, the results did not reach statistical significance and an adequately powered study will be required to confirm this effect.

Antecedents to hospital deaths

BACKGROUND

Recent studies have suggested there are a large number of potentially preventable deaths in Australian hospitals.

AIM

This study aimed to document antecedent factors in hospital deaths in an attempt to identify potentially preventative factors.

METHODS

The study was conducted at three separate acute hospitals. Demographics of all deaths were recorded over a 6-month period as well as antecedent factors present within 0-8 and 8-48 h of all deaths including vital sign abnormalities, cardiorespiratory arrests and admission to intensive care. Separate analysis was performed on 'not for resuscitation' deaths.

RESULTS

There were a total of 778 deaths, of which 549 (71%) were 'not for resuscitation'. There were 171 (22%) deaths preceded by arrest and 160 (21%) preceded by admission to intensive care. Of the remaining deaths, 30% had severely abnormal physiological abnormalities documented. This incidence was 50% in the non-do not resuscitate (DNR) subgroup. Concern about the patient's condition was expressed in the patient's notes by attending nursing staff and junior medical staff in approximately one-third of non-DNR deaths. Hypotension (30%) and tachypnoea (17%) were the most common antecedents in the non-DNR deaths.

CONCLUSION

There is a high incidence of serious vital sign abnormalities in the period before potentially preventable hospital deaths. These antecedents may identify patients who would benefit from earlier intervention.