Decision-making and neurosurgeons' agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography

BACKGROUND

To determine the neurosurgeon's agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater's level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation.

METHOD

Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated.

RESULTS

There was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387-0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386-0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398-0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416-235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03-0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044-0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088-0.643; p = 0.005) were associated with a recommendation for endovascular treatment.

CONCLUSIONS

Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.

Lurasidone for the Treatment of Major Depressive Disorder with Mixed Features: Do Manic Symptoms Moderate Treatment Response?

Background

This post-hoc analysis evaluated whether the efficacy of lurasidone in major depressive disorder (MDD) with mixed features is moderated by the number and characteristics of manic symptoms present at study baseline.

Methods

Patients meeting DSM-IV-TR criteria for MDD who presented with two or three manic symptoms (consistent with the DSM–5 mixed features specifier) were randomly assigned to 6 weeks of double-blind treatment with either lurasidone 20–60 mg/d (n = 109) or placebo (n = 100). Finite mixture models were applied to identify latent class patterns of the 10 baseline manic symptoms.

Results

Three latent class profiles were identified: 105 (50.5%) patients had manic symptom profile 1 (MIX 1) with mean MADRS 33.0, mean YMRS 9.2, mean number of manic symptoms 3.8; 63 (30.3%) patients had manic symptom profile 2 (MIX 2) with similar baseline mean MADRS (32.4) and YMRS (9.3) and lower number of manic symptoms 3.5; 40 patients had manic symptom profile 3 (MIX 3) with significantly higher severity scores in MADRS (35) and YMRS (14.9) and mean number of manic symptoms 4.6. A significant moderating effect on change in YMRS score was observed for the “decreased need for sleep” symptom, with greater lurasidone effect size (vs. Placebo) found in patients without vs. With this symptom (P < 0.05).

Conclusions

In this post-hoc analysis of a placebo-controlled trial involving MDD patients with mixed features, absence of “decreased need for sleep” was found to be significantly associated with improvement in manic and depressive symptoms and to moderate the treatment effect on manic symptoms.

Disclosure of interest

I am full time employee of Sunovion pharmaceuticals Inc.

Abstract P5-16-26: National trends in neoadjuvant therapy for breast cancer

Purpose:Neoadjuvant therapy has been widely integrated in the treatment of locally advanced breast cancer. Over time, this strategy has been extended to include patients with earlier stage disease to allow for assessment of in vivo response to treatment. The aim of this study was to describe the national trends in neoadjuvant therapy for all invasive breast cancers with a particular focus on triple negative disease and HER2 status.

Methods: The National Cancer Database (NCDB), an oncology outcomes database that collects data from more than 1500 Commission on Cancer (CoC) accredited cancer programs, was queried for all women diagnosed with invasive breast cancer from 2006-2013. Patients with unknown systemic therapy sequence were excluded. Women were classified by whether or not they received neoadjuvant systemic, chemo and/or endocrine, therapy.

Results: We identified 1,221,976 cases that were eligible for this analysis. Of these, 29.7% were HER2 negative, 18.4% were classified as triple negative, and 8.9% received neoadjuvant systemic therapy. The percentage of patients receiving neoadjuvant therapy increased from 7.5% in 2006 to 9.8% in 2012 with a slight decrease to 9.5% in 2013. This increase in the use of neoadjuvant therapy over the time period was statistically significant (p&lt;0.0001). There was a small increase in the percent of patients with HER2 positive status who received neoadjuvant therapy, from 5.7% in 2006 to 6.5% in 2013. During this time period, there was a 9% increase in the percent of triple negative patients who received neoadjuvant therapy (13.1% in 2016 to 22.1% in 2013).

Number and percent of patients who received/did not receive neoadjuvant therapy by year2006 (N=136117)2007 (N=143033)2008 (N=148888)2009 (N=154713)2010 (N=154040)2011 (N=162333)2012 (N=163395)2013 (N=159457)No Neoadjuvant Therapy | 125908 (92.5)131559 (91.98)136593 (91.74)141364 (91.37)139459 (90.53)146500 (90.25)147401 (90.21)144306 (90.5)Neoadjuvant Therapy | 10209 (7.5)11474 (8.02)12295 (8.26)13349 (8.63)14581 (9.47)15833 (9.75)15994 (9.79)15151 (9.5)

Conclusions: Over the time period from 2006-2013, there has been an apparent increase in the percentage of patients who received neoadjuvant therapy. This trend is accompanied by increases in the percentage of TNBC patients and in Her2 positive patients who received neoadjuvant therapy. Other factors and the joint effects of these factors on the observed increase in the use of neoadjuvant therapy are under evaluation to elucidate the basis for this observation in the NCDB data.

