Emotional well-being and HbA1c following the implementation of the Diabetes Psychosocial Assessment Tool (DPAT) in young adults with Type 1 Diabetes (T1DM): An observational study

AIMS

This observational study evaluated the implementation of the Diabetes Psychosocial Assessment Tool (DPAT), assessing emotional well-being of young adults with type 1 diabetes (T1DM) and the clinical congruency between DPAT-recommended and specialist-led referrals.

METHODS

Young adults with T1DM attending the clinic completed the DPAT on two occasions. The DPAT includes the PAID (diabetes distress), PHQ-4 (depression/anxiety) and WHO-5 (general well-being), a diabetes health audit and a referral pathway to (allied) health professionals. Demographic and clinical information was retrieved from medical records. Data was analyzed using descriptive statistics and generalized estimating equations.

RESULTS

115 people with T1DM, aged 16-25 years, were included in the analysis. Symptoms of moderate-severe diabetes distress were present in 29 (25%) participants, symptoms of depression/anxiety and impaired well-being in 21 (19%) and 26 (23%) participants, respectively. The odds of depression/anxiety symptoms was lower at the second timepoint compared to the first timepoint (OR 0.55, 95% CI 0.32-0.96, p=0.03). The odds of moderate-severe diabetes distress tended to be lower. No change was observed in general well-being or HbA1c. There was moderate concordance between DPAT and clinician referrals to psychologists (81%) and dieticians (70%).

CONCLUSIONS

Using the DPAT facilitates the conversation about emotional well-being during routine consultation and follow-up.

A national qualitative investigation of the impact of service change on doctors' training during Covid-19

BACKGROUND

The Covid-19 crisis sparked service reconfigurations in healthcare systems worldwide. With postgraduate medical education sitting within these systems, service reconfigurations substantially impact trainees and their training environment. This study aims to provide an in-depth qualitative understanding of the impact of service reconfiguration on doctors' training during the pandemic, identifying opportunities for the future as well as factors that pose risks to education and training and how these might be mitigated.

METHODS

Qualitative parallel multi-centre case studies examined three Trusts/Health Boards in two countries in the United Kingdom. Data were collected from online focus groups and interviews with trainees and supervisors using semi-structured interview guides (September to December 2020). A socio-cultural model of workplace learning, the expansive-restrictive continuum, informed data gathering, analysis of focus groups and coding.

RESULTS

Sixty-six doctors participated, representing 25 specialties/subspecialties. Thirty-four participants were male, 26 were supervisors, 17 were specialty trainees and 23 were foundation doctors. Four themes described the impact of pandemic-related service reconfigurations on training: (1) Development of skills and job design, (2) Supervision and assessments, (3) Teamwork and communication, and (4) Workload and wellbeing. Service changes were found to both facilitate and hinder education and training, varying across sites, specialties, and trainees' grades. Trainees' jobs were redesigned extensively, and many trainees were redeployed to specialties requiring extra workforce during the pandemic.

CONCLUSIONS

The rapid and unplanned service reconfigurations during the pandemic caused unique challenges and opportunities to doctors' training. This impaired trainees' development in their specialty of interest, but also presented new opportunities such as cross-boundary working and networking.

218 DEVELOPING CONSENSUS-BASED INTEGRATED NUTRITION CARE PATHWAYS TO PREVENT, IDENTIFY AND MANAGE MALNUTRITION IN IRELAND

Background

The expected policy and standards of nutritional care in acute settings in Ireland has recently been developed (Department of Health, 2020). Based on these and international guidelines, integrated care pathways have been proposed by a panel of experts for (i) the transition of nutrition care of adult patients (>18 years) from hospital to community and, (ii) screening and identifying nutrition risk among community dwelling older adults (>65 years). The purpose of this study was to develop a consensus amongst diverse stakeholders for the proposed integrated nutrition care pathways.

Methods

A cross-sectional online survey collected data to identify pathway practices for retention. The survey was adapted to the Irish context based on previous research. Relevant stakeholders including healthcare professionals working in hospital, community and primary care, general practitioners, nurses, registered dietitians, healthcare workers from voluntary community services, and patients/patient advocates were recruited. Participants responded on the relevance and importance of discreet care practices in the proposed Nutrition Care Pathway and a consensus was set at ≥ 80%.

Results

Ninety-seven healthcare professionals and eight patient/patient advocates completed the survey. There was no response from healthcare workers from voluntary community services. Most of the discreet care practices gained consensus ratings ≥80% from healthcare professionals. Among the patient/patient advocates, only 3 pathway elements gained consensus ≥80%.

Conclusion

Healthcare professionals’ agreement with the relevance and importance of the proposed integrated nutrition care pathways offer guidance to prevent, identify, and manage malnutrition among older adults transitioning between care settings or living at home. The opinion of patients/patient advocates and healthcare workers of voluntary community services providers requires further engagement using alternative methodologies.

294 INTEGRATION OF MUSIC THERAPY WITHIN A MULTIDISCIPLINARY TEAM FOR OLDER ADULTS IN AN ACUTE HOSPITAL

Background

Music Therapy (MT) is an evidence-based intervention in which a music therapist uses music within a therapeutic relationship to achieve targeted goals. Studies show that MT may improve patient communication, cognition and mood, and facilitate rehabilitation by improving motor skills, particularly in those with stroke and Parkinson’s disease. We aimed to integrate MT within our geriatric multidisciplinary team (MDT) by: (1) promoting knowledge of MT among MDT staff; and (2) developing and implementing a MT referral pathway for patients. Furthermore, we aimed to assess its overall impact.

