An Approach to Managing Recurrent Cochlear Implant Wound Infection and Skin Breakdown

We report the case of a cochlear implant patient who developed multiple infections with device extrusion necessitating explanation and reimplantation twice. An approach using a vancomycin washout followed by a temporalis muscle rotation and scalp rotation flap was utilized to salvage the device.

Chemoproteomic discovery of a covalent allosteric inhibitor of WRN helicase

WRN helicase is a promising target for treatment of cancers with microsatellite instability (MSI) due to its essential role in resolving deleterious non-canonical DNA structures that accumulate in cells with faulty mismatch repair mechanisms1-5. Currently there are no approved drugs directly targeting human DNA or RNA helicases, in part owing to the challenging nature of developing potent and selective compounds to this class of proteins. Here we describe the chemoproteomics-enabled discovery of a clinical-stage, covalent allosteric inhibitor of WRN, VVD-133214. This compound selectively engages a cysteine (C727) located in a region of the helicase domain subject to interdomain movement during DNA unwinding. VVD-133214 binds WRN protein cooperatively with nucleotide and stabilizes compact conformations lacking the dynamic flexibility necessary for proper helicase function, resulting in widespread double-stranded DNA breaks, nuclear swelling and cell death in MSI-high (MSI-H), but not in microsatellite-stable, cells. The compound was well tolerated in mice and led to robust tumour regression in multiple MSI-H colorectal cancer cell lines and patient-derived xenograft models. Our work shows an allosteric approach for inhibition of WRN function that circumvents competition from an endogenous ATP cofactor in cancer cells, and designates VVD-133214 as a promising drug candidate for patients with MSI-H cancers.

A 13.2 mg epinephrine intranasal spray demonstrates comparable pharmacokinetics, pharmacodynamics, and safety to a 0.3 mg epinephrine autoinjector

Background

Recent acute anaphylaxis guideline updates have identified remaining unmet needs based on currently available therapeutic options as a critical focus.

Objective

We compared the pharmacokinetic, pharmacodynamic, safety, and tolerability profiles of intranasal epinephrine with intramuscular epinephrine administered by autoinjector and manual syringe.

Methods

An open-label, 3-period crossover study was conducted in 116 healthy adult volunteers to assess the bioavailability of a single 13.2 mg intranasal dose of epinephrine compared to a 0.3 mg intramuscular autoinjector and a 0.5 mg manual syringe. Patients with epinephrine concentrations of 50, 100, and 200 pg/mL at 10, 20, 30, and 60 minutes after dosing were also evaluated.

Results

Pharmacokinetic parameters for the 13.2 mg intranasal dose exceeded those of the 0.3 mg autoinjector with a rapid and higher maximum observed concentration (intranasal, 429.4 pg/mL; autoinjector, 328.6 pg/mL) and greater systemic exposure (AUC0-360; intranasal, 39,060 pg∙min/mL; autoinjector, 17,440 pg∙min/mL). Similar results were observed compared to the 0.5 mg manual syringe. Pharmacokinetic parameters for opposite-nostril and same-nostril dosing were higher than both intramuscular doses, except time to reach maximum observed concentration, which was bracketed between the 2 intramuscular doses (intranasal opposite and same nostril, 20 minutes; autoinjector, 14.9 minutes; manual syringe, 45 minutes). Similar effects on blood pressure and heart rate were observed for intranasal and autoinjector administration. Intranasal epinephrine was safe and well tolerated. No serious or unexpected adverse events were reported, confirming results from earlier clinical studies.

Conclusions

Bidose epinephrine spray addresses the unmet medical and patient needs for a needle-free, convenient, and effective dose-delivery system for self-administration of epinephrine that is as good as or better than the 0.3 mg autoinjector.

What are the common factors that lead to the failure to achieve minimal clinically important difference after shoulder surgery? A scoping review

INTRODUCTION

The goal of this research is to identify the factors that negatively impact the achievement of the minimum clinically significant change (MCID) for the American Shoulder and Elbow Surgeons (ASES) score within the realm of various orthopedic shoulder procedures.

