Postoperative cerebellar mutism syndrome is an acquired autism-like network disturbance

BACKGROUND

Cerebellar mutism syndrome (CMS) is a common and debilitating complication of posterior fossa tumor surgery in children. Affected children exhibit communication and social impairments that overlap phenomenologically with subsets of deficits exhibited by children with Autism spectrum disorder (ASD). Although both CMS and ASD are thought to involve disrupted cerebro-cerebellar circuitry, they are considered independent conditions due to an incomplete understanding of their shared neural substrates.

METHODS

In this study, we analyzed postoperative cerebellar lesions from 90 children undergoing posterior fossa resection of medulloblastoma, 30 of whom developed CMS. Lesion locations were mapped to a standard atlas, and the networks functionally connected to each lesion were computed in normative adult and pediatric datasets. Generalizability to ASD was assessed using an independent cohort of children with ASD and matched controls (n = 427).

RESULTS

Lesions in children who developed CMS involved the vermis and inferomedial cerebellar lobules. They engaged large-scale cerebellothalamocortical circuits with a preponderance for the prefrontal and parietal cortices in the pediatric and adult connectomes, respectively. Moreover, with increasing connectomic age, CMS-associated lesions demonstrated stronger connectivity to the midbrain/red nuclei, thalami and inferior parietal lobules and weaker connectivity to the prefrontal cortex. Importantly, the CMS-associated lesion network was independently reproduced in ASD and correlated with communication and social deficits, but not repetitive behaviors.

CONCLUSIONS

Our findings indicate that CMS-associated lesions may result in an ASD-like network disturbance that occurs during sensitive windows of brain development. A common network disturbance between CMS and ASD may inform improved treatment strategies for affected children.

Heterogeneity of CFTR modulator-induced sweat chloride concentrations in people with cystic fibrosis

BACKGROUND

Sweat chloride (SC) concentrations in people with cystic fibrosis (PwCF) reflect relative CF transmembrane conductance regulator (CFTR) protein function, the primary CF defect. Populations with greater SC concentrations tend to have lesser CFTR function and more severe disease courses. CFTR modulator treatment can improve CFTR function within specific CF genotypes and is commonly associated with reduced SC concentration. However, SC concentrations do not necessarily fall to concentrations seen in the unaffected population, suggesting potential for better CFTR treatment outcomes. We characterized post-modulator SC concentration variability among CHEC-SC study participants by genotype and modulator.

METHODS

PwCF receiving commercially approved modulators for ≥90 days were enrolled for a single SC measurement. Clinical data were obtained from chart review and the CF Foundation Patient Registry (CFFPR). Variability of post-modulator SC concentrations was assessed by cumulative SC concentration frequencies.

RESULTS

Post-modulator SC concentrations (n = 3787) were collected from 3131 PwCF; most (n = 1769, 47 %) were collected after elexacaftor/tezacaftor/ivacaftor (ETI) treatment. Modulator use was associated with lower SC distributions, with post-ETI concentrations the lowest on average. Most post-ETI SC concentrations were <60 mmol/L (79 %); 26 % were <30 mmol/L. Post-ETI distributions varied by genotype. All genotypes containing at least one F508del allele had individuals with post-ETI SC ≥60 mmol/L, with the largest proportion being F508del/minimal function (31 %).

CONCLUSIONS

Post-modulator SC concentration heterogeneity was observed among all genotypes and modulators, including ETI. The presence of PwCF with post-modulator SC concentrations within the CF diagnostic range suggests room for additional treatment-associated CFTR restoration in this population.

The liver-heart axis in patients with severe obesity: The association between liver fibrosis and chronic myocardial injury may be explained by shared risk factors of cardiovascular disease

BACKGROUND

Severe obesity is associated with increased risk of non-alcoholic fatty liver disease and cardiovascular disease. We hypothesized that liver fibrosis as quantified by the Enhanced Liver Fibrosis (ELF) test would be predictive of myocardial injury and fibrosis, expressed by higher concentrations of cardiac troponin T and I measured by high-sensitivity assays (hs-cTnT and hs-cTnI, respectively).

MATERIAL AND METHODS

We performed cross-sectional analyses of baseline data from 136 patients (mean age 45 years, 38 % male) with severe obesity participating in the non-randomized clinical trial Prevention of Coronary Heart Disease in Morbidly Obese Patients (ClinicalTrials.gov NCT00626964). Associations between ELF scores, hs-cTnT, and hs-cTnI concentrations were assessed using linear regression analysis.