Methods

Music therapists delivered oral presentations and experiential learning through creative workshops, collaboration and feedback to allied health therapists in our geriatric MDT. Criteria for referrals for MT and a referral pathway were developed. Data on patients who received MT was collated.

Results

There were 70 referrals for MT from our MDT. 61% were female, mean age 77 years. Referral sources were occupational therapists (45%), speech therapists (34%), medical social workers (13%), physiotherapists (8%). Patients included those with stroke (41%), general medical conditions (23%), dementia (16%), Parkinson's (11%) and mental health concerns (9%). There were 16 joint MDT sessions and a mean of 5 MT sessions per patient (about 40 minutes in duration). Interventions included: Melodic Intonation Therapy (MIT), singing and vocal exercises, Rhythmic Auditory Stimulation (RAS), Musical Neglect Training (MNT), Therapeutic Instrumental Musical Performance (TIMP), reminiscence and song-writing. Overall, we identified better engagement with rehabilitation and improvements in mood, speech (voice strength and verbal fluency) and upper and lower limb co-ordination.

Conclusion

MT was successfully integrated into a geriatric MDT and had beneficial effects on patient mood, speech, communication and motor function. Education of MDT members was crucial in achieving appropriate MT referrals. Joint MDT’s also facilitated individualised MT interventions. Findings strongly support our model that incorporates MT within an MDT.

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

301 BENEFITS OF ENVIRONMENTAL MUSIC THERAPY IN AN ACUTE HOSPITAL

Background

Environmental Music Therapy (EMT) uses live music played by a music therapist to enhance the surrounding environment and is increasingly used in clinical settings. Studies show that EMT may reduce anxiety, enhance wellbeing, promote better communication between patients and staff, and reduce patient perception of waiting times in hospital. We aimed to explore the benefit of EMT for older adults in a geriatric outpatient setting and on rehabilitation wards.

Methods

Harp music was played by a music therapist in the vicinity of ambulatory clinics and on rehabilitation wards for 4 hours per week (over a 2-day period) for 20 weeks. Music exposure on any given day was to an estimated 50 outpatients, as well as 50 people passing the vicinity or to about 30 patients on the rehabilitation ward. Music was selected and played in a dynamic process, responding to verbal and non-verbal reactions of patients, family, and staff. Voluntary responses were recorded and collated.

Results

There were 36 recorded responses and all reflected positively on EMT. Patients cited that the music created a welcoming space and stimulated interaction and conversation. Several patients waiting for their clinic appointment noted that it distracted from fearful expectation and was a source of comfort. Some commented that they felt more relaxed and that it reduced stress. On rehabilitation wards, patients found familiar music to be calming with nurses citing that it stimulated social interaction between patients, family and staff. Responses to EMT gave insights that resulted in patient referrals for music therapy.

Conclusion

Environmental music played by a music therapist was found to modify patient hospital experiences. In particular, it appeared to reduce self-perceived stress and stimulate positive social interaction and conversation. This supports the use of EMT to advance the integration of the arts for wellbeing in an acute hospital.

Abstract 3580: Integrative genomics of checkpoint blockade response in advanced non-small cell lung cancer

The introduction of checkpoint blockade therapy, specifically anti-PD-1/PD-L1 agents, has transformed the treatment landscape of advanced Non-Small Cell Lung Cancer (NSCLC). While our understanding of the biology underlying immunotherapy in NSCLC is still incomplete, studies to date have established central roles for Tumor Mutation Burden (TMB) and PD-L1 Tumor Proportion Score (PDL1-TPS). In order to expand our understanding of the molecular features underlying response in NSCLC, we describe here the first joint analysis of the Stand Up 2 Cancer-Mark Foundation (SU2C-MARK) Cohort, a collection of 393 patients with whole exome and/or RNA sequencing along with matched checkpoint blockade response annotation. We identify a number of significant associations between molecular features and response, including: 1) favorable and unfavorable genomic subgroups; 2) distinct immune infiltration signatures associated with wound healing (unfavorable) and immune activated (favorable) microenvironments; and 3) a novel de-differentiated tumor-intrinsic subtype characterized by high TMB, immune activation, and enhanced response rate. Taken together, results from this cohort extend our understanding of NSCLC-specific predictors, providing a rich set of molecular and immunologic hypotheses with which to further our understanding of the biology of checkpoint blockade in NSCLC.

Citation Format: Arvind Ravi, Justin Gainor, Monica Arniella, Chip Stewart, Sam Freeman, Mark M. Awad, Patrick Forde, Valsamo Anagnostou, Brian Henick, Jonathan W. Riess, Don Gibbons, Nathan Pennell, Vamisdhar Velcheti, Ignaty Leshchiner, Jaegil Kim, Subba Digumarthy, Mari Mino-Kenudson, John Heymach, Natalie Vokes, Andrew Griffin, Biagio Ricciuti, Naiyer Rizvi, Roy Herbst, Victor Velculescu, Julie Brahmer, Kurt Schalper, Pasi Janne, Jedd Wolchok, Alice Shaw, Nir Hacohen, Gad Getz, Matthew D. Hellmann. Integrative genomics of checkpoint blockade response in advanced non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3580.

POS0243 THE EFFECT OF A MEDITERRANEAN DIET ON PHYSICAL FUNCTION AND QUALITY OF LIFE IN PATIENTS WITH RHEUMATOID ARTHRITIS – THE MEDRA STUDY

Background

The immunomodulatory and anti-inflammatory effects of the Mediterranean Diet (MedDiet) suggest a protective role in rheumatic conditions1. A small but increasing body of evidence from randomised controlled trials demonstrates that increased adherence to a MedDiet in patients with Rheumatoid Arthritis (RA) can have a beneficial effect on disease activity, pain levels and physical function2.

