WP1-16 Does time to diagnosis influence surgical decision making in primary malignant brain tumours?

Objectives

To assess whether time to diagnosis influenced surgical procedure and survival in primary malignant brain tumours

Design

Retrospective cohort study of adult patients newly diagnosed with a primary intra-cerebral tumour April 2010 – March 2015 referred to neuro-oncology centre in South-East Scotland

Subjects

400 patients with primary malignant intracerebral tumours

Methods

Univariate logistic regression analysis and multivariate Cox regression survival analysis were performed

Results

Our dataset included 229 Males (57.7%), mean age 62.05 (SD14.01). Time to diagnosis did affect choice of surgical procedure. Patients undergoing biopsy had significantly longer TtD than those undergoing resection (28 vs 21 days, MWU test, p=0.035). 233 (58.3%) patients were deceased at 12 months. Having a cognitive first symptom (e.g confusion/memory changes) predicted not getting any surgical procedure (OR 2.95 [95% CI 1.8–4.8]). Where surgery was performed, first cognitive symptom was not predictive of type of surgery (biopsy vs debulking/excision) (OR 1.5 [95% CI 0.8–2.9] norhaving tumour in the frontal lobe (OR 0.9 [95% CI 0.5–1.7]. In multivariate analysis, increased hazard ratio of death at 12 month was significantly associated with a cognitive first symptom (HR 1.4 [95% CI 1.0–1.9] and KPS <70 (HR 1.69 [95% CI 1.2–2.4]).

Conclusions

Earlier diagnosis is associated with getting debulking surgery rather than biopsy, and patient’s presenting symptoms influence surgical decision making and outcome.

TM1-1 Seizure prophylaxis in gliomas (SPRING): a phase III randomised controlled trial comparing prophylactic levetiracetam versus no prophylactic anti-epileptic drug in glioma surgery

Objectives

There is no consensus regarding the need for prophylactic anti-epileptic drug (AED) in seizure-naive newly-diagnosed glioma patients. Data regarding prophylactic AED use are scant and inconclusive from older, small studies that enrolled patients with brain metastases, benign tumours and gliomas. A definitive randomised controlled trial (RCT) is needed to determine whether the policy of prophylactic AED therapy reduces the risk of first seizures in this population.

Design

Multi-centre RCT.

Subjects

Inclusion criteria: i. seizure-naive, ii. supratentorial glioma suitable for surgery (biopsy/resection), iii. age ≥16 years; iv. Karnofsky performance status >60.

Methods

Patients are randomised 1:1. Levetiracetam 500 mg bd for 2 weeks, increased to 750 mg bd thereafter for 1 year. Non-blinded. No placebo. Primary Outcome: one year risk of first seizure. Secondary outcomes: time to first seizure, time to first tonic-clonic seizure, mood, fatigue, quality of life, progression free survival, overall survival and incremental cost per QALY. Estimate of 1 year seizure rate in glioma after surgery is 20%. Based on a reduction in seizure rate to 10% a total of 806 patients will be recruited.

Results

Grant awarded by NIHR. Feasibility questionnaire demonstrated prophylactic AED rarely used. Neurosurgeons willing to randomise. 15 UK centres have expressed interest in participating.

Conclusions

SPRING will establish class I evidence for the use of seizure prophylaxis in glioma surgery. The trial will open to recruitment in January 2019.

Insights on the relationship between total grazing pressure management and sustainable land management: key indicators to verify impacts

Demonstrating sustainable land management (SLM) requires an understanding of the linkages between grazing management and environmental stewardship. Grazing management practices that incorporate strategic periods of rest are promoted internationally as best practice. However, spatial and temporal trends in unmanaged feral (goat) and native (kangaroo) populations in the southern Australian rangelands can result land managers having, at times, control over less than half the grazing pressure, precluding the ability to rest pastures. Few empirical studies have examined the impacts of total grazing pressure (TGP) on biodiversity and resource condition, while the inability to manage grazing intensity at critical times may result in negative impacts on ground cover, changes in pasture species composition, increased rates of soil loss and reduce the ability for soils to store carbon. The widespread adoption of TGP control through exclusion fencing in the southern Australian rangelands has created unprecedented opportunities to manage total grazing pressure, although there is little direct evidence that this infrastructure leads to more sustainable land management. Here we identify several key indicators that are either outcome- or activity-based that could serve as a basis for verification of the impacts of TGP management. Since TGP is the basic determinant of the impact of herbivory on vegetation it follows that the ability for rangeland pastoral management to demonstrate SLM and environmental stewardship will rely on using evidence-based indicators to support environmental social licence to operate.

