The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Real-world analysis of teclistamab in 123 RRMM patients from Germany

Teclistamab, a B-cell maturation antigen (BCMA) × CD3 directed bispecific antibody, has shown high response rates and durable remissions in the MAJESTEC-1 trial in patients with relapsed and refractory multiple myeloma (RRMM). We retrospectively assessed efficacy and tolerability in 123 patients treated at 18 different German centers to determine whether outcome is comparable in the real-world setting. Most patients had triple-class (93%) or penta-drug (60%) refractory disease, 37% of patients had received BCMA-directed pretreatment including idecabtagene vicleucel (ide-cel) CAR-T cell therapy (21/123, 17.1%). With a follow-up of 5.5 months, we observed an overall response rate (ORR) of 59.3% and a median progression-free survival (PFS) of 8.7 months. In subgroup analyses, we found significantly lower ORR and median PFS in patients with extramedullary disease (37%/2.1 months), and/or an ISS of 3 (37%/1.3 months), and ide-cel pretreated patients (33%/1.8 months). Nonetheless, the duration of response in ide-cel pretreated patients was comparable to that of anti-BCMA naive patients. Infections and grade ≥3 cytopenias were the most frequent adverse events. In summary, we found that teclistamab exhibited a comparable efficacy and safety profile in the real-world setting as in the pivotal trial.

Self-management-competency as a new target in Hidradenitis suppurativa care

Background: Hidradenitis suppurativa affects approximately 1% of the population.Objective: Highlighting the relevance of self-management-competency as a new therapeutic target.Method: 258 patients from the 'Epidemiology and Care in Acne inversa (EpiCAi)' project were included in the study. Disease burden was measured by patient-rated questionnaires in terms of disease activity, pain, quality of life, depression and insomnia and correlated with the domains of the health education impact questionnaire (heiQ) measuring self-management-competency.Results: 66 male (25.6%) and 192 female (74.4%) patients, with a mean age of 40.3 ± 10.24 years were included. Mean scores of pain on the numeric rating scale (NRS), Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS) were 5.11 ± 2.68, 11.35 ± 7.79 and 13.71 ± 7.57, respectively. The Insomnia severity index (ISI) showed a mean of 9.58 ± 5.76. The HADS has the highest increased total risk across all heiQ domains. With respect to the heiQ domains, the highest exposure can be attributed to improving constructive attitudes and approaches as well as decreasing emotional distress.Conclusion: There is a clear association of self-management-competency with overall disease burden, which underlines the need for psychoeducational support. This study provides ideas to develop new possible strategies of care.

Effect of thoracic cage width on surgery time and postoperative outcome in minimally invasive esophagectomy

INTRODUCTION

Minimally invasive esophagectomy (MIE) for esophageal cancer is a complex procedure that reduces postoperative morbidity in comparison to open approach. In this study, thoracic cage width as a factor to predict surgical difficulty in MIE was evaluated.

METHODS

All patients of our institution receiving either total MIE or robotic-assisted MIE (RAMIE) with intrathoracic anastomosis between February 2016 and April 2021 for esophageal cancer were included in this study. Right unilateral thoracic cage width on the level of vena azygos crossing the esophagus was measured by the horizontal distance between the esophagus and parietal pleura on preoperative computer tomography. Patients' data as well as operative and postoperative details were collected in a prospective database. Correlation between thoracic cage width with duration of the thoracic procedure and postoperative complication rates was analyzed.

RESULTS

Overall, 313 patients were eligible for this study. Thoracic width on vena azygos level ranged from 85 to 149 mm with a mean of 116.5 mm. In univariate analysis, a small thoracic width significantly correlated with longer duration of the thoracic procedure (p = 0.014). In multivariate analysis, small thoracic width and neoadjuvant therapy were identified as independent factors for long duration of the thoracic procedure (p = 0.006). Regarding postoperative complications, thoracic cage width was a significant risk factor for occurrence of postoperative pneumonia in the multivariate analysis (p = 0.045). Dividing the cohort into two groups of patients with narrow (≤ 107 mm, 19.5%) and wide thoraces (≥ 108 mm, 80.5%), the thoracic procedure was significantly prolonged by 17 min (204 min vs. 221 min, p = 0.014).