Objectives

The primary aim of the MEDRA study was to determine the effects of a MedDiet compared to the current food based dietary guidelines in Ireland (Healthy Eating Guidelines/HEG) on the physical function and quality of life in patients with RA.

Methods

In this randomised controlled trial, 44 patients with RA were randomly allocated to either the MedDiet or the HEG arm of the study. The 12-week dietary intervention study was delivered online by a Registered Dietitian (RD) and included data collection at three time points: baseline, mid-intervention (6 weeks) and post-intervention (12 weeks). Participants in both dietary intervention groups attended three video consultations with the RD, at baseline, weeks 6 and 12, and two follow up reviews by telephone at weeks 3 and 9. All participants were provided resources designed to specifically explain the assigned diet and how it can be successfully adhered to. Primary outcomes were changes in physical function and quality of life measured using the validated Health Assessment Questionnaire - Disability Index (HAQ-DI) and Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL), respectively. Secondary outcomes included changes in physical activity and patient-reported pain levels.

Results

Forty patients with RA completed the study (mean age:47.5 SD10.9 years, females: 87.5%). No significant differences were found in the distribution of age, anthropometric measures, disease duration, physical activity, and quality of life between the two diet groups at baseline. However, the group assigned to the MedDiet had better mean values for quality of life compared to the HEG group; 0.9 ± 0.5 vs. 1.4 ±0.7, p<0.001, respectfully. Compared to baseline, there was a significant improvement in HAQ-DI scores in participants following both the MedDiet (0.9 ±0.5 to 0.5 ± 0.4, p<0.001) and HEG (1.4 ± 0.7 to 1.0 ± 0.6, p<0.001). Significant improvements in RAQoL scores were also seen in both the MedDiet (10.1 ±7.5 to 4.0 ± 4.7, p<0.001) and HEG (11.25 ± 7.2 to 7.9 ± 6.4, p=0.02) groups. At 12 weeks, participants in the MedDiet group reported a significantly better physical function status (mean difference -0.5, 95% CI -0.8 to -0.1, p=0.007) and quality of life (mean difference -3.9, 95% CI -7.5 to -0.2, p=0.04) compared to the HEG group. Participants in the MedDiet group demonstrated a significant increase in physical activity levels (56.7 ± 28.6 to 70.6 ± 33.5, p=0.01). Conversely, a non-significant decrease in physical activity levels was observed in the HEG group from baseline to post-intervention.

Conclusion

The study indicates positive effects of a Mediterranean and low-fat diet as per the Healthy Eating Guidelines on physical function and quality of life in patients with RA. The MedDiet may be superior in improving physical activity levels. Further studies and a larger cohort are needed to confirm these findings.

References

[1]Oliviero, F., Spinella, P., Fiocco, U., Ramonda, R., Sfriso, P. and Punzi, L., 2015. How the Mediterranean diet and some of its components modulate inflammatory pathways in arthritis. Swiss medical weekly, 145(4546).

[2]Forsyth, C., Kouvari, M., D’Cunha, N.M., Georgousopoulou, E.N., Panagiotakos, D.B., Mellor, D.D., Kellett, J. and Naumovski, N., 2018. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatology international, 38(5), pp.737-747.

Acknowledgements

This work was funded by the School of Allied Health Postgraduate scholarship at the University of Limerick.

Disclosure of Interests

None declared

127 Optimum Treatment for Sigmoid Volvulus Remains Elusive but Surgery May Provide Considerable Benefit: Results of a 5-Year Audit

Background

Sigmoid volvulus is a surgical emergency and patients are often elderly with significant comorbidities. Whilst endoscopic decompression is easy and effective in the short-term, recurrence and repeated admissions are common with surgery generally being reserved for non-resolution or complications. Consensus an optimum management is lacking.

Method

A retrospective audit of all patients admitted with sigmoid volvulus to a DGH General Surgery service between 01/01/2015-20/10/2020 was undertaken. Patient demographics, comorbidities, clinical findings, investigations, and treatment were recorded.

Results

Sixty-three patients were identified (median age 71.5 years; 58.7% male]. Some 50.8% had more than one previous presentation (range 1–6), 19% presented after 3 days of symptoms and 3.2% presented with perforation. Plain radiography and CT scanning was undertaken in 90.5% and 54%, respectively.

Endoscopic detorsion was performed in 77.77% and repeated in the same admission for 33.3% of cases. Flatus tubes and rigid sigmoidoscopy was used in 47.6% with a 59.6% success rate. Seventeen patients (27%) underwent sigmoid resection, 14 having open surgery and 3 laparoscopic. Primary anastomosis was undertaken in 64.7% (11 patients), with only one anastomotic leak; the remaining 6 patients had a colostomy. The re-admission rate was 30.1% (19% non-operated patients, 11.1% operated patients).

Conclusions

Most patients with sigmoid volvulus are managed non-operatively with endoscopic detorsion which may be associated with a considerable healthcare burden and high readmission rates. Selective resection can be associated with low morbidity and good outcomes. Clinicians could reasonably adopt a lower threshold for surgical intervention, particularly for recurrent volvulus.

The novel persistent sodium current inhibitor PRAX-562 has potent anticonvulsant activity with improved protective index relative to standard of care sodium channel blockers

OBJECTIVE

This study investigates the effects of PRAX-562 on sodium current (I_Na ), intrinsic neuronal excitability, and protection from evoked seizures to determine whether a preferential persistent I_Na inhibitor would exhibit improved preclinical efficacy and tolerability compared to two standard voltage-gated sodium channel (Na_V ) blockers.