METHODS

We conducted a comprehensive review of studies published from 2002 to 2023, utilizing OvidMedline and PubMed databases. Our search criteria included terms such as "minimal clinically important difference" or "MCID" along with associated MeSH terms, in addition to "American shoulder and elbow surgeon" or "ASES." We selectively included primary investigations that assessed factors linked to the failure to achieve MCID for the ASES score subsequent to orthopedic shoulder procedures, while excluding papers addressing anatomical, surgical, or injury-related aspects.

RESULTS

Our analysis identified 149 full-text articles, leading to the inclusion of 12 studies for detailed analysis. The selected studies investigated outcomes following various orthopedic shoulder procedures, encompassing biceps tenodesis, total shoulder arthroplasty, and rotator cuff repair. Notably, factors, such as gender, body mass index, diabetes, smoking habits, opioid usage, depression, anxiety, workers' compensation, occupational satisfaction, and the preoperative ASES score, were all associated with the inability to attain MCID.

CONCLUSION

In summary, numerous factors exert a negative influence on the attainment of MCID following shoulder procedures, and these factors appear to be irrespective of the specific surgical technique employed. Patients presenting with these factors may perceive their surgical outcomes as less successful when compared to those without these factors. Identifying these factors can enable healthcare providers to provide more effective counseling to patients regarding their expected outcomes and rehabilitation course. Furthermore, these findings can aid in the development of a screening tool to better identify these risk factors and optimize them before surgery.

The transition from cranial surgery to neurosurgery in East London, 1760-1960

The emergence of neurosurgery from the practice of cranial surgery between the eighteenth and the twentieth centuries in London, UK, is well documented, including the role of Sir Victor Horsley, the first neurosurgical appointee at the National Hospital Queen Square in 1886. The process of this transition elsewhere in London and the subsequent foundation of other neurosurgical units are less well described. In East London, the status of St. Bartholomew's Hospital (Barts) as the oldest London hospital still active on its original site and its comprehensive archives allow an unusually long history of surgical practice in the specialty to be studied. Using these archives and other primary and secondary sources, this article describes the transition of cranial surgery in East London from the general surgeons, limited to the treatment of brain and skull injury, to the specialized discipline of neurosurgery. We discuss the culmination of this process in the foundation of three neurosurgical units at London Hospital, Whitechapel, by Sir Hugh B. Cairns from 1927; at Barts Hospital, Smithfield, by John E. A. O'Connell from 1937; and at Oldchurch Hospital, Romford, by Leslie C. Oliver from 1945. Two modern neurosurgical units, in Whitechapel and Romford, have taken forward the work begun by this group.

Craniectomy with soft tissue reconstruction for locally advanced non-melanoma skin cancer of scalp with calvarial invasion: The Nottingham experience

INTRODUCTION

Locally advanced non-melanoma skin cancer (NMSC) involving the periosteum or calvarium poses a clinical challenge for patients who are unfit for immunotherapy due to medical comorbidities and/or frailty. This case series aims to investigate outcomes for patients undergoing craniectomy and soft tissue reconstruction.

METHOD

Patients who underwent craniectomy and soft tissue reconstruction for invasive NMSC with calvarium or periosteal invasion between 2016 and 2022 were included. Data, including demographics, operative details, and clinical outcomes, were gathered from Nottingham University Hospitals' digital health record and the histopathology electronic database.

RESULT

Eight patients (average age: 78.4 years, 3 females 5 males) with significant comorbidities and varying degrees of periosteal or bone invasion fulfilled the inclusion criteria. Diagnoses included four squamous cell carcinomas, two basal cell carcinomas, and two pleomorphic dermal sarcomas. Five patients had a history of prior incomplete deep margin excision. The median sizes for soft tissue defect, tumor and bone defect size were 51.83 cm2, 34.63 cm2 and 42.25 cm2, respectively. Intraoperative complications included one dural tear. Four patients underwent local flap reconstruction and with split-thickness skin grafting, four patients underwent free flap reconstruction. Adjuvant radiotherapy was administered to three patients. Complications comprised partial graft loss in two and complete graft loss in one. There was partial flap loss in one case. One patient required subsequent parotidectomy due to regional progression before achieving disease control. All patients achieved lasting locoregional disease control (average follow-up 29.7 months).