Citation Format: Schnabel F, Schwartz S, Hochman T, Chun J, Goldberg J. National trends in neoadjuvant therapy for breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-16-26.

Banff Histopathological Consensus Criteria for Preimplantation Kidney Biopsies

The Banff working group on preimplantation biopsy was established to develop consensus criteria (best practice guidelines) for the interpretation of preimplantation kidney biopsies. Digitally scanned slides were used (i) to evaluate interobserver variability of histopathologic findings, comparing frozen sections with formalin-fixed, paraffin-embedded tissue of wedge and needle core biopsies, and (ii) to correlate consensus histopathologic findings with graft outcome in a cohort of biopsies from international medical centers. Intraclass correlations (ICCs) and univariable and multivariable statistical analyses were performed. Good to fair reproducibility was observed in semiquantitative scores for percentage of glomerulosclerosis, arterial intimal fibrosis and interstitial fibrosis on frozen wedge biopsies. Evaluation of frozen wedge and core biopsies was comparable for number of glomeruli, but needle biopsies showed worse ICCs for glomerulosclerosis, interstitial fibrosis and tubular atrophy. A consensus evaluation form is provided to help standardize the reporting of histopathologic lesions in donor biopsies. It should be recognized that histologic parameters may not correlate with graft outcome in studies based on organs deemed to be acceptable after careful clinical assessment. Significant limitations remain in the assessment of implantation biopsies.

Dural Arteriovenous Fistula Mimicking a Supratentorial Tumor

BACKGROUND

The pathophysiology of dural arteriovenous fistulas (dAVF) is not fully understood. Retrograde venous flow can lead to venous congestion and disruption of the blood-brain barrier, resulting in diffuse contrast enhancement.

CASE DESCRIPTION

We present the case of a patient with a supratentorial dAVF associated with a solid, tumor-appearing, corticosubcortical contrast-enhancing lesion. Surgical occlusion of the dAVF was followed by complete regression of the contrast-enhancing lesion. Histologic analysis of the lesion showed normal brain tissue.

CONCLUSIONS

This case report highlights how venous congestion is an important differential diagnosis in contrast-enhancing lesions associated with dAVF and how it should be taken in consideration to avoid radiologic misdiagnoses and unnecessary treatment.

Methylglyoxal, the foe and friend of glyoxalase and Trx/TrxR systems in HT22 nerve cells

Methylglyoxal (MGO) is a major glycating agent that reacts with basic residues of proteins and promotes the formation of advanced glycation end products (AGEs) which are believed to play key roles in a number of pathologies, such as diabetes, Alzheimer's disease, and inflammation. Here, we examined the effects of MGO on immortalized mouse hippocampal HT22 nerve cells. The endpoints analyzed were MGO and thiol status, the glyoxalase system, comprising glyoxalase 1 and 2 (GLO1/2), and the cytosolic and mitochondrial Trx/TrxR systems, as well as nuclear Nrf2 and its target genes. We found that nuclear Nrf2 is induced by MGO treatment in HT22 cells, as corroborated by induction of the Nrf2-controlled target genes and proteins glutamate cysteine ligase and heme oxygenase 1. Nrf2 knockdown prevented MGO-dependent induction of glutamate cysteine ligase and heme oxygenase 1. The cystine/glutamate antiporter, system xc(-), which is also controlled by Nrf2, was also induced. The increased cystine import (system xc(-)) activity and GCL expression promoted GSH synthesis, leading to increased levels of GSH. The data indicate that MGO can act as both a foe and a friend of the glyoxalase and the Trx/TrxR systems. At low concentrations of MGO (0.3mM), GLO2 is strongly induced, but at high MGO (0.75 mM) concentrations, GLO1 is inhibited and GLO2 is downregulated. The cytosolic Trx/TrxR system is impaired by MGO, where Trx is downregulated yet TrxR is induced, but strong MGO-dependent glycation may explain the loss in TrxR activity. We propose that Nrf2 can be the unifying element to explain the observed upregulation of GSH, GCL, HO1, TrxR1, Trx2, TrxR2, and system xc(-) system activity.