METHODS

Inhibition of I_Na  was characterized using patch clamp analysis. The effect on intrinsic excitability was measured using evoked action potentials recorded from hippocampal CA1 pyramidal neurons in mouse brain slices. Anticonvulsant activity was evaluated using the maximal electroshock seizure (MES) model, and tolerability was assessed by measuring spontaneous locomotor activity (sLMA).

RESULTS

PRAX-562 potently and preferentially inhibited persistent I_Na induced by ATX-II or the SCN8A mutation N1768D (half-maximal inhibitory concentration [IC₅₀ ] = 141 and 75 nmol·L^-1 , respectively) relative to peak I_Na tonic/resting block (60× preference). PRAX-562 also exhibited potent use-dependent block (31× preference to tonic block). This profile is considerably different from standard Na_V blockers, including carbamazepine (CBZ; persistent I_Na IC₅₀ = 77 500 nmol·L^-1 , preference ratios of 30× [tonic block], less use-dependent block observed at various frequencies). In contrast to CBZ, PRAX-562 reduced neuronal intrinsic excitability with only a minor reduction in action potential amplitude. PRAX-562 (10 mg/kg po) completely prevented evoked seizures without affecting sLMA (MES unbound brain half-maximal efficacious concentration = 4.3 nmol·L^-1 , sLMA half-maximal tolerated concentration = 69.7 nmol·L^-1 , protective index [PI] = 16×). In contrast, CBZ and lamotrigine (LTG) had PIs of approximately 5.5×, with significant overlap between doses that were anticonvulsant and that reduced locomotor activity.

SIGNIFICANCE

PRAX-562 demonstrated robust preclinical anticonvulsant activity similar to CBZ but improved compared to LTG. PRAX-562 exhibited significantly improved preclinical tolerability compared with standard Na_V blockers (CBZ and LTG), potentially due to the preference for persistent I_Na . Preferential targeting of persistent I_Na may represent a differentiated therapeutic option for diseases of hyperexcitability, where standard Na_V blockers have demonstrated efficacy but poor tolerability.

SURG-09. Benefits of laser interstitial thermal therapy in the treatment of biopsy-proven radiation necrosis

Introduction

Laser interstitial thermal therapy (LITT) is a minimally-invasive treatment option often used for patients with deep-seated intracranial lesions. It has been implemented as a definitive treatment for radiation necrosis (RN), which occurs in 9–14% of patients after stereotactic radiosurgery (SRS) for brain metastases (BM). Medical management (MM) with steroids is a common first-line therapy, with variable response and numerous side effects, especially regarding immunotherapy.

Methods

Patients with biopsy-proven RN after SRS for BM who received LITT or MM at two academic centers were retrospectively reviewed. Treatment failure was defined as radiographic progression that necessitated a change in management. Measurements of total (TLV) and contrast-enhancing lesion volume (ceLV) were obtained from MRI by semi-automated analysis using the BrainLab iPlan Cranial 3.0 software.

Results

Seventy-two patients were followed for 10.0 (4.2–25.1) months and 57 (79%) received LITT. Steroid cessation occurred at a median of 37 days post-LITT compared to 245 days after MM (p&lt;0.01). On Kaplan-Meier analyses, there was no significant difference between the two groups in overall survival (LITT median of 15.2 months vs 11.6 months, p = 0.60) or freedom from local progression (13.6 months vs. 7.06 months), though LITT trended to show a benefit in both metrics. When controlled for follow-up duration, patients treated with LITT were three times more likely to be weaned off steroids prior to the study endpoint compared to those who were medically managed (p=0.003). The LITT cohort demonstrated a general radiographic trend of initially increased CeLV followed by contraction, with significant decreases from pre-operative at 10–12 months (p&lt;0.01). The MM group did not demonstrate any statistically significant radiographic trends.

Conclusion

These results suggest that LITT for RN significantly reduces the time to steroid cessation and characterize a stereotyped radiographic response to LITT. Future prospective studies will be important to their validation.

Incidence of new-onset atrial fibrillation after cavotricuspid isthmus ablation for isolated typical atrial flutter: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

There is a lack of consensus guidelines regarding the continuation of anticoagulant therapy following cavotricuspid isthmus (CTI) ablation for typical atrial flutter.  This is despite a significant number of patients developing new-onset atrial fibrillation (AF) following the procedure.  Furthermore, a summary of Kaplan-Meier estimates for drug-free, arrhythmia-free survival has never been reported.

Purpose

 To estimate the incidence of drug-free, new-onset AF stratified by rhythm monitoring strategy in patients undergoing  CTI ablation for isolated typical atrial flutter.

Methods

PubMed, Embase and MEDLINE databases were searched to identify relevant studies. Only studies where anti-arrhythmic drugs were discontinued post-ablation and that accounted for patient censoring by reporting results in the form of time to event data were included.  Data was extracted from published Kaplan-Meier curves using a digitizing software and confidence intervals for the survivor function were estimated based on the number at risk at the time point of interest. Results were pooled in a random effects model using the DerSimonian-Laird estimator.

Results

 Thirteen relevant studies incorporating 1712 patients (79 % male, mean age 63.2 +/-11.2 years,  LVEF 55.2 +/-10.8%) were identified. The estimated  freedom from  new-onset atrial fibrillation was 89.7% (95% CI: 80.3-90.1%) at 1 year and 86.2% (95% CI: 78.4-94.0%) at 2 years in patients undergoing predominantly symptom –based monitoring, 74.6% (95%CI: 67.0-82.3%) at 1 year and 69.5% (95%CI: 63.5-75.6%) at 2 years  in patients undergoing regular clinic follow-up with periodic Holter monitoring and 51.4% (95% CI: 41.8-61.0%) at 1 year and 22.7% (95% CI: 8.7% - 36.6%) at 2 years in patients with implantable loop recorders.