CONCLUSION

Craniectomy with soft tissue reconstruction proves to be a safe and effective treatment option in advanced NMSC of the scalp in patients unsuitable for immunotherapy due to frailty or medical co-morbidity.

Aberrant Arterial Anatomy at the Floor of the Third Ventricle: Video Case Report

A 65-year-old woman presented with a 2-month progressive history of forgetfulness, headaches, and decline in mobility. Imaging showed a large, enhancing pineal region tumor with triventricular hydrocephalus. She underwent an endoscopic third ventriculostomy and biopsy after appropriate consent was gained. Video 1 demonstrates the endoscopic procedure during which 2 aberrant arteries were identified at the floor of the third ventricle. The endoscopic third ventriculostomy was performed between these 2 arteries with great care to preserve them. The patient improved postoperatively with resolution of the hydrocephalus. Histology showed a metastatic malignant melanoma. To the best of our knowledge, no similar anatomy has been shown in an endoscopic procedure. We speculate that these are perforating arteries from the posterior communicating artery (premamillary artery) or a branch from the first part of the posterior cerebral artery P1 (thalamoperforators). Other options include perforators from the ophthalmic segment of the internal carotid artery, the communicating segment of the internal carotid artery, the superior hypophyseal artery, or a branch of the medial posterior choroidal arteries. We look at each in turn.

Hydrocephalus in patients with vestibular schwannoma

BACKGROUND

Hydrocephalus (HC) is common in patients with vestibular schwannoma (VS). This can be managed with a cerebrospinal fluid (CSF) diversion procedure prior to VS resection or with VS resection, keeping CSF diversion in reserve unless required postoperatively. No clear consensus exists as to which approach is superior. This study identifies factors predictive of the development of HC, and analyses outcomes for those managed with primary CSF resection versus tumour resection.

METHODS

Single-centre retrospective cohort study of 204 consecutive adult patients with a unilateral VS from May 2009 to June 2021. Data was collected on patient and tumour demographics, management, and outcome.

RESULTS

204 patients, with a mean age at presentation of 59.5 (21-83), with 50% female, and a mean follow-up of 7.5 years (1.8-13.9) were included. 119 were managed conservatively, 36 with stereotactic radiosurgery only, and 49 with surgery. 30 (15%) patients had radiological HC, of which 23 (77%) were obstructive, and 7 (23%) were communicating. Maximum intracranial tumour diameter and Koos grade were higher in patients with HC. Of the patients with HC the majority (20, 67%) were managed initially with CSF diversion, with 12 patients undergoing subsequent tumour resection, and three patients avoiding primary resection. Nine (30%) were managed with primary surgical resection, of whom three required subsequent CSF diversion. Complication rates and Modified Rankin Scale (MRS) were comparable or lower in the CSF diversion group (8%, MRS ≤2 = 83%), versus the primary resection group (67%, MRS ≤2 = 67%), and the primary surgical resection without HC group (25%, MRS ≤2 = 86%).

CONCLUSIONS

CSF diversion prior to tumour resection is a safe and acceptable strategy compared to primary VS resection, with improved outcomes and reduced surgical complications. Randomized studies and national databases are needed to determine the long-term outcomes of patients treated with CSF diversion versus primary resection.

The Use of the Suboccipital Transtentorial Approach to the Posterior Inferior Incisural Space