RESULTS

ELF scores were associated with hs-cTnT in the unadjusted model (B 0.381, 95 % Confidence Interval [CI] 0.247, 0.514), but the association was attenuated upon adjustment for potential confounders (B -0.031, 95 % CI -0.155, 0.093). Similarly, for hs-cTnI, an observed association with ELF scores in the unadjusted model was attenuated upon adjustment for potential confounders ((B 0.432, 95 % CI 0.179, 0.685) and (B 0.069, 95 % CI -0.230, 0.367), respectively). Age, sex, hypertension, and estimated glomerular filtration rate were amongst the shared predictors of ELF score, hs-cTnT, and hs-cTnI that provided the univariable models with the highest R-squared and lowest Akaike Information Criterion values.

CONCLUSIONS

Contrary to our hypothesis, ELF score did not predict myocardial injury and fibrosis, but we rather demonstrated an association between liver fibrosis and myocardial injury and fibrosis may be explained by shared risk factors of cardiovascular disease.

Willingness of people with cystic fibrosis receiving elexacaftor/tezacaftor/ivacaftor (ETI) to participate in randomized modulator and inhaled antimicrobial clinical trials

OBJECTIVE

To assess the feasibility of enrolling people with CF (pwCF) taking the CFTR modulator elexacaftor/tezacaftor/ivacaftor (ETI) in clinical trials of a new modulator.

METHODS

PwCF receiving ETI at CHEC-SC study (NCT03350828) enrollment were surveyed for interest in 2-week to 6-month placebo- (PC) and active-comparator (AC) modulator studies. Those taking inhaled antimicrobials (inhABX) were surveyed for interest in PC inhABX studies.

RESULTS

Of 1791 respondents, 75% [95% CI 73, 77] would enroll in a 2-week PC modulator study versus 51% [49, 54] for a 6-month study; 82% [81, 84] and 63% [61, 65] would enroll in 2-week and 6 month AC studies; 77% [74, 80] of 551 taking inhABX would enroll in a 2-week PC inhABX study versus 59% [55, 63] for a 6-month study. Previous clinical trial experience increased willingness.

CONCLUSIONS

Study designs will affect feasibility of future clinical trials of new modulators and inhABX in people receiving ETI.

Characterizing CFTR modulated sweat chloride response across the cf population: Initial results from the CHEC-SC study

BACKGROUND

CHEC-SC is an ongoing epidemiologic study characterizing modulator-induced sweat chloride (SC) responses across the CF population, with interim results available prior to the availability of triple combination modulator therapy.

METHODS

Eligible participants had been prescribed a modulator for ≥90 days with re-enrollment allowed upon establishment of a new modulator. Pre-modulator SC values were obtained from chart review; post-modulator sweat was collected and analyzed locally. SC changes were descriptively summarized with biologic sex effects adjusted for age, weight, and CFTR genotype. Heterogeneity in ivacaftor SC response was characterized in relation to published CFTR functional responses.

RESULTS

1848 participants provided 2004 SC measurements, 26.2% on ivacaftor, 39.1% on lumacaftor/ivacaftor, and 34.7% on tezacaftor/ivacaftor. Average SC changes for all modulators were consistent with those reported in previous clinical studies, with greater variation in SC response observed among rarer mutations and notable shifts in the proportion with SC <60mmol/L independent of the magnitude of SC change. Ivacaftor induced in vitro CFTR functional change was significantly correlated with ivacaftor-modulated SC response (Pearson correlation= ‒0.52, 95% CI: ‒0.773, ‒0.129). Average SC change from ivacaftor to tezacaftor/ivacaftor was ‒4.9 mmol/L (n=17,95% CI:‒9.3, ‒0.5) and differed from those switching from lumacaftor/ivacaftor (10.0 mmol/L, n=139, 95% CI:7.8,12.3). Sex at birth was not associated with SC response.

CONCLUSIONS

CHEC-SC is the largest study characterizing modulator-induced SC changes across the CF population. There was a strong association between ivacaftor induced in vitro CFTR function and SC response across a genotypically heterogenous cohort. Biological sex was not associated with SC response.