Conclusion

 With the advent of implantable loop recorders, it is apparent that most patients with isolated atrial flutter manifest new-onset AF following CTI ablation and the merits of discontinuing anticoagulation must be carefully considered in this population.  Symptom-based monitoring likely severely underestimates the incidence of new-onset AF and may lead to adverse outcomes, particularly in patients with a high risk of stroke.

INNV-02. RADIOGRAPHIC CHARACTERISTICS AND STEROID USAGE IN LASER INTERSTITIAL THERMAL THERAPY VERSUS MEDICAL MANAGEMENT FOR BIOPSY-PROVEN RADIATION NECROSIS AFTER STEREOTACTIC RADIOSURGERY OF BRAIN METASTASES

INTRODUCTION

Radiation necrosis (RN) occurs in 9–14% of patients after stereotactic radiosurgery (SRS) for brain metastases (BM). Medical management (MM) with steroids is a common first-line therapy, with variable response and numerous side effects, especially regarding immunotherapy. Laser interstitial thermal therapy (LITT) has been introduced as an efficacious, steroid-reducing alternative, however limited data exists comparing LITT to MM.

METHODS

Patients with biopsy-proven RN after SRS for BM who received LITT or MM at two academic centers were retrospectively reviewed. Treatment failure was defined as radiographic progression that necessitated a change in management. Measurements of total (TLV) and contrast-enhancing lesion volume (ceLV) were obtained from MRI by semi-automated analysis using the BrainLab iPlan Cranial 3.0 software.

RESULTS

Eighty-one patients were followed for 11.7 (4.3–27.0) months and 57 (70%) received LITT. Steroid cessation occurred at a median of 37 days post-LITT compared to 162 days after MM (p&lt; 0.01). Treatment failure occurred in 5% of LITT patients at 4.0 (3.2–4.8) months and 13% of MM patients at 4.4 (4.1–5.3) months (p &gt;0.05). Patients were 3.2 times more likely to be weaned off steroids when treated with LITT compared to MM (p&lt; 0.01), when controlled for age, pre-operative ceLV, and post-operative seizure on multivariate analysis. Both groups demonstrated decreasing TLV and ceLV between baseline and last follow-up MRI. At 6–9 months, the LITT cohort demonstrated a -59% change in ceLV compared to -7% with MM (p &gt;0.05). The LITT cohort demonstrated a significant decrease in ceLV between scans at 0–2 and 6–9 months (p&lt; 0.01). The MM group did not demonstrate a statistically significant decrease in ceLV until 12 months.

CONCLUSION

This study suggests that LITT for RN significantly reduces the time to steroid cessation, and earlier radiographic response to treatment by LITT. Large, prospective trials are needed to validate these findings.

Management of unruptured incidentally found intracranial saccular aneurysms

Unruptured intracranial saccular aneurysms occur in 3-5% of the general population. As the use of diagnostic medical imaging has steadily increased over the past few decades with the increased availability of computed tomography (CT) and magnetic resonance imaging (MRI), so has the detection of incidental aneurysms. The management of an unruptured intracranial saccular aneurysm is challenging for both patients and physicians, as the decision to intervene must weigh the risk of rupture and resultant subarachnoid hemorrhage against the risk inherent to the surgical or endovascular procedure. The purpose of this paper is to provide an overview of factors to be considered in the decision to offer treatment for unruptured intracranial aneurysms in adults. In addition, we review aneurysm and patient characteristics that favor surgical clipping over endovascular intervention and vice versa. Finally, the authors propose a novel, simple, and clinically relevant algorithm for observation versus intervention in unruptured intracranial aneurysms based on the PHASES scoring system.

Combined Targeting of the BRD4-NUT-p300 Axis in NUT Midline Carcinoma by Dual Selective Bromodomain Inhibitor, NEO2734

NUT midline carcinoma (NMC) is a rare, aggressive subtype of squamous carcinoma that is driven by the BRD4-NUT fusion oncoprotein. BRD4, a BET protein, binds to chromatin through its two bromodomains, and NUT recruits the p300 histone acetyltransferse (HAT) to activate transcription of oncogenic target genes. BET-selective bromodomain inhibitors have demonstrated on-target activity in patients with NMC, but with limited efficacy. P300, like BRD4, contains a bromodomain. We show that combining selective p300/CBP and BET bromodomain inhibitors, GNE-781 and OTX015, respectively, induces cooperative depletion of MYC and synergistic inhibition of NMC growth. Treatment of NMC cells with the novel dual p300/CBP and BET bromodomain-selective inhibitor, NEO2734, potently inhibits growth and induces differentiation of NMC cells in vitro; findings that correspond with potentiated transcriptional effects from combined BET and p300 bromodomain inhibition. In three disseminated NMC xenograft models, NEO2734 provided greater growth inhibition, with tumor regression and significant survival benefit seen in two of three models, compared with a lead clinical BET inhibitor or "standard" chemotherapy. Our findings provide a strong rationale for clinical study of NEO2734 in patients with NMC. Moreover, the synergistic inhibition of NMC growth by CBP/p300 and BET bromodomain inhibition lays the groundwork for greater mechanistic understanding of the interplay between p300 and BRD4-NUT that drives this cancer.