Objective To describe our experience with the microsurgical technique of the suboccipital transtentorial (SOTT) approach in the removal of posterior fossa lesions located in the posterior incisural space. Method Between 2002 and 2020 we reviewed all patients who underwent microsurgical resection of lesions of the posterior incisural space at the Department of Neurosurgery, Essex Neuroscience Centre, London, England (eight patients, male to female 3:5, mean age: 51, range 35-69). We describe the preoperative symptoms, radiological findings, surgical techniques, histology and postoperative outcomes in this cohort of patients. Results Eight patients with tumours located in the posterior incisural space underwent surgery during the study period including four meningiomas (50%), two haemangioblastomas (25%), one metastasis (13%) and one giant prolactinoma (13%). Gross or near total resection was achieved in six patients (75%): the giant prolactinoma could not be radically removed and one of the meningiomas required a small fragment to be left in place to protect the Vein of Galen. No patient developed a visual field deficit due to occipital lobe retraction. One patient developed a temporary trochlear nerve palsy (13%). Five patients had mild disability (Glasgow Outcome Scale (GOS) = 5), and four had moderate disability (GOS = 4). Conclusion In our series, the SOTT approach provided excellent access for all cases of tumours in the posterior incisural space. The tumour's size and relationship to the deep venous system contributed to the choice of approach and in one patient who had previously undergone surgery via the supracerebellar route, the SOTT approach enabled the avoidance of gliotic scar tissue. Success is dependent on careful case selection, though from our series of 8 patients, we conclude that this approach allows safe access to the posterior incisural space, with acceptable outcomes with regard to postoperative disability and cranial nerve palsy. As such, the approach should be in the armamentarium of any neurosurgeon who regularly deals with posterior fossa pathology.

The management of symptomatic hyperostotic bilateral spheno-orbital meningiomas: patient series

BACKGROUND

The occurrence of hyperostotic bilateral spheno-orbital meningiomas (BSOMs) is very rare. Patients present with bilateral symptoms and require bilateral treatment. This series describes 6 patients presenting to 2 UK neurosurgical units and includes a literature review. To the best of the authors' knowledge, this is the largest series documented.

OBSERVATIONS

This is a retrospective review of patients with BSOMs presenting between 2006 and 2023. Six females, whose mean age was 43 (range: 36-64) years, presented with features of visual disturbance. Bilateral sphen-oorbital meningiomas were identified. All patients underwent bilateral staged resections. The patients had an initial improvement in their symptoms. Extensive genetic testing was performed in 4 patients, with no variants in the NF2, LZTR1, SMARCB1, SMARCE1, and SMARCA4 genes or other variants detected. The mean follow-up was 100.3 (range: 64-186) months. Sixty-seven percent of patients had good long-term visual acuity. The progression rate was 75% and was particularly aggressive in 1 patient. Four patients required radiation therapy, and 2 needed further surgery.

LESSONS

Hyperostotic BSOMs are extensive, challenging tumors causing significant disability. They can recur, with significant patient impact. Multidisciplinary management and indefinite long-term follow-up are essential. The biology of these tumors remains unclear. As molecular testing expands, the understanding of BSOM oncogenesis and potential therapeutic targets is likely to improve.

IL-4/IL-13-producing ILC2s are required for timely control of intestinal helminth infection in mice

Infection of mice with Nippostrongylus brasiliensis (Nb) serves as a model for human hookworm infection affecting about 600 million people world-wide. Expulsion of Nb from the intestine requires IL-13-mediated mucus secretion from goblet cells and activation of smooth muscles cells. Type 2 innate lymphoid cells (ILC2s) are a major cellular source of IL-13 but it remains unclear whether IL-13 secretion from ILC2s is required for Nb expulsion. Here, we compared the immune response to Nb infection in mixed bone marrow chimeras with wild-type or IL-4/IL-13-deficient ILC2s. ILC2-derived IL-4/IL-13 was required for recruitment of eosinophils to the lung but had no influence of systemic eosinophil levels. In the small intestine, goblet cell hyperplasia and tuft cell accumulation was largely dependent on IL-4/IL-13 secretion from ILC2s. This further translated to higher eggs counts and impaired worm expulsion in mice with IL-4/IL-13-deficient ILC2s. Overall, we demonstrate that ILC2s constitute a non-redundant source of IL-4/IL-13 required for protective immunity against primary Nb infection.

Exploratory Study of the Brain Response in Facial Synkinesis after Bell Palsy with Systematic Review and Meta-analysis of the Literature

BACKGROUND

Facial synkinesis, characterized by unintentional facial movements paired with intentional movements, is a debilitating sequela of Bell palsy.

PURPOSE

Our aim was to determine whether persistent peripheral nerve changes arising from Bell palsy result in persistent altered brain function in motor pathways in synkinesis.