CONCLUSION

A small thoracic cage width is significantly correlated with longer operation time during thoracic phase of a MIE in Europe, which suggests increased surgical difficulty. Patients with small thoracic cage width may preferably be operated by MIE-experienced surgeons.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Two-dimensional speckle-tracking echocardiography in tafamidis-treated patients with transthyretin amyloid cardiomyopathy: a glimmer of hope for viable therapy monitoring?

Background

Treatment with Tafamidis in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) has been shown to have beneficial effects on the left ventricle (LV), as assessed by cardiac magnetic resonance (CMR) imaging. Although CMR represents the gold standard among imaging modalities, its limited availability in clinical practice makes it unfeasible for routine therapy monitoring.

Purpose

We aimed to determine Tafamidis-induced changes using two-dimensional (2D) speckle-tracking echocardiography and to identify echocardiographic imaging parameters that could be used for specific therapy monitoring.

Methods

We subjected a series of ATTR-CM patients to transthoracic echocardiography (TTE) at baseline and follow-up and compared patients treated with Tafamidis 61mg once daily (QD) to a historical control cohort treated with Tafamidis 20mg QD, as well as to a historical treatment-naïve control cohort reflecting the natural course of the disease.

Results

Patients receiving Tafamidis 61mg (n=62) or 20mg (n=21) QD showed stable measurements at follow-up [61mg: 8.5 months, 20mg: 7.0 months] in LV global longitudinal strain (GLS) (61mg: −11.75% vs. −11.58%, p=0.534; 20mg: −10.61% vs. −10.12%, p=0.309), right ventricular (RV) GLS (61mg: −14.18% vs. −13.72%, p=0.377; 20mg: −14.53% vs. −13.99%, p=0.452) and left atrial (LA) reservoir strain (LASr; 61mg: 8.80% vs. 9.42%, p=0.283; 20mg: 8.23% vs. 8.67%, p=0.589), whereas treatment-naïve ATTR-CM patients (n=54) had clear signs of disease progression at the end of the observation period [10.5 months; LV-GLS: −11.71% vs. −10.59%, p=0.001; RV-GLS: −14.36% vs. −12.99%, p=0.038; LASr: 10.67% vs. 8.41%, p=0.005]. Between-group comparison at follow-up revealed beneficial effects of Tafamidis 61mg on LASr (p=0.003), LV-GLS (p=0.030) and interventricular septum (IVS) thickness (p=0.006), resulting in clinical benefits (six-minute walk distance (6-MWD): p=0.006, NT-proBNP: p≤0.001), while patients treated with Tafamidis 20mg QD showed positive effects on LASr (p=0.039) but no differences in LV-GLS (p=0.274), IVS thickness (p=0.068) and clinical status (6-MWD: p=0.124, NT-proBNP: p=0.053) compared to the natural course.

Conclusion

Treatment with Tafamidis 61mg in ATTR-CM patients delays the increase in IVS thickness and the deterioration of LA and LV longitudinal function, resulting in significant clinical benefits compared with natural history. Serial TTE with 2D speckle-tracking imaging may be appropriate for disease-specific therapy monitoring.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This work was supported by the Pfizer Inc. However, Pfizer Inc. did not have influence on study design, data processing, or statistical analysis.

Scanning the solutions for the sustainable supply of forest ecosystem services in Europe

Forests are key components of European multifunctional landscapes and supply numerous forest ecosystem services (FES) fundamental to human well-being. The sustainable provision of FES has the potential to provide responses to major societal challenges, such as climate change, biodiversity loss, or rural development. To identify suitable strategies for the future sustenance of FES, we performed a solution scanning exercise with a group of transdisciplinary forest and FES experts from different European regions. We identified and prioritized fifteen major challenges hindering the balanced provision of multiple FES and identified a series of potential solutions to tackle each of them. The most prominent challenges referred to the increased frequency and impacts of extreme weather events and the normative mindset regarding forest management. The respective solutions pointed to the promotion of forest resilience via climate-smart forestry and mainstreaming FES-oriented management through a threefold strategy focusing on education, awareness raising, and networking. In a subsequent survey, most solutions were assessed as highly effective, transferable, monitorable, and with potential for being economically efficient. The implementation of the solutions could have synergistic effects when applying the notion of leverage points. Seven emerging pathways towards the sustainable supply of FES have been identified. These pathways build on each other and are organized based on their potential for transformation: (1) shifting forest management paradigms towards pluralistic ecosystem valuation; (2) using integrated landscape approaches; (3) increasing forest resilience; (4) coordinating actions between forest-related actors; (5) increasing participation in forest planning and management; (6) continuous, open, and transparent knowledge integration; and (7) using incentive-based instruments to support regulating and cultural FES. These pathways can contribute to the implementation of the new EU Forestry Strategy to support the balanced supply of multiple FES.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11625-022-01111-4.