Lawn Mower Versus Left Ventricular Assist Device

A 77-year-old man with history of ischemic cardiomyopathy and left ventricular assist device (LVAD) presented with abdominal pain after a lawn mower accident. Examination and imaging revealed a displaced LVAD driveline and a pericardial hematoma secondary to traumatic coronary artery injury. The patient was treated with coronary artery coil embolization. (Level of Difficulty: Advanced.)

Transitioning the Doctor of Nursing Practice Final Project Defense to Large Venue Poster Sessions

BACKGROUND

Accelerated growth in Doctor of Nursing Practice (DNP) programs has mandated the need for innovative strategies for doctoral students to defend their final scholarly work while protecting the integrity and rigor of the experience.

METHOD

A poster defense strategy was implemented and evaluated via a faculty focus group and a Likert-scale survey. Sessions highlighting eight projects each were scheduled at 75-minute intervals allowing for both informal poster viewing and formal audience questioning facilitated by a moderator. Evaluation of the event trended positive, with focus group members celebrating the energy around each session, noting the significant increase in audience size compared to past podium defenses.

CONCLUSION

Evaluators who attended previous DNP project defenses all indicated that the large venue poster session approach was just as or more effective than previous methods. [J Nurs Educ. 2020;59(1):51-53.].

Predictors of Clinical Outcome After Treatment of Intracranial Aneurysms with the Pipeline Embolization Device

BACKGROUND

Flow-diverting stents have revolutionized the endovascular treatment of intracranial aneurysms. The purpose of this study is to identify predictors of adverse outcomes associated with the pipeline embolization device (PED).

METHODS

A retrospective analysis of all patients treated with PED at a single high-volume center from January 2014 to September 2018. Patient outcomes, neurologic morbidity/mortality, and other clinical variables were analyzed.

RESULTS

We treated 204 aneurysms in 170 patients with PED. Mean length of follow-up was 11 months. Most (181) aneurysms (89%) were located in the anterior circulation, and 23 (11%) were found in the posterior circulation. Most aneurysms were saccular (82%), followed by fusiform (11%), blister (4%), and dissecting pseudoaneurysms (3%). Mean aneurysm size was 8.2 + 5.7 mm with 145 (71%) small aneurysms (≤10 mm), 53 (26%) large aneurysms (between 10 and 25 mm), and 6 (3%) giant aneurysms (≥25 mm). Ninety-two percent of aneurysms were unruptured, and 8% were ruptured. The overall major neurologic morbidity/mortality was 4.7% and 1.8%, respectively. The all-cause mortality was 2.9%. Predictors of neurologic morbidity/mortality included the baseline modified Rankin Scale (P = 0.001), aneurysm neck size (P = 0.003), aneurysm size (P = 0.006), anterior versus posterior location (P = 0.02), and rupture at presentation (0.006). The P2Y12 Reactivity Unit, parent vessel diameter, and patient age did not correlate with adverse events.

CONCLUSIONS

The PED has a satisfactory safety profile in both on- and off-label indications. A poor clinical patient baseline, wider aneurysm neck or larger size, and rupture predict an increased risk of an unfavorable outcome.

Treatment of a Fusiform Anterior Cerebral Artery Aneurysm by Remodeling the Circle of Willis with Flow Diversion: A Novel Technical Note

BACKGROUND

Fusiform aneurysms are challenging lesions to manage given their poorly understood natural history and lack of a distinct neck. Historically, they have been treated surgically but endovascular management has recently evolved as a viable alternative. In this case, we describe a novel flow diversion technique for treatment of a fusiform anterior cerebral artery (ACA) aneurysm by jailing the compromised parent vessel obtaining endovascular aneurysm trapping.

METHODS

A 25-year-old man underwent brain magnetic resonance imaging and magnetic resonance angiography for workup of a headache, which revealed a fusiform right ACA A1 segment aneurysm. The patient subsequently underwent catheter digital subtraction angiography, which confirmed a 9 × 5.5 mm fusiform right ACA A1 segment aneurysm. The patient elected to undergo endovascular treatment. A Pipeline Embolization Device (Medtronic, Dublin, Ireland) was placed from the right anterior cerebral artery to the right middle cerebral artery, thereby jailing the right ACA A1 segment.

RESULTS

At 6-month follow-up, the patient was asymptomatic and his headache had resolved. An angiogram was obtained, showing patency of the Pipeline Embolization Device and near complete occlusion of the right ACA A1 segment. The right ACA A2 segment remained patent via collateral flow through the anterior communicating artery. These findings were confirmed on magnetic resonance imaging. The patient remained asymptomatic for the duration of the follow-up.

CONCLUSIONS

This case illustrates the efficacy of the Pipeline Embolization Device for treatment of a fusiform anterior circulation aneurysm via remodeling the circle of Willis.

The effects of a multidisciplinary high-throughput skin clinic on healthcare costs of organ transplant recipients

BACKGROUND

A long-term complication among organ transplant recipients (OTRs) is skin malignancies which are associated with level and duration of immunosuppressive treatment, sun exposure and age. Dermatological surveillance is recommended for OTRs at high risk of skin malignancies, but evidence is lacking on the benefits of such services.

OBJECTIVE

To examine the economic impact on patients and on the hospital service of a multidisciplinary high-throughput skin cancer clinic in Brisbane, Australia, dedicated to dermatological and surgical care of high-risk OTRs.