DATA SOURCES

A literature search using terms related to facial paralysis, Bell palsy, synkinesis, and fMRI through May 2021 was conducted in MEDLINE and EMBASE. Additionally, an fMRI study examined lip and eyeblink movements in 2 groups: individuals who fully recovered following Bell palsy and individuals who developed synkinesis.

STUDY SELECTION

Task-based data of the whole brain that required lip movements in healthy controls were extracted from 7 publications. Three studies contributed similar whole-brain analyses in acute Bell palsy.

DATA ANALYSIS

The meta-analysis of fMRI in healthy control and Bell palsy groups determined common clusters of activation within each group using activation likelihood estimates. A separate fMRI study used multivariate general linear modeling to identify changes associated with synkinesis in smiling and blinking tasks.

DATA SYNTHESIS

A region of the precentral gyrus contralateral to the paretic side of the face was hypoactive in synkinesis during lip movements compared with controls. This region was centered in a cluster of activation identified in the meta-analysis of the healthy controls but absent from individuals with Bell palsy.

LIMITATIONS

The meta-analysis relied on a small set of studies. The small sample of subjects with synkinesis limited the power of the fMRI analysis.

CONCLUSIONS

Premotor pathways show persistent functional changes in synkinesis first identifiable in acute Bell palsy.

Potential Surgical Implications of Internal Jugular Stenosis in a Craniocervical Junction Meningioma

We report a case of a 61-year-old lady presenting with several weeks of progressive left-sided weakness, and found to have a foramen magnum meningioma. She was counselled on surgical resection of the tumour, and a preoperative computed tomography angiogram (CTA) was obtained for operative planning purposes. CTA demonstrated incidental bilateral internal jugular vein (IJV) stenosis, with enlarged extracranial collateral vessels and elongated styloid processes. The main surgical concern was potential injury of the extracranial collateral vessels during operative exposure, which may compromise her intracranial venous outflow in light of the IJV stenosis. A doppler ultrasound scan of the IJVs was performed, which demonstrated that blood flow was still present through both vessels. Through careful soft tissue dissection during surgery, potential complications and injury to the extracranial collaterals were avoided.

We performed a literature review of the incidence of IJV stenosis, its associated conditions, and potential surgical implications. Complications from injury to vital collateral extracranial vessels should be considered during preoperative planning in patients with anatomical variants or risk factors for IJV stenosis, as seen in this case.

Discerning a smile - The intricacies of analysis of post-neck dissection asymmetry

INTRODUCTION

Iatrogenic facial nerve palsy is distressing to the patient and clinician. The deformity is aesthetically displeasing, and can be functionality problematic for oral competence, dental lip trauma and speech. Furthermore such injuries have litigation implications. Marginal mandibular nerve (MMN) palsy causes an obvious asymmetrical smile. MMN is at particular risk during procedures such as rhytidoplasties, mandibular fracture, tumour resection and neck dissections. Cited causes for the high incidence are large anatomical variations, unreliable landmarks, an exposed neural course and tumour grade or nodal involvement dictating requisite nerve sacrifice. An alternative cause for post-operative asymmetry is damage to the cervical branch of the facial nerve or platysmal dysfunction due to its division. The later tends to have a transient course and recovers. Distinction between MMN palsy and palsy of the cervical branch of the facial nerve or platysma division should therefore be made. In 1979 Ellenbogen differentiated between MMN palsy and "Pseudo-paralysis of the mandibular branch of the facial nerve". Despite this, there is paucity in the literature & confusion amongst clinicians in distinguishing between these palsies, and there is little regarding these post-operative sequelae and neck dissections.

METHOD

This article reflects on the surgical anatomy of the MMN and cervical nerve in relation to danger zones during lymphadenectomy. The authors review the anatomy of the smile. Finally, case studies are utilised to evaluate the differences between MMN palsy and its pseudo-palsy to allow clinical differentiation.

CONCLUSION

Here we present a simple method for clinical differentiation between these two prognostically different injuries, allowing appropriate reassurance, ongoing therapy & management.