The impact on authors and editors of introducing Data Availability Statements at Nature journals

This article describes the adoption of a standard policy for the inclusion of data availability statements in all research articles published at the Nature family of journals, and the subsequent research which assessed the impacts that these policies had on authors, editors, and the availability of datasets. The key findings of this research project include the determination of average and median times required to add a data availability statement to an article; and a correlation between the way researchers make their data available, and the time required to add a data availability statement.

Emotional hyper-reactivity and cardiometabolic risk in remitted bipolar patients: a machine learning approach

OBJECTIVE

Remitted bipolar disorder (BD) patients frequently present with chronic mood instability and emotional hyper-reactivity, associated with poor psychosocial functioning and low-grade inflammation. We investigated emotional hyper-reactivity as a dimension for characterization of remitted BD patients, and clinical and biological factors for identifying those with and without emotional hyper-reactivity.

METHOD

A total of 635 adult remitted BD patients, evaluated in the French Network of Bipolar Expert Centers from 2010-2015, were assessed for emotional reactivity using the Multidimensional Assessment of Thymic States. Machine learning algorithms were used on clinical and biological variables to enhance characterization of patients.

RESULTS

After adjustment, patients with emotional hyper-reactivity (n = 306) had significantly higher levels of systolic and diastolic blood pressure (P < 1.0 × 10^-8 ), high-sensitivity C-reactive protein (P < 1.0 × 10^-8 ), fasting glucose (P < 2.23 × 10^-6 ), glycated hemoglobin (P = 0.0008) and suicide attempts (P = 1.4 × 10^-8 ). Using models of combined clinical and biological factors for distinguishing BD patients with and without emotional hyper-reactivity, the strongest predictors were: systolic and diastolic blood pressure, fasting glucose, C-reactive protein and number of suicide attempts. This predictive model identified patients with emotional hyper-reactivity with 84.9% accuracy.

CONCLUSION

The assessment of emotional hyper-reactivity in remitted BD patients is clinically relevant, particularly for identifying those at higher risk of cardiometabolic dysfunction, chronic inflammation, and suicide.

A survey of current management of Benign Paroxysmal Positional Vertigo (BPPV) by physiotherapists' interested in vestibular rehabilitation in the UK

OBJECTIVES

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of dizziness. Extensive research has identified the best assessment and treatment manoeuvres for each subtype of BPPV. Education in vestibular rehabilitation (VR) is inconsistent. It is unclear if the evidence has been adopted by UK physiotherapists in clinical practice and no research has investigated this specifically.

DESIGN

An online survey with closed- and open-text answers.

PARTICIPANTS

A purposive sample of physiotherapists interested in VR. A response rate of 67% (100/150) was obtained, from which 20 responses were excluded.

RESULTS

Participants had good evidence-based awareness in assessment (79/80, 99%) and treatment (72/80, 90%) of posterior BPPV. Horizontal BPPV assessment awareness was lower than treatment (37/80, 46% vs 60/80, 75%). Differential diagnosis was poor in subjective (20/80, 25%) and objective stages of assessment (34/80, 43%). Thirty six percent (29/80) were able to list ≥3 test precautions with all three nystagmus characteristics described by 29% (23/80). Eighty one percent (65/80) encourage activity restrictions post-treatment. Only 28% (22/80) were aware of practice guidelines or Cochrane reviews in BPPV. External courses were rated the top method for learning how to manage BPPV. Lack of peer support (26/77, 34%) was the main challenge faced whilst learning. Recommendations for improving BPPV education included more external courses (23/87, 26%) and competency guidelines (13/87, 15%).