Quantification of myocardial amyloid deposition in tafamidis-treated patients with transthyretin amyloid cardiomyopathy

Background

Tafamidis kinetically stabilizes the tetrameric form of transthyretin (TTR) and thus may halt disease progression in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). However, the effect of tafamidis treatment on the progression of myocardial amyloid deposition is still unclear.

Methods

In our explorative analysis, we aimed to investigate the treatment effect of tafamidis on myocardial amyloid deposition measured by myocardial standardized uptake value (SUV) peak and SUV retention index using quantitative single-photon emission computed tomography/computed tomography (SPECT/CT) of the thorax and to observe its association with clinical parameters. Therefore, clinical, laboratory, imaging, and SPECT/CT examinations were performed in twenty consecutive ATTR-CM patients who started treatment with tafamidis 61mg, both at baseline and at a median of 6 months.

Results

Main results are summarized in Table 1. In brief, we observed a significant reduction of mean myocardial SUV peak (baseline: 15.50 vs. follow-up: 11.61, p<0.001) and mean SUV retention index (5.64 vs. 3.58, p=0.001) after treatment with tafamidis (Figure 1A). Interestingly, a higher percentage decrease in the SUV retention index is more likely to be associated with clinical benefit, with a threshold of −30% distinguishing between patients who respond clinically (n=12) and those who do not (n=8, Figure 1B). Clinical response is demonstrated by improvement in exertional dyspnea (NYHA class III: 83.3% vs. 41.7%, p=0.047) and mean functional capacity as measured by 6-minute walk distance (349.5m vs. 356.7m, p=0.736). Cardiac biomarkers analysis showed a clear reduction in median NT-proBNP levels in the responder cohort (2765.0 pg/mL vs. 1904.0 pg/mL, p=0.041) compared to an increase in the non-responder cohort (1825.0 pg/mL vs. 1944.0 pg/mL, p=0.208; cohort comparison: p=0.026, Figure 1C). Echocardiographic findings revealed improvement in mean left ventricular (LV) strain (−12.0% vs. −13.5%, p=0.049) and mean LV ejection fraction (LVEF, 48.5% vs. 52.7%, p=0.287) in the responder cohort, while significant deterioration in mean LV function (LV strain: −13.9 vs. −10.5, p=0.035; LVEF: 53.2% vs. 46.5%, p=0.012) was observed in the non-responder cohort, with an additional substantial deterioration in right ventricular (RV) function as measured by tricuspid annular plane systolic excursion (TAPSE, mean, BL: 19.2mm vs. FU: 12.6mm, p=0.037) in those patients. These results are consistent with changes in the LV and RV function in cardiac magnetic resonance imaging parameters in each of the two cohorts.

Conclusion

Treatment with tafamidis in patients with ATTR-CM results in a significant reduction in myocardial amyloid deposition as measured by the SUV retention index, with a threshold of −30% distinguishing patients who respond clinically from those who do not. However, a larger patient sample is needed to verify these results.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer Inc.

Cardiac imaging in tafamidis-treatment patients with transthyretin amyloid cardiomyopathy

Background

Tafamidis kinetically stabilizes the tetrameric form of transthyretin (TTR) and thus may halt disease progression in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). In our explorative analysis, we aimed to investigate the treatment effect on functional capacity and cardiac biomarkers as well as cardiac function and structure using echocardiography and cardiac magnetic resonance imaging (CMR), and to compare patients treated with tafamidis with an untreated control cohort.

Methods

Consecutive ATTR-CM patients either received tafamidis 61mg (n=64) or tafamidis 20mg (n=23) or were assigned to an untreated control cohort (n=54) reflecting the natural history of the disease. Subsequently, we performed clinical, laboratory, echocardiography and CMR follow-up at a median of 9 to 12.5 months.