CSF Rhinorrhea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 2: Impact of COVID-19

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised regarding the increased risk of perioperative mortality for patients with COVID-19, and the transmission risk to healthcare workers, especially during endonasal neurosurgical operations. The Pituitary Society has produced recommendations to guide management during this era. We sought to assess contemporary neurosurgical practice and the effects of COVID-19.

METHODS

A multicenter prospective observational cohort study was conducted at 12 tertiary neurosurgical units (United Kingdom and Ireland). Data were collected from March 23 to July 31, 2020, inclusive. The data points collected included patient demographics, preoperative COVID-19 test results, operative modifications, and 30-day COVID-19 infection rates.

RESULTS

A total of 124 patients were included. Of the 124 patients, 116 (94%) had undergone COVID-19 testing preoperatively (transsphenoidal approach, 97 of 105 [92%]; expanded endoscopic endonasal approach, 19 of 19 [100%]). One patient (1 of 116 [0.9%]) had tested positive for COVID-19 preoperatively, requiring a delay in surgery until the infection had been confirmed as resolved. Other than transient diabetes insipidus, no other complications were reported for this patient. All operating room staff had worn at least level 2 personal protective equipment. Adaptations to surgical techniques included minimizing drilling, draping modifications, and the use of a nasal iodine wash. At 30 days postoperatively, no evidence of COVID-19 infection (symptoms or positive formal testing results) were found in our cohort and no mortality had occurred.

CONCLUSIONS

Preoperative screening protocols and operative modifications have facilitated endonasal neurosurgery during the COVID-19 pandemic, with the Pituitary Society guidelines followed for most of these operations. We found no evidence of COVID-19 infection in our cohort and no mortality, supporting the use of risk mitigation strategies to continue endonasal neurosurgery in subsequent pandemic waves.

128 Comparison of multiple maturation times on juvenile invitro embryo transfer (JIVET)-derived oocytes and embryo development in the goat

Juvenile invitro embryo transfer (JIVET) is an assisted reproductive technology (ART) with the potential to produce numerous offspring from a single young female goat at 4 to 8 weeks of age. It has been reported in small ruminants that there can be a marked variable response to the administration of exogenous hormones for superovulation, the subsequent number of oocytes generated, and subsequent embryo developmental potential. The industry standard (as well as the recommendation of commercial media suppliers) invitro maturation time is 21 to 24h for conventionally derived oocytes. This study investigated multiple maturation times for JIVET-derived oocytes: 16, 22, and 28h. Oocytes were collected from four JIVET animals at 6 to 8 weeks of age. The hormonal superovulation regimen used on the juvenile animals consisted of 4×40-mg FSH injections at ∼12h apart and a 400IU of PMSG injection given with the first FSH injection. Surgical recovery of the oocytes via a midline laparotomy was performed the day following the last FSH injection. All of the oocytes were collected via aspirating follicles that were 4mm and larger. Oocytes with compact cumulus cells subsequently underwent IVM, IVF, and invitro culture (IVC) utilising IVF Bioscience media and methods. A single straw of identical cryopreserved/thawed semen from the same buck was utilised for each of the IVF procedures. The results were (37/88) 42%, (37/85) 44%, and (39/91) 43% cleaved and (23/88) 26%, (24/85) 28%, and (28/91) 31% blastocyst rate based on respective maturation times for JIVET-derived ova. Development rate during the cleavage stage and blastocyst stage was analysed using a repeated-measures logistic regression model utilising generalized estimating equations (GEE), with maturation time as fixed effect and a compound symmetry within subject (juvenile goat) covariance structure. The main effect of maturation time on the odds of development during the cleavage stage (P=0.8727) and blastocyst stage (P=0.3857) was not significant. These results indicate that the time in maturation media does not have as profound an effect on development to blastocysts as a factor in the variability reported by other laboratories. The development rate of embryos from one juvenile goat produced very high blastocyst rates of (5/12) 42%, (11/12) 92%, and (11/15) 73%, respectively. Additional logistic regression analysis showed that the odds of development in this juvenile donor was significantly different compared with the other donors (pooled) during the cleavage stage at 16h (P=0.0083) and 28h (P=0.0021) maturation times. Likewise, the odds of development in this donor was significantly different than that of the other donors (pooled) during the blastocyst stage at 22h (P=0.0002) and 28h (P=0.0003) maturation times. This further indicates the wide variation of oocyte quality from JIVET-derived oocytes and indicates potential for higher development rates at 22 and 28h in this specific goat.