CONCLUSIONS

Good awareness of research evidence was observed in some aspects of BPPV management but many areas require development. Translation and implementation of evidence remains poor and suggests changes in education and knowledge dissemination are warranted.

Reported Direct and Indirect Contact with Dromedary Camels among Laboratory-Confirmed MERS-CoV Cases

Dromedary camels (Camelus dromedarius) are now known to be the vertebrate animal reservoir that intermittently transmits the Middle East respiratory syndrome coronavirus (MERS-CoV) to humans. Yet, details as to the specific mechanism(s) of zoonotic transmission from dromedaries to humans remain unclear. The aim of this study was to describe direct and indirect contact with dromedaries among all cases, and then separately for primary, non-primary, and unclassified cases of laboratory-confirmed MERS-CoV reported to the World Health Organization (WHO) between 1 January 2015 and 13 April 2018. We present any reported dromedary contact: direct, indirect, and type of indirect contact. Of all 1125 laboratory-confirmed MERS-CoV cases reported to WHO during the time period, there were 348 (30.9%) primary cases, 455 (40.4%) non-primary cases, and 322 (28.6%) unclassified cases. Among primary cases, 191 (54.9%) reported contact with dromedaries: 164 (47.1%) reported direct contact, 155 (44.5%) reported indirect contact. Five (1.1%) non-primary cases also reported contact with dromedaries. Overall, unpasteurized milk was the most frequent type of dromedary product consumed. Among cases for whom exposure was systematically collected and reported to WHO, contact with dromedaries or dromedary products has played an important role in zoonotic transmission.

Kinetic Studies of Platelet Aggregation Induced by Adenosine Diphosphate and Its Inhibition by Chelating Agents, Guanidino Compounds, and Adenosine

The kinetics, activation, pH dependence and inhibition of platelet aggregation induced by ADP were studied by recording the OD of stirred PRP from blood anticoagulated with acid-citrate-dextrose solution. There was a lag period between the addition of ADP and the initiation of aggregation. Addition of ADP in the absence of stirring or ionized calcium did not cause aggregation. When aggregation was subsequently initiated by stirring or the addition of CaCl2 there was no lag period. The steepest slope of the OD curve was used as the reaction velocity (V). It was affected by the concentration of calcium ions and was maximum at pH 8.0. When the ADP concentration was varied in the presence of different concentrations of ionized calcium, the overall kinetics revealed a series of rectangular hyperbola segments which did not pass through the origin. These observations led to the conclusion that the overall reaction can be depicted as a chain reaction: ADP interacts reversibly with platelets; when calcium is present these platelets become “sticky” and, when stirred, they aggregate. Kinetic studies of inhibition indicated that adenosine is a competitive inhibitor of ADP. The guanidino compounds tested were noncompetitive with respect to ADP but their inhibitory activity was counteracted by calcium.

Exopolysaccharide from Bifidobacterium longum subsp. longum 35624™ modulates murine allergic airway responses

Interactions between the host and the microbiota are thought to significantly influence immunological tolerance mechanisms at mucosal sites. We recently described that the loss of an exopolysaccharide (EPS) from Bifidobacterium longum 35624™ eliminated its protective effects in colitis and respiratory allergy murine models. Our goal was to investigate the immune response to purified EPS from B. longum 35624, determine if it has protective effects within the lung and identify the protective mechanisms. Isolated EPS from B. longum 35624 cultures was used for in vitro, ex vivo and in vivo studies. Human monocyte-derived dendritic cells (MDDCs) were used to investigate in vitro immunological responses to EPS. Cytokine secretion, expression of surface markers and signalling pathways were examined. The ovalbumin (OVA) respiratory allergy murine model was used to evaluate the in vivo immunomodulatory potential of EPS. In addition, interleukin (IL)-10 knockout (KO) mice and anti-Toll-like receptor (TLR)-2 blocking antibody were used to examine the underlying protective mechanisms of intranasal EPS administration. Stimulation of human MDDCs with EPS resulted in IL-10 secretion, but not proinflammatory cytokines. IL-10 secretion was TLR-2-dependent. Eosinophil recruitment to the lungs was significantly decreased by EPS intranasal exposure, which was associated with decreased expression of the Th2-associated markers C-C motif chemokine 11 (CCL11), C-C chemokine receptor type 3 (CCR3), IL-4 and IL-13. TLR-2-mediated IL-10 secretion was shown to be required for the reduction in eosinophils and Th2 cytokines. EPS-treatment reduced eosinophil recruitment within the lung in a respiratory inflammation mouse model, which is both TLR-2 and IL-10 mediated. EPS can be considered as a novel molecule potentially reducing the severity of chronic eosinophil-related airway disorders.