Results

Main results are summarized in Table 1. In brief, we observed evidence of improvement in functional capacity as measured by the 6-minute walk distance (6MWD) in tafamidis 61mg treated patients (baseline: 377.1m vs. follow-up: 383.2m, p=0.678) compared to a significant decline in mean 6MWD in untreated patients (388.1m vs. 336.4m, p=0.002; cohort comparison: p=0.005). Analysis of cardiac biomarkers revealed evidence of therapeutic response by a decrease in median NT-proBNP levels in patients treated with tafamidis 61mg (2633.0pg/mL vs. 2244.0pg/mL, p=0.366), whereas a significant increase was observed in untreated patients (2798.0pg/mL vs. 3422.0pg/mL, p<0.001; cohort comparison: p<0.001). Echocardiographic findings revealed evidence of approximate stabilization in mean left ventricular (LV) strain (−11.75% vs. −11.58%, p=0.534) and mean right ventricular (RV) strain (−14.18% vs. −13.72, p=0.377) in the tafamidis 61mg treatment cohort compared to significant deterioration of mean LV longitudinal function (−11.71% vs. −10.59%, p=0.001) and mean RV longitudinal function (−14.36% vs. −12.99%, p=0.038) in the untreated cohort (cohort comparison: p=0.030 and p=0.269). Furthermore, cardiac structural assessment by CMR showed a significant increase in mean LV mass (199.1g vs. 214.3g, p=0.040) and mean extracellular volume (50.52% vs. 55.96%, p=0.026) in untreated patients, suggesting increased progression of myocardial amyloid deposition.

Conclusion

Treatment with tafamidis in patients with ATTR-CM results in significant improvements in functional capacity and cardiac biomarkers, and shows marked benefits in functional as well as structural imaging parameters compared with an untreated control cohort.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer Inc.

POS0910 EVALUATION OF THE NONSTEROIDAL ANTI-INFLAMMATORY DRUG-SPARING EFFECT OF SECUKINUMAB IN PATIENTS WITH ANKYLOSING SPONDYLITIS: RESULTS OF THE MULTICENTER, RANDOMISED, DOUBLE-BLIND, PHASE IV ASTRUM-TRIAL

Background:

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat inflammatory back pain in patients (pts) with ankylosing spondylitis (AS). However, an increased risk of side effects associated with NSAIDs and their dosage has been reported1. Therefore, lower doses and a dose reduction is desirable.

Objectives:

To evaluate the short-term NSAID sparing effect of secukinumab (SEC) in AS pts with NSAID intake.

Methods:

In a prospective controlled trial, 211 adult pts with active AS (BASDAI ≥4) and an inadequate response (IR) to at least 2 NSAIDs at the highest recommended/tolerated dose and pts with an IR, or those who were naïve/intolerant to a maximum of 2 tumour necrosis factor inhibitors (TNFi) were enrolled. NSAID intake was evaluated using the ASAS-NSAID score. To be eligible, pts had to take at least 50% of the highest recommended/tolerated NSAID dose regularly. Pts were randomised (1:1:1) to receive SEC 150 mg s.c. from Week (Wk) 0 (group [gp] 1), Wk 4 (gp 2) and Wk 16 (gp 3). All groups received SEC 150 mg from Wk 16. NSAID tapering was allowed in all groups from Wk 4 onwards. The primary endpoint (PE) was an ASAS20 response of pooled gp 1 and gp 2 vs. gp 3 at Wk 12.

Results:

There were 71 pts in gp 1, 70 in gp 2 and 70 in gp 3. Baseline (BL) characteristics were comparable across groups; mean age (SD) was 45.2 (12.3) years (yrs), time since diagnosis was 7.4 (9.8) yrs, 57.8% male, 79.0% HLA-B27 positive, 48.6% pts had an elevated CRP 40.8% were current/ever smoker and 72.0% were TNFi-naïve. The ASAS-NSAID (SD) scores at BL were: gp 1 vs. gp 2 vs. gp 3: 82.9 (37.7) vs. 79.9 (45.3) vs.82.3 (39.1). BASDAI and ASDAS-CRP scores were similar between groups: 6.0 (1.4) vs. 6.2 (1.5) vs. 6.2 (1.3), and 3.4 (0.7) vs. 3.3 (0.8) vs. 3.4 (0.7), respectively. The ASAS20 response at Wk 12 of pooled gp 1 and 2 vs. gp 3 was 51.1% vs. 44.3% but PE was not met (p=0.35). A higher proportion of pts in gp 1 and 2 achieved ASAS40 and BASDAI50 and other secondary outcomes at Wk 16 (Table 1). More pts in gp 1 and 2 reduced their NSAID intake from BL through Wk 16 vs. gp 3 (Table 1 and Figure 1).