Alternatives to antibiotics in a One Health context and the role genomics can play in reducing antimicrobial use

BACKGROUND

This review follows on from the International Conference on One Health Antimicrobial Resistance (ICOHAR 2019), where strategies to improve the fundamental understanding and management of antimicrobial resistance at the interface between humans, animals and the environment were discussed.

OBJECTIVE

This review identifies alternatives to antimicrobials in a One Health context, noting how advances in genomic technologies are assisting their development and enabling more targeted use of antimicrobials.

SOURCES

Key articles on the use of microbiota modulation, livestock breeding and gene editing, vaccination, antivirulence strategies and bacteriophage therapy are discussed.

CONTENT

Antimicrobials are central for disease control, but reducing their use is paramount as a result of the rise of transmissible antimicrobial resistance. This review discusses antimicrobial alternatives in the context of improved understanding of fundamental host-pathogen and microbiota interactions using genomic tools.

IMPLICATIONS

Host and microbial genomics and other novel technologies play an important role in devising disease control strategies for healthier animals and humans that in turn reduce our reliance on antimicrobials.

Group cognitive-behavioural programme to reduce the impact of rheumatoid arthritis fatigue: the RAFT RCT with economic and qualitative evaluations

BACKGROUND

Fatigue is a major problem in rheumatoid arthritis (RA). There is evidence for the clinical effectiveness of cognitive-behavioural therapy (CBT) delivered by clinical psychologists, but few rheumatology units have psychologists.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of a group CBT programme for RA fatigue [named RAFT, i.e. Reducing Arthritis Fatigue by clinical Teams using cognitive-behavioural (CB) approaches], delivered by the rheumatology team in addition to usual care (intervention), with usual care alone (control); and to evaluate tutors' experiences of the RAFT programme.

DESIGN

A randomised controlled trial. Central trials unit computerised randomisation in four consecutive cohorts within each of the seven centres. A nested qualitative evaluation was undertaken.

SETTING

Seven hospital rheumatology units in England and Wales.

PARTICIPANTS

Adults with RA and fatigue severity of ≥ 6 [out of 10, as measured by the Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scale (BRAF-NRS)] who had no recent changes in major RA medication/glucocorticoids.

INTERVENTIONS

RAFT - group CBT programme delivered by rheumatology tutor pairs (nurses/occupational therapists). Usual care - brief discussion of a RA fatigue self-management booklet with the research nurse.

MAIN OUTCOME MEASURES

Primary - fatigue impact (as measured by the BRAF-NRS) at 26 weeks. Secondary - fatigue severity/coping (as measured by the BRAF-NRS); broader fatigue impact [as measured by the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ)]; self-reported clinical status; quality of life; mood; self-efficacy; and satisfaction. All data were collected at weeks 0, 6, 26, 52, 78 and 104. In addition, fatigue data were collected at weeks 10 and 18. The intention-to-treat analysis conducted was blind to treatment allocation, and adjusted for baseline scores and centre. Cost-effectiveness was explored through the intervention and RA-related health and social care costs, allowing the calculation of quality-adjusted life-years (QALYs) with the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). Tutor and focus group interviews were analysed using inductive thematic analysis.