Cardiac resynchronization therapy in patients with a history of atrial fibrillation: insights from five major clinical trials

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Heart, Lung, and Blood Institute

Background

Many patients with heart failure who are considered for cardiac resynchronization therapy (CRT) have a history of (h/o) atrial fibrillation (AF) but there are doubts about the efficacy of CRT in patients with AF.

Purpose

To investigate the association of CRT on morbidity and mortality among patients with and without a h/o AF.

Methods

Original, patient-level data from five clinical trials of CRT that permitted enrolment of patients with a h/o AF were included: COMPANION, MADIT-CRT, BLOCK HF, REVERSE, and MIRACLE trial. Patients with permanent or persistent AF were excluded from these trials, and therefore from this analysis. The outcomes of interest were the composite endpoint of time to heart failure hospitalization (HFH) or all-cause mortality or all-cause mortality alone. The association of CRT (versus no CRT) with outcomes for patients with and without a h/o AF was assessed using a Bayesian-Weibull survival regression model with random terms for the trial-specific treatment effects and the trial-specific baseline hazard functions including an interaction between history of paroxysmal AF and CRT. All results are presented as hazard ratios (HRs) with 95% posterior credible intervals (CIs) and posterior probabilities of no association, adjusting for baseline characteristics.

Results

A total of 4062 patients were included, 661 (16.3%) of whom had a h/o AF. Patients with a h/o AF were older (mean [SD] age 68 [10] years versus 64 [11] years) and had a higher proportion of ischemic cardiomyopathy (67% versus 53%, p&lt;0.001), a higher baseline serum creatinine (1.3 mg/dl versus 1.2 mg/dl, p&lt;0.001), and a lower left ventricular ejection fraction (25% versus 26%, p&lt;0.001). The HRs for all outcomes and the interaction term are shown in Table 1. For the overall population, CRT delayed the time to HFH or all-cause mortality (HR: 0.74, 95% CI: 0.62 – 0.87, p=0.005); for patients with a h/o AF, it did not (HR: 0.87, 95% CI: 0.64 to 1.19, p=0.37). In this patient-level meta-analysis, CRT was not associated with a reduction in mortality, overall or by h/o AF. Howevber, the interaction (estimate shown as a ratio of HRs) between those with or without a h/o AF and the effects of CRT was not significant for either outcome (Table 1).

Conclusion

In the largest post hoc analysis to date, we confirm the benefits of CRT in patients without a h/o AF in reducing HFH or mortality. There was no statistically significant interaction between CRT and h/o AF for any analysed outcome.

347 A Bit of a Headache: Management of Head Injuries in a District General Hospital

Aim

Head Injury is a common presentation in our DGH, which covers a large rural area and is now a regional trauma centre. We audited our management of head injuries against current guidelines and planned a new pathway to ensure patients receive the correct advice and follow up on discharge.

Method

Data was requested from IT for all head injury episodes in 2019, to reflect usual numbers pre-pandemic.

Electronic letters, radiology and notes were used to identify whether imaging criteria was met/carried out, discharge destinations, re-presentations, specialty discussions, and head injury advice on discharge.

Results

307 individual patients identified. 13 re-presentations. 10 required neurosurgical discussions

Destinations

226 (73.6%) discharged direct from ED. Admissions: Surgical - 37 (12%), Medical - 6 (2%), Paeds – 14 (4.5%), ITU 2 (0.7%), Did not wait – 2 (0.7%), Not Recorded – 7 (2.3%)

Imaging

100 patients met NICE criteria for CT, 100% were documented in notes and had CT. 76% reported normal, 18% had a bleed, contusion, or haematoma.

HI advice

90% of ED discharges, 16% of Surgical and 16% of medical discharges had head injury discharge advice documented

Conclusions

Guidelines were met for 100% of patients requiring imaging. Head injury advice was well documented in ED but fell down in ward paperwork. We have written a robust pathway where all inpatients have a proforma completed during admission with prompts for discharge advice and rehab referral where appropriate, this is currently undergoing a re-audit to ensure improvement and if successful will become an established part of the trauma pathway in our hospital.