Composite Resin Core Buildups With and Without Post for the Restoration of Endodontically Treated Molars Without Ferrule

OBJECTIVE

The aim of this study was to investigate the restoration of highly damaged, broken-down endodontically treated molars without the ferrule effect using glass ceramic crowns on different dual-cure composite resin core buildups.

METHODS AND MATERIALS

Thirty (N=30, n=15) decoronated, endodontically treated teeth (no ferrule) were restored without a ferrule with a direct buildup using the dual-curing composite Multicore HB (group MHB) or the dual-curing composite core buildup Multicore Flow in combination with glass-fiber-reinforced composite post (FRC post; group MFP). All teeth were prepared to receive bonded glass ceramic crowns (Empress CAD luted with Variolink II) and were subjected to accelerated fatigue testing. Cyclic isometric loading was applied to the palatal cusp at an angle of 30 degrees and a frequency of 5 Hz, beginning with a load of 200 N (×5000 cycles), followed by stages of 400, 600, 800, 1000, 1200, and 1400 N at a maximum of 30,000 cycles each. Specimens were loaded until failure or to a maximum of 185,000 cycles. Groups were compared using the life table survival analysis (log rank test at p=0.05). Average fracture loads and number of survived cycles were compared with one-way analysis of variance (Scheffé post hoc at p=0.05). Previously published data from the same authors about core buildups made of high-performance polymers (group HPP, n=15) and light-curing composite resin without FRC posts (group TEC, n=15) and with FRC posts (group TECP, n=15) using the same experimental setup were included for comparison.

RESULTS

None of the tested specimen withstood all 185,000 load cycles. There was no significant difference in mean fracture load (p=0.376), survived cycles (p=0.422), and survival (p=0.613) between MHB (facture load 859.4 N±194.92) and MFP (796.13 N±156.34). Group HPP from a previous study appeared to have significantly higher performance than all other groups except MHB. All groups with posts were affected by an initial failure phenomenon (wide gap at the margin between the buildup/crown assembly and the root).

CONCLUSIONS

HPP and MHB enhanced the performance of all-ceramic leucite-reinforced glass ceramic crowns, and insertion of a fiber-reinforced composite post was not influential when using other materials.

Diagnostic performance of the PTSD checklist and the Vietnam Era Twin Registry PTSD scale

AIMS

Self-report questionnaires are frequently used in clinical and epidemiologic studies to assess post-traumatic stress disorder (PTSD). A number of studies have evaluated these scales relative to clinician administered structured interviews; however, there has been no formal evaluation of their performance relative to non-clinician administered epidemiologic assessments such as the Composite International Diagnostic Interview (CIDI). We examined the diagnostic performance of two self-report PTSD scales, the PTSD checklist (PCL) and the Vietnam Era Twin Registry (VET-R) PTSD scale, compared to the CIDI.

METHODS

Data were derived from a large epidemiologic follow-up study of PTSD in 5141 Vietnam Era Veterans. Measures included the PCL, VET-R PTSD scale and CIDI. For both the PCL and VET-R PTSD scale, ROC curves, areas under the curve (AUC), sensitivity, specificity, % correctly classified, likelihood ratios, predictive values and quality estimates were generated based on the CIDI PTSD diagnosis.

RESULTS

For the PCL and VET-R PTSD scale the AUCs were 89.0 and 87.7%, respectively. Optimal PCL cutpoints varied from the 31-33 range (when considering sensitivity and specificity) to the 36-56 range (when considering quality estimates). Similar variations were found for the VET-R PTSD, ranging from 31 (when considering sensitivity and specificity) to the 37-42 range (when considering quality estimates).

CONCLUSIONS

The PCL and VET-R PTSD scale performed similarly using a CIDI PTSD diagnosis as the criterion. There was a range of acceptable cutpoints, depending on the metric used, but most metrics suggested a lower PCL cutpoint than in previous studies in Veteran populations.