RESULTS

A total of 308 out of 333 patients completed 26 weeks (RAFT, n/N = 156/175; control, n/N = 152/158). At 26 weeks, the mean BRAF-NRS impact was reduced for the RAFT programme (-1.36 units; p < 0.001) and the control interventions (-0.88 units; p < 0.004). Regression analysis showed a difference between treatment arms in favour of the RAFT programme [adjusted mean difference -0.59 units, 95% confidence interval (CI) -1.11 to -0.06 units; p = 0.03, effect size 0.36], and this was sustained over 2 years (-0.49 units, 95% CI -0.83 to -0.14 units; p = 0.01). At 26 weeks, further fatigue differences favoured the RAFT programme (BRAF-MDQ fatigue impact: adjusted mean difference -3.42 units, 95% CI -6.44 to - 0.39 units, p = 0.03; living with fatigue: adjusted mean difference -1.19 units, 95% CI -2.17 to -0.21 units, p = 0.02; and emotional fatigue: adjusted mean difference -0.91 units, 95% CI -1.58 to -0.23 units, p = 0.01), and these fatigue differences were sustained over 2 years. Self-efficacy favoured the RAFT programme at 26 weeks (Rheumatoid Arthritis Self-Efficacy Scale: adjusted mean difference 3.05 units, 95% CI 0.43 to 5.6 units; p = 0.02), as did BRAF-NRS coping over 2 years (adjusted mean difference 0.42 units, 95% CI 0.08 to 0.77 units; p = 0.02). Fatigue severity and other clinical outcomes were not different between trial arms and no harms were reported. Satisfaction with the RAFT programme was high, with 89% of patients scoring ≥ 8 out of 10, compared with 54% of patients in the control arm rating the booklet (p < 0.0001); and 96% of patients and 68% of patients recommending the RAFT programme and the booklet, respectively, to others (p < 0.001). There was no significant difference between arms for total societal costs including the RAFT programme training and delivery (mean difference £434, 95% CI -£389 to £1258), nor QALYs gained (mean difference 0.008, 95% CI -0.008 to 0.023). The probability of the RAFT programme being cost-effective was 28-35% at the National Institute for Health and Care Excellence's thresholds of £20,000-30,000 per QALY. Tutors felt that the RAFT programme's CB approaches challenged their usual problem-solving style, helped patients make life changes and improved tutors' wider clinical practice.

LIMITATIONS

Primary outcome data were missing for 25 patients; the EQ-5D-5L might not capture fatigue change; and 30% of the 2-year economic data were missing.

CONCLUSIONS

The RAFT programme improves RA fatigue impact beyond usual care alone; this was sustained for 2 years with high patient satisfaction, enhanced team skills and no harms. The RAFT programme is < 50% likely to be cost-effective; however, NHS costs were similar between treatment arms.

FUTURE WORK

Given the paucity of RA fatigue interventions, rheumatology teams might investigate the pragmatic implementation of the RAFT programme, which is low cost.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN52709998.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 57. See the NIHR Journals Library website for further project information.

CSF rhinorrhoea after endonasal intervention to the anterior skull base (CRANIAL): proposal for a prospective multicentre observational cohort study

BACKGROUND

The endonasal transsphenoidal approach (TSA) has emerged as the preferred approach in order to treat pituitary adenoma and related sellar pathologies. The recently adopted expanded endonasal approach (EEA) has improved access to the ventral skull base whilst retaining the principles of minimally invasive surgery. Despite the advantages these approaches offer, cerebrospinal fluid (CSF) rhinorrhoea remains a common complication. There is currently a lack of comparative evidence to guide the best choice of skull base reconstruction, resulting in considerable heterogeneity of current practice. This study aims to determine: (1) the scope of the methods of skull base repair; and (2) the corresponding rates of postoperative CSF rhinorrhoea in contemporary neurosurgical practice in the UK and Ireland.

METHODS

We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units in the UK and Ireland performing the relevant surgeries (TSA and EEA) will be eligible to participate. Eligible cases will be prospectively recruited over 6 months with 6 months of postoperative follow-up. Data points collected will include: demographics, tumour characteristics, operative data), and postoperative outcomes. Primary outcomes include skull base repair technique and CSF rhinorrhoea (biochemically confirmed and/or requiring intervention) rates. Pooled data will be analysed using descriptive statistics. All skull base repair methods used and CSF leak rates for TSA and EEA will be compared against rates listed in the literature.

ETHICS AND DISSEMINATION

Formal institutional ethical board review was not required owing to the nature of the study - this was confirmed with the Health Research Authority, UK.

CONCLUSIONS

The need for this multicentre, prospective, observational study is highlighted by the relative paucity of literature and the resultant lack of consensus on the topic. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and will inform future studies.