Weight-adapted iodinated contrast media administration in abdomino-pelvic CT: Can image quality be maintained?

INTRODUCTION

In many centres, a fixed method of contrast-media administration is used for CT regardless of patient body habitus. The aim of this trial was to assess contrast enhancement of the aorta, portal vein, liver and spleen during abdomino-pelvic CT imaging using a weight-adapted contrast media protocol compared to the current fixed dose method.

METHODS

Thirty-nine oncology patients, who had previously undergone CT abdomino-pelvic imaging at the institution using a fixed contrast media dose, were prospectively imaged using a weight-adapted contrast media dose (1.4 ml/kg). The two sets of images were assessed for contrast enhancement levels (HU) at locations in the liver, aorta, portal vein and spleen during portal-venous enhancement phase. The t-test was used to compare the difference in results using a non-inferiority margin of 10 HU.

RESULTS

When the contrast dose was tailored to patient weight, contrast enhancement levels were shown to be non-inferior to the fixed dose method (liver p < 0.001; portal vein p = 0.003; aorta p = 0.001; spleen p = 0.001). As a group, patients received a total contrast dose reduction of 165 ml using the weight-adapted method compared to the fixed dose method, with a mean cost per patient of £6.81 and £7.19 respectively.

CONCLUSION

Using a weight-adapted method of contrast media administration was shown to be non-inferior to a fixed dose method of contrast media administration. Patients weighing 76 kg, or less, received a lower contrast dose which may have associated cost savings. A weight-adapted contrast media protocol should be implemented for portal-venous phase abdomino-pelvic CT for oncology patients with adequate renal function (>70 ml/min/1.73 m²).

Recordkeeping and research data management: a review of perspectives

Purpose

The purpose of this paper is to explore a range of perspectives on the relationship between research data and records and between recordkeeping and research data management.

Design/methodology/approach

This paper discusses literature in the field of research data management as part of preliminary work for the author’s doctoral research on the topic. The literature included in the review reflects contemporary and historical perspectives on the management and preservation of research data.

Findings

Preliminary findings indicate that records professionals have been involved in the management and preservation of research data since the early twentieth century. In the literature, research data is described as comparable to records, and records professionals are widely acknowledged to have skills and expertise which are applicable to research data management. Records professionals are one of a number of professions addressing research data management. However, they are not currently considered to be leaders in research data management practice.

Originality/value

Research data management is an emerging challenge as stakeholders in the research lifecycle increasingly mandate the publication of open, transparent research. Recent developments such as the publication of the OCLC report “The Archival Advantage: Integrating Archival Expertise into Management of Born-digital Library Materials”, and the creation of the Research Data Alliance Interest Group Archives and Records Professionals for Research Data indicates that research data is, or can be, within the remit of records professionals. This paper represents a snapshot of contemporary and historical attitudes towards research data and recordkeeping and thus contributes to this emerging area of discussion.

Informed consent in the context of research involving acute injuries and emergencies

Traditionally, informed consent for clinical research involves the patient reading an approved Participant Information Sheet, considering the information presented and having as much time as they need to discuss the study information with their friends and relatives, their clinical care and the research teams. This system works well in the 'planned' or 'elective' setting. But what happens if the patient requires urgent treatment for an injury or emergency? This article reviews the legal framework which governs informed consent in the emergency setting, discusses how the approach taken may vary according to the details of the emergency and the treatment required, and reports on the patients' view of providing consent following a serious injury. We then provide some practical tips for managing the process of informed consent in the context of injuries and emergencies. Cite this article: Bone Joint J 2017;99-B:147-150.