238 The Use of MRCP in the Assessment of Choledocholithiasis in Patients Presenting with Symptomatic Gallstone Disease

Aim

Magnetic Resonance Cholangiopancreatography (MRCP) is the investigation of choice for choledocholithiasis; however, use is varied and guidelines vague. The National Institute for Health and Care (NICE) recommend MRCP when common bile duct (CBD) dilatation ≥ 8mm or liver function tests (LFTs) are abnormal but do not quantify this further. The Sunflower Study classifies patients as “high-risk” for choledocholithiasis if alanine aminotransferase (ALT) ≥ 80 IU/L, alkaline phosphatase (ALP) ≥ 200 IU/L or CBD ≥ 8mm. We aimed to assess compliance with NICE criteria and determine what biochemical abnormalities are most associated with choledocholithiasis.

Method

A retrospective analysis of inpatient MRCPs performed at QEH between March and May 2021 was performed (n = 72). Pre-MRCP bloods and imaging were used to assess concordance with NICE guidelines. We compared LFTs between patients with and without choledocholithiasis, looking for significant differences.

Results

84.7% of MRCPs were performed in accordance with NICE guidance, of which 31.1% demonstrated choledocholithiasis. No cases of choledocholithiasis were identified if NICE criteria were not fulfilled. A significant difference between the mean values of gamma glutamyltransferase (GGT) and ALP was noted between patients with and without choledocholithiasis.

Conclusions

We identified that the majority of MRCPs were performed in accordance with guidance. Significantly, no cases of choledocholithiasis were identified if these criteria were not met. Although our sample size was small, we found the most specific biochemical markers were ALP and GGT and propose that further research with larger cohorts may help develop a risk stratification tool to aid decision making.

Identification of a novel cancer microbiome signature for predicting prognosis of human breast cancer patients

BACKGROUND

Prognosis of breast cancer (BC) patients differs considerably and identifying reliable prognostic biomarker(s) is imperative. With evidence that the microbiome plays a critical role in the response to cancer therapies, we aimed to identify a cancer microbiome signature for predicting the prognosis of BC patients.

METHODS

The TCGA BC microbiome data (TCGA-BRCA-microbiome) was downloaded from cBioPortal. Univariate and multivariate Cox regression analyses were used to examine association of microbial abundance with overall survival (OS) and to identify a microbial signature for creating a prognostic scoring model. The performance of the scoring model was assessed by the area under the ROC curve (AUC). Nomograms using the microbial signature, clinical factors, and molecular subtypes were established to predict OS and progression-free survival (PFS).

RESULTS

Among 1406 genera, the abundances of 94 genera were significantly associated with BC patient OS in TCGA-BRCA-microbiome dataset. From that set we identified a 15-microbe prognostic signature and developed a 15-microbial abundance prognostic scoring (MAPS) model. Patients in low-risk group significantly prolong OS and PFS as compared to those in high-risk group. The time-dependent ROC curves with MAPS showed good predictive efficacy both in OS and PFS. Moreover, MAPS is an independent prognostic factor for OS and PFS over clinical factors and PAM50-based molecular subtypes and superior to the previously published 12-gene signature. The integration of MAPS into nomograms significantly improved prognosis prediction.

CONCLUSION

MAPS was successfully established to have independent prognostic value, and our study provides a new avenue for developing prognostic biomarkers by microbiome profiling.

Evaluating direct oral anticoagulants versus vitamin K antagonists for treatment of left ventricular thrombus: a systematic review and meta-analysis

Background/Introduction

Left ventricular thrombi are associated with high rates of stroke and systemic embolism (1). While vitamin K antagonists (VKAs) have historically been the anticoagulant of choice, they have a narrow therapeutic window and require frequent monitoring. Direct oral anticoagulants (DOACs) offer more predictable anticoagulation but the use of DOACs to treat left ventricular thrombus has not been well studied (1,2). Guideline recommendations around the topic are based on expert consensus and very low-quality evidence.

Purpose

This systematic review and meta-analysis compares DOACs or VKAs in the treatment of left ventricular thrombus. Outcomes of interest were stroke and systemic embolism, thrombus resolution, any bleeding, major bleeding, and mortality.