Discovery of τ Neutrino Appearance in the CNGS Neutrino Beam with the OPERA Experiment

The OPERA experiment was designed to search for ν_{μ}→ν_{τ} oscillations in appearance mode, i.e., by detecting the τ leptons produced in charged current ν_{τ} interactions. The experiment took data from 2008 to 2012 in the CERN Neutrinos to Gran Sasso beam. The observation of the ν_{μ}→ν_{τ} appearance, achieved with four candidate events in a subsample of the data, was previously reported. In this Letter, a fifth ν_{τ} candidate event, found in an enlarged data sample, is described. Together with a further reduction of the expected background, the candidate events detected so far allow us to assess the discovery of ν_{μ}→ν_{τ} oscillations in appearance mode with a significance larger than 5σ.

CAD/CAM Polymer vs Direct Composite Resin Core Buildups for Endodontically Treated Molars Without Ferrule

OBJECTIVES

The aim of this study was to investigate the restoration of broken-down endodontically treated molars without ferrule effect using glass ceramic crowns on different composite resin core buildups.

METHODS AND MATERIALS

Forty-five decoronated endodontically treated teeth (no ferrule) were restored with a semidirect buildup using an experimental computer-aided design/computer-aided manufacturing (CAD/CAM) high-performance polymer (HPP group) or with light-curing composite core buildups of Tetric EvoCeram with (TECP group) or without (TEC group) a glass-fiber-reinforced post. All teeth were prepared to receive bonded glass ceramic crowns (Empress CAD luted with Variolink II) and were subjected to accelerated fatigue testing. Cyclic isometric loading was applied to the palatal cusp at an angle of 30° and a frequency of 5 Hz, beginning with a load of 200 N (×5000 cycles) and followed by stages of 400, 600, 800, 1000, 1200, and 1400 N at a maximum of 30,000 cycles each. Specimens were loaded until failure or to a maximum of 185,000 cycles. Groups were compared using the life-table survival analysis (log rank test at p=0.05). Average fracture loads and number of survived cycles were compared with one-way analysis of variance (Scheffé post hoc at p=0.05).

RESULTS

None of the tested specimen withstood all 185,000 load cycles. There was a significant difference in mean fracture load, survived cycles, and survival; the HPP group (fracture load 975.27N±182.74) was significantly higher than the TEC (716.87N±133.43; p=0.001) and TECP (745.67±156.34; p=0.001) groups, and the TEC and TECP groups showed no difference (p=0.884). Specimens in the TECP group were affected by an initial failure phenomenon (wide gap at the margin between the buildup/crown assembly and the root).

CONCLUSIONS

Semidirect core buildup made from high-performance polymer enhanced the performance of all-ceramic leucite-reinforced glass ceramic crowns compared with direct light-curing composite resin buildups. The use of a fiber-reinforced post system did not influence the fatigue strength of all-ceramic crowns.

Nuchal Translucency Quality Review (NTQR) program: first one and half million results

OBJECTIVE

To evaluate the performance of first-trimester nuchal translucency (NT) measurement by providers (physician-sonologists and sonographers) within the Nuchal Translucency Quality Review (NTQR) program.

METHODS

After training and credentialing providers, the NTQR monitored performance of NT measurement by the extent to which an individual's median multiple of the normal median (MoM) for crown-rump length (CRL) was within the range 0.9-1.1 MoM of a published normal median curve. The SD of log10 MoM and regression slope of NT on CRL were also evaluated. We report the distribution between providers of these performance indicators and evaluate potential sources of variation.

RESULTS

Among the first 1.5 million scans in the NTQR program, performed between 2005 and 2011, there were 1 485 944 with CRL in the range 41-84 mm, from 4710 providers at 2150 ultrasound units. Among the 3463 providers with at least 30 scans in total, the median of the providers' median NT-MoMs was 0.913. Only 1901 (55%) had a median NT-MoM within the expected range; there were 89 above 1.1 MoM, 1046 at 0.8-0.9 MoM, 344 at 0.7-0.8 MoM and 83 below 0.7 MoM. There was a small increase in the median NT-MoM according to providers' length of time in the NTQR program and number of scans entered annually. On average, physician-sonologists had a higher median NT-MoM than did sonographers, as did those already credentialed before joining the program. The median provider SD was 0.093 and the median slope was 13.5%. SD correlated negatively with the median NT-MoM (r = -0.34) and positively with the slope (r = 0.22).

CONCLUSION

Even with extensive training, credentialing and monitoring, there remains considerable variability between NT providers. There was a general tendency towards under-measurement of NT compared with expected values, although more experienced providers had performance closer to that expected.