Conclusion:

In this population of pts with AS, SEC provided clinical improvements in conventional clinical outcomes and a short-term NSAID sparing effect.

References:

[1]Burmester G, et al. Ann Rheum Dis 2011;70:818-822.

Table 1.

Effect of SEC 150 mg s.c. in AS pts (Intention-to-Treat population) at Wk 16

(%), unless otherwise specifiedGroup 1 (N=71)(SEC 150 mg from BL until Wk 20)Group 2 (N=70)(PBO from BL until Wk 4; SEC 150 mg from Wk 4)Group 3 (N=70)(PBO from BL until Wk 16; SEC 150 mg from Wk 16)ASAS20*56.350.041.4ASAS40*43.7§32.921.4ASAS5/6*39.4‡32.921.4ASAS-PR*8.520.0‡5.7ASAS20 TNF-IR^*60.0‡‡26.345.0 TNF-naïve^^*54.958.8‡40.0ASAS40 TNF-IR^*45.015.825.0 TNF-naïve^^*43.1‡39.2‡20.0ASDAS-CRP change (mean±SD)**-1.2±0.9§-1.0±0.9‡-0.7±0.8BASDAI change (mean±SD)***-2.3±1.9‡-2.0±2.0-1.7±2.0BASDAI50+32.428.622.9ASAS-NSAID score change (mean±SD)++-51.5±46.2‡-42.5±68.6-33.7±38.8ASAS-NSAID score decrease ≥50%*64.8‡58.642.9 <10*52.1§45.7‡28.6 =0*32.4‡38.6§17.1

AS, ankylosing spondylitis; ASAS, Assessment of SpondyloArthritis International Society; ASDAS, AS Disease Activity score; BASDAI, Bath AS Disease Activity Index; BL, baseline; CRP, C-reactive protein; IR, inadequate responder; NSAID, nonsteroidal anti-inflammatory drug; N, total number of subjects in each treatment gp; PBO, placebo; PR, partial remission; pts, patients; SEC, secukinumab; TNFi, tumour necrosis factor inhibitor; Wk, week.

†p<0.001; §p<0.01 and ‡p<0.05 vs. gp 3; ‡‡p<0.05 vs. gp 2

*p-values are from a logistic regression model with treatment, TNFi status (IR / naïve) and CRP status (>/ ≤ central lab ULN) as factors.

+p-values are from MMRM with treatment, TNFi status (IR / naïve), CRP status (>/ ≤ central lab ULN) and visit as factors, BL value as continuous covariate.

*+Missing values were imputed as non-response.

Observed data (pts) for gp 1, 2, 3, respectively:

**67, 66, 62

***67, 66, 63

++67, 67, 65

^20, 19, 20

^^51, 51, 50

Disclosure of Interests:

Uta Kiltz Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Grünenthal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: Abbvie, Amgen, Biogen, Fresenius, GSK, Novartis and Pfizer, Xenofon Baraliakos Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Jan Brandt-Juergens Speakers bureau: Abbvie, Pfizer, Roche, Sanofi-Aventis, Novartis, Lilly, MSD, UCB, BMS, Janssen, Medac, Consultant of: Abbvie, Pfizer, Roche, Sanofi-Aventis, Novartis, Lilly, MSD, UCB, BMS, Janssen, Medac, Ulf Wagner Speakers bureau: Pfizer, Novartis and Roche, Consultant of: Pfizer, Novartis and Roche, Grant/research support from: Roche, Novartis, BMS, Pfizer, Sebastian Lieb Employee of: Novartis, Christian Sieder Employee of: Novartis, Christian Mann Employee of: Novartis, Juergen Braun Speakers bureau: Abbvie, Amgen, Celltrion, Chugai, Medac, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: Abbvie, Amgen, Celltrion, Chugai, Medac, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: Abbvie, Amgen, Celltrion, Chugai, Medac, MSD, Novartis, Pfizer, Roche, and UCB

Brain morphometry in 22q11.2 deletion syndrome: an exploration of differences in cortical thickness, surface area, and their contribution to cortical volume