Methods

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, ACPJC, and Web of Science for studies comparing DOACs and VKAs in the treatment of left ventricular thrombus. We also searched reference lists from included studies and relevant conferences' proceedings. Two reviewers independently screened titles and abstracts and then the full-text of potentially relevant citations in duplicate. They then extracted data and evaluated risk of bias in duplicate. The data was analyzed using Revman 5.3. We used the DerSimonian and Laird random-effects model to pool the weighted effect of estimates across all studies. The pooled relative risks (RRs) were calculated with corresponding 95% confidence intervals (CIs). We assessed the quality of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

Results

Of 443 citations screened, 12 observational studies (n=2,225) were included. We found no randomized controlled trial addressing the question. Most included studies were at high risk of bias due to unmatched baseline variables. We found no significant difference in any of our outcomes with DOACs versus VKAs: stroke and systemic embolism (RR 1.14, 95% CI [0.82, 1.58], p=0.43), thrombus resolution (RR 1.02, 95% CI [0.91, 1.15], p=0.69), any bleeding (RR 1.47, 95% CI [0.65, 3.33], p=0.36), major bleeding (RR 0.22, 95% CI [0.01, 4.21], p=0.32), and mortality (RR 0.99, 95% CI [0.67, 1.45], p=0.95). Evidence for each of these outcomes was of very low-quality due to risk of bias, inconsistency, and imprecision of the studies.

Conclusions

Very low quality evidence suggests no difference in outcomes with DOACs versus VKAs in the treatment of left ventricular thrombus. More robust data are needed to guide clinicians.

Funding Acknowledgement

Type of funding sources: None.

219 Have New National Guidelines Changed Practice in Referrals with Suspected Ureteric Colic?

Aim

To assess how many patients had a non-contrast CT as first-line investigation for suspected renal colic, and how this was affected by the release of the 2019 NICE guidelines. A secondary aim was to assess the proportion of patients who had CT KUBs that demonstrated a ureteric calculus.

Method

CT KUB scans performed over two separate 3 month periods were identified. These reflected periods of time before and after the new NICE guidelines. Electronic records were used to assess if the patients had an ultrasound performed as the initial diagnostic investigation, instead of a CT scan. The results of the scans were reviewed to identify if a ureteric or renal calculus had been positively identified.

Results

In the period before the new guidelines, 61 patients were scanned. 4 had an ultrasound to assess for a stone prior to a CT. All of these patients were medical inpatients. None of the ultrasounds diagnosed a stone. 22/61 patients had CT-proven stones (36%) In the period after the new guidelines, 79 patients were scanned. 12 had an ultrasound to assess for a stone prior to a CT. 8 were medical patients, 3 were surgical and 1 was gynaecological. 1 ultrasound diagnosed a stone. 28/79 patients had CT-proven stones (35.4%)

Conclusions

The release of new guidelines did not improved compliance with suggested imaging pathways. This clearly demonstrates an area for improvement. It is also worth noting that only 1/3 of referrals with suspected renal colic did actually have a stone, which has implications for specialty referral pathways.

468 IMPROVING ADVANCE CARE PLANNING SKILLS IN JUNIOR DOCTORS

Introduction

Junior doctors are increasingly encountering Advance Care Planning (ACP) when they look after frail, older or multi-morbid patients during their hospital rotations. However, there remains a lack of formal training and resources, particularly with DNACPR discussions and when engaging patients and their loved ones with Emergency Health Care Planning (EHCP). We aimed to assess the need for ACP, improve the infrastructure by which ACP is delivered, and better support junior doctors to have these difficult conversations.

Method

Discharges from the Geriatrics Department at Kettering General Hospital were reviewed initially in May 2019 and again in January 2020 following intervention. We introduced a focused communication skills training session delivered at departmental teaching, which included a combination of simulation training and lectures. We additionally designed and implemented an EHCP template to aid junior doctors’ discussions. This could also be copied to the discharge letter, to facilitate safe transfer of care to primary care.

Results

In May 2019 of 32 patients, 100% met at least one SPICTTM criterion, with median of 4 criteria, thus indicating a high need for ACP in this cohort. Despite this, only one discharge letter included an EHCP and two had a request for GP colleagues to complete one. Evaluation of discharges again in January of 2020 reconfirmed a similar need for ACP, but following our interventions, the number of EHCP’s performed had increased. Of 22 identified patients 4 had a completed EHCP and 3 were requested for completion by their GP. Qualitative questionnaires demonstrated an improvement in both knowledge and confidence amongst junior doctors following the training session.

Conclusion

We have shown that there is a necessity for ACP to be considered for Geriatrics inpatients, and that providing structure and training in this challenging area offers benefit to both patients and junior doctors.