METHODS

In a pre/postdesign, hospital admission and cost data were obtained for 101 consecutively enrolled study participants from 12 months prior to the introduction of the clinic (to February 2016), the 3-month 'run-in' period (March to May 2016) and 12 months subsequent (to June 2017). Differences between pre- and post-clinic hospital costs were tested using non-parametric bootstrapping and interrupted time series analysis. A survey of patient out-of-pocket costs and perceived financial burden was also undertaken during the clinic.

RESULTS

Overall hospital costs were higher after the clinic but 3-monthly hospital costs for skin procedures trended downwards. Despite 3-monthly mean, hospital visits increasing from 85 to 314, mean 3-monthly costs reduced by AU$1491 (P < 0.001) indicating greater cost efficiency. Total patient out-of-pocket costs were AU$18 377 over 3 months.

CONCLUSION

Clinical costing data revealed higher, more rapid throughput and significantly lower per patient costs pre- and postestablishment of a multidisciplinary skin cancer clinic for OTRs.

Thromboembolic Events with Enterprise Versus Pipeline: Porcine In Vivo Experiment

BACKGROUND

Thromboembolic complications are serious adverse events associated with stenting of intracranial aneurysms. For the development of novel devices, currently no practical model exists to evaluate distal embolic events. The purpose of the current study was 2-fold: 1) assess the feasibility of a porcine carotid bifurcation model for in vivo testing of stent thrombogenicity and 2) compare the thrombogenicity of the Enterprise vascular reconstruction device versus the Pipeline embolization device (PED).

METHODS

Six Yorkshire pigs underwent implantation of size-matched devices across the carotid bifurcation. Each animal received 1 Enterprise and 1 PED contralaterally. Baseline and 2-week follow-up angiography were performed. Images were analyzed including detailed measurements of the rete mirabile, a small-vessel conglomerate supplied by branches of the common carotid artery.

RESULTS

In the absence of thromboembolic events at 2 weeks (n = 8), the perfused rete area measured 134.4 ± 6.9 mm². In the presence of thromboembolic events (n = 4), the perfused rete was reduced to an area covering 37.1 ± 8.6 mm² (P < 0.01). There was no difference in thrombogenicity between Enterprise and PED with a thromboembolic event rate of 33.3% for both devices (P > 0.99).

CONCLUSION

The swine carotid stent model allows in vivo analysis of device-related thrombogenicity and distal embolic event rates. Size reduction of the perfused rete mirabile indicates the presence of thromboembolic events. Both Enterprise and PED were associated with similar thrombogenicity in this experiment.

Case Report: Spontaneous Hemorrhage of a Rare Renal Tumor in the Native Kidney of a Renal Transplant Recipient

Renal cancers are some of the most common solid organ malignancies found during follow-up of patients who have undergone renal transplantation (RT). In this case report, we describe a life-threatening spontaneous hemorrhage of a rare subtype of renal cell carcinoma in the native kidney of a 27-year-old man, 4 years after RT. After fluid resuscitation and stabilization, the patient underwent emergent open radical nephrectomy with the final histopathology reporting T1bN0Mx mucinous tubular and spindle cell (MTSC) carcinoma. This case report highlights the need to consider an underlying malignancy in patients who presents with spontaneous hemorrhage of native kidneys after RT.

Light scattering and random lasing in aqueous suspensions of hexagonal boron nitride nanoflakes

Liquid phase exfoliation allows large scale production of 2D materials in solution. The particles are highly anisotropic and strongly scatter light. While spherical particles can be accurately and precisely described by a single parameter-the radius, 2D nanoflakes, however, cannot be so easily described. We investigate light scattering in aqueous solutions of 2D hexagonal boron nitride nanoflakes in the single and multiple scattering regimes. In the single scattering regime, the anisotropic 2D materials show a much stronger depolarization of light when compared to spherical particles of similar size. In the multiple scattering regime, the scattering as a function of optical path for hexagonal boron nitride nanoflakes of a given lateral length was found to be qualitatively equivalent to scattering from spheres with the same diameter. We also report the presence of random lasing in high concentration suspensions of aqueous h-BN mixed with Rhodamine B dye. The h-BN works as a scattering agent and Rhodamine B as a gain medium for the process. We observed random lasing at 587 nm with a threshold energy of 0.8 mJ.

Wellness and Thriving in a Student Registered Nurse Anesthetist Population

With the creation of its Wellness Program, the American Association of Nurse Anesthetists (AANA) has advocated for renewed emphasis in education, research, and practice on anesthesia provider wellness. This research was designed to explore the relationship between student registered nurse anesthetists' perceived wellness and students' thriving throughout their academic program. Because of the multifactorial nature of wellness and its alignment with the AANA's wellness model, a salutogenic wellness framework provided the theoretical basis for this study. Four variables related to thriving in a nurse anesthesia program were studied in relationship to students' perceived wellness, measured using the Salutogenic Wellness Promotion Scale (SWPS): self-efficacy, academic achievement, technical clinical competence, and patients' perceptions of students' relational skills. Measurements were taken at 5 points during the academic program. There was a significant correlation, using multiple regression analysis, between SWPS and self-efficacy at times 1, 2, and 3, but not at times 4 and 5. The Emotional Score subscale of the SWPS significantly correlated with self-efficacy at the same intervals. Within the variable of student academic achievement, overall wellness negatively correlated with the National Board of Certification & Recertification for Nurse Anesthetists' Self-Evaluation Examination scores. These results have potential implications on nurse anesthesia education.

Applying Criteria of Active Surveillance to Low-Risk Papillary Thyroid Cancer Over a Decade: How Many Surgeries and Complications Can Be Avoided?