22q11.2 Deletion Syndrome (22q11.2DS) is the most common microdeletion in humans, with a heterogenous clinical presentation including medical, behavioural and psychiatric conditions. Previous neuroimaging studies examining the neuroanatomical underpinnings of 22q11.2DS show alterations in cortical volume (CV), cortical thickness (CT) and surface area (SA). The aim of this study was to identify (1) the spatially distributed networks of differences in CT and SA in 22q11.2DS compared to controls, (2) their unique and spatial overlap, as well as (3) their relative contribution to observed differences in CV. Structural MRI scans were obtained from 62 individuals with 22q11.2DS and 57 age-and-gender-matched controls (aged 6-31). Using FreeSurfer, we examined differences in vertex-wise estimates of CV, CT and SA at each vertex, and compared the frequencies of vertices with a unique or overlapping difference for each morphometric feature. Our findings indicate that CT and SA make both common and unique contributions to volumetric differences in 22q11.2DS, and in some areas, their strong opposite effects mask differences in CV. By identifying the neuroanatomic variability in 22q11.2DS, and the separate contributions of CT and SA, we can start exploring the shared and distinct mechanisms that mediate neuropsychiatric symptoms across disorders, e.g. 22q11.2DS-related ASD and/or psychosis/schizophrenia.

Effects of tafamidis on exercise capacity, cardiac function and myocardial amyloid deposition in patients with transthyretin amyloid cardiomyopathy

Background

Transthyretin amyloid cardiomyopathy (ATTR-CA) is caused by deposition of amyloid fibrils in the myocardium. Tafamidis is a kinetic stabilizer of TTR that prevents tetramer dissociation and amyloidogenesis.

Methods

Thirty-eight patients with diagnosis of ATTR-CA were treated with tafamidis (20mg or 61mg) for a period of six months. In our explorative analysis we aimed to evaluate the effects of tafamdis by changes from baseline of the serum NT-proBNP concentration, 6MWD, as well as cardiac structure and function, compared to untreated amyloidosis patients.

Results

The analysis showed a significant reduction in the serum NT-proBNP concentration in tafamidis-treated patients compared to untreated patients (median difference, −1042.5 pg/mL, p=0.015). Tafamidis also improved the walking distance at month six, while reduction in untreated patients was observed (mean difference, +29.27 m, p=0.175). Echocardiographic findings revealed a decrease in LV size (mean, −1.56 mm) as well as improvements regarding the LA size (mean difference, −2.51 mm) and the GLS (mean difference, 0.80%) in tafamidis-treated patients. T1 mapping in cardiac MRI showed a decrease in ECV (mean, −1.79%) in patients receiving tafamidis, while an increase in ECV in untreated patients was observed (mean, +0.41%).

Conclusion

Treatment with tafamidis for a period of six months in patients with ATTR-CA results in a significant improvement in NT-proBNP levels and may have positive effects on exercise capacity, cardiac function and myocardial amyloid deposition compared to untreated amyloidosis patients.

Picture 1. Change from baseline.

Funding Acknowledgement

Type of funding source: None

[Surgical treatment of esophagotracheal and esophagobronchial fistulas]

BACKGROUND

Esophagotracheal and esophagobronchial fistulas are pathological communications between the airway system and the digestive tract, which often lead to major pulmonary complications with a high mortality. Endoscopic treatment is the primary therapeutic approach; however, in cases of failure early surgical treatment is obligatory.

METHODS

This article describes the clinical course of patients with esophagotracheal and esophagobronchial fistulas treated in this hospital over a period of 10 years. Patients were retrospectively analyzed with respect to the etiology of fistulas, management, in particular to the operative procedures, complications and outcome.

RESULTS

Between 2009 and 2019, a total of 15 patients with esophagotracheal and esophagobronchial fistula were treated in this hospital. Of these 12 underwent an endoscopic intervention, of which 5 were successful. In total, eight patients needed surgical intervention, six of the eight surgically treated patients recovered fully, one had a recurrent fistula, which was successfully treated by subsequent endoscopy after surgery and one patient died.

DISCUSSION

Management of esophagotracheal and esophagobronchial fistulas is challenging. This retrospective analysis reflects the published data with a success rate of endoscopic treatment in approximately 50%. Surgical intervention should be carried out after unsuccessful endoscopic treatment or if endoscopic treatment is primarily not feasible. Direct closure with resorbable sutures or reconstruction with alloplastic or allogeneic material should be preferred. For larger defects or high proximal esophagotracheal fistulas local transposition of muscular flaps or free muscular flaps play a major role. During operative closure of high intrathoracic or cervical fistulas, intraoperative neuromonitoring can be useful to prevent nerve damage.