BACKGROUND

The 2015 American Thyroid Association guidelines acknowledged that "an active surveillance management approach can be considered as an alternative to immediate surgery" in patients with low-risk papillary thyroid carcinoma (PTC). The aim of this study was to determine the proportion of PTC that would meet the criteria for active surveillance and the surgeries and complications that could have been avoided.

METHODS

A total of 681 patients with thyroid cancer who underwent thyroid surgery from 2003 to 2012 were retrospectively reviewed. A decision-making framework for active surveillance was applied to patients with PTC in nodules measuring ≤1.5 cm on ultrasound. Patients were identified as suitable for active surveillance based on imaging and patient characteristics. These patients were reviewed for management and outcomes.

RESULTS

PTC was diagnosed based on fine-needle aspiration histology of Bethesda V or VI in thyroid nodules in 243 patients. Of these, 77 patients had nodules measuring ≤1.5 cm on ultrasound, and 56/77 (23%) patients met the criteria for surveillance: 15/243 (6%) patients met the criteria with a ≤1 cm size threshold, and 41/243 (17%) met the criteria with a 1.1-1.5 cm threshold. Of the 56 patients who met the criteria for active surveillance, 52 underwent total thyroidectomy, and four had a lobectomy. Forty-five (80%) patients had elective central nodal dissection, and 14 had nodal metastases on pathology (all <4 mm). Three patients had permanent complications from surgery, including vocal cord paralysis, hypoparathyroidism, and a chipped tooth from intubation. No patients died or had recurrent disease.

CONCLUSION

Future programs in the United States should consider increasing the size threshold for active surveillance of PTC to 1.5 cm, since this will allow up to one quarter of patients to be eligible instead of only 6% with a 1 cm size threshold. Without an active surveillance program, the majority of patients with low-risk cancers have thyroidectomy and carry a small risk of permanent complications.

The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial

OBJECTIVES

The diagnosis of surgical site infection following endoprosthetic reconstruction for bone tumours is frequently a subjective diagnosis. Large clinical trials use blinded Central Adjudication Committees (CACs) to minimise the variability and bias associated with assessing a clinical outcome. The aim of this study was to determine the level of inter-rater and intra-rater agreement in the diagnosis of surgical site infection in the context of a clinical trial.

MATERIALS AND METHODS

The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) trial CAC adjudicated 29 non-PARITY cases of lower extremity endoprosthetic reconstruction. The CAC members classified each case according to the Centers for Disease Control (CDC) criteria for surgical site infection (superficial, deep, or organ space). Combinatorial analysis was used to calculate the smallest CAC panel size required to maximise agreement. A final meeting was held to establish a consensus.

RESULTS

Full or near consensus was reached in 20 of the 29 cases. The Fleiss kappa value was calculated as 0.44 (95% confidence interval (CI) 0.35 to 0.53), or moderate agreement. The greatest statistical agreement was observed in the outcome of no infection, 0.61 (95% CI 0.49 to 0.72, substantial agreement). Panelists reached a full consensus in 12 of 29 cases and near consensus in five of 29 cases when CDC criteria were used (superficial, deep or organ space). A stable maximum Fleiss kappa of 0.46 (95% CI 0.50 to 0.35) at CAC sizes greater than three members was obtained.

CONCLUSIONS

There is substantial agreement among the members of the PARITY CAC regarding the presence or absence of surgical site infection. Agreement on the level of infection, however, is more challenging. Additional clinical information routinely collected by the prospective PARITY trial may improve the discriminatory capacity of the CAC in the parent study for the diagnosis of infection.Cite this article: J. Nuttall, N. Evaniew, P. Thornley, A. Griffin, B. Deheshi, T. O'Shea, J. Wunder, P. Ferguson, R. L. Randall, R. Turcotte, P. Schneider, P. McKay, M. Bhandari, M. Ghert. The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial. Bone Joint Res 2016;5:347-352. DOI: 10.1302/2046-3758.58.BJR-2016-0036.R1.

Adrenal Steroid Metabolites Accumulating in Congenital Adrenal Hyperplasia Lead to Transactivation of the Glucocorticoid Receptor

Patients with congenital adrenal hyperplasia (CAH) are often clinically less severely affected by cortisol deficiency than anticipated from their enzymatic defect. We hypothesize that adrenal steroid hormone precursors that accumulate in untreated or poorly controlled CAH have glucocorticoid activity and partially compensate for cortisol deficiency. We studied the in vitro effects of 17-hydroxyprogesterone (17OHP), progesterone (P), 21-deoxycortisol (21DF), and androstenedione (Δ4) on the human glucocorticoid receptor (hGR). Competitive binding assays were performed in HeLa cells. Nuclear translocation of the hGR was studied by transfection of COS-7 cells with a GFP-tagged hGR and fluorescence microscopy. Transactivation assays were performed in COS-7 cells and in HEK 293 cells after cotransfection with hGR and luciferase reporter vectors using a dual luciferase assay. 17OHP, P, and 21DF are able to bind to the hGR with binding affinities of 24-43% compared with cortisol. Δ4 has a low binding affinity. Incubation with 21DF led to complete nuclear translocation of the hGR, whereas treatment with 17OHP or P resulted in partial nuclear translocation. 21DF transactivated the hGR with an EC50 approximately 6 times the EC50 of cortisol. 17OHP and P transactivated the hGR with EC50s of more than 100 times the EC50 of cortisol. No hGR transactivation was detected after incubation with Δ4. 21DF, 17OHP, and P are able to bind, translocate, and transactivate the hGR in vitro and thus may have glucocorticoid activity. 21DF might have a clinically relevant agonistic effect on the hGR and could potentially partially compensate the cortisol deficiency in CAH patients.