The relationship between an electronic mental health stigma campaign and suicidal thoughts and behaviours: a two-arm randomized controlled trial in the Australian construction industry

Males employed in the construction industry are at greater risk of suicide than other employed males. It is plausible that a high level of stigma against mental health problems explains the elevated rates of suicide among this group. This study sought to test the effectiveness of an electronic mental health stigma intervention on suicide ideation, communication about suicide and attempts. Participants were randomly assigned to receive either a series of brief contact interventions over a 6-week period or a wait list control. Suicidal ideation, communication about suicide and suicide attempts were assessed using the Suicidal Behaviors Questionnaire-Revised at post-intervention. We used linear regression to assess effectiveness at post-intervention, adjusting for relevant covariates using both conventional methods and a propensity score approach. Results indicate that the intervention had no significant impact on suicidal thoughts, communication or suicide attempts. There was some indication that individuals in the intervention group reported a slight increase in attempts and communication about suicide. These observations underscore an urgent need for more research to understand the complex and nuanced relationship between stigma and suicide in non-clinical populations.

Electroencephalographic markers in dementia

Dementia is a global health problem with a huge impact on the lives of those afflicted. There are several distinct diseases that are classified under the umbrella term "dementia" ranging from neurodegenerative disorders such as Alzheimer's disease to chronic infections of the central nervous system such as subacute sclerosing panencephalitis (SSPE), a rare complication of measles virus infection in childhood. Clinical features, neuropsychological profiles and imaging characteristics of the various dementia syndromes can be sufficiently distinct to distinguish them from one another. However, in some cases, the cognitive, psychiatric and behavioural features can sufficiently overlap such that neurophysiologic testing may be of help. While it is recognized the electroencephalogram (EEG) may have a special role to play in the diagnosis of certain dementing illnesses such as SSPE and Creutzfeldt-Jakob disease (CJD) that have characteristic EEG changes, current research focusses on the potential utility of quantitative EEG as one more tool in the armamentarium of clinicians dealing with patients who suffer from a dementing illness. We searched PubMed and the Cochrane Database from 1 January 1946 up to 1 January 2016, combining the search terms "EEG," "electroencephalography," "dementia" and "status epilepticus"; identified papers from these searches were then read in detail and summarized. Here, we discuss both the qualitative and quantitative EEG findings in the various types of dementia.

International consensus on the definition and classification of fibrosis of the knee joint

AIMS

The aim of this consensus was to develop a definition of post-operative fibrosis of the knee.

PATIENTS AND METHODS

An international panel of experts took part in a formal consensus process composed of a discussion phase and three Delphi rounds.

RESULTS

Post-operative fibrosis of the knee was defined as a limited range of movement (ROM) in flexion and/or extension, that is not attributable to an osseous or prosthetic block to movement from malaligned, malpositioned or incorrectly sized components, metal hardware, ligament reconstruction, infection (septic arthritis), pain, chronic regional pain syndrome (CRPS) or other specific causes, but due to soft-tissue fibrosis that was not present pre-operatively. Limitation of movement was graded as mild, moderate or severe according to the range of flexion (90° to 100°, 70° to 89°, < 70°) or extension deficit (5° to 10°, 11° to 20°, > 20°). Recommended investigations to support the diagnosis and a strategy for its management were also agreed.

CONCLUSION

The development of standardised, accepted criteria for the diagnosis, classification and grading of the severity of post-operative fibrosis of the knee will facilitate the identification of patients for inclusion in clinical trials, the development of clinical guidelines, and eventually help to inform the management of this difficult condition. Cite this article: Bone Joint J 2016;98-B:1479-88.

Surface-Sensitive Microwear Texture Analysis of Attrition and Erosion

Scale-sensitive fractal analysis of high-resolution 3-dimensional surface reconstructions of wear patterns has advanced our knowledge in evolutionary biology, and has opened up opportunities for translatory applications in clinical practice. To elucidate the microwear characteristics of attrition and erosion in worn natural teeth, we scanned 50 extracted human teeth using a confocal profiler at a high optical resolution (X-Y, 0.17 µm; Z < 3 nm). Our hypothesis was that microwear complexity would be greater in erosion and that anisotropy would be greater in attrition. The teeth were divided into 4 groups, including 2 wear types (attrition and erosion) and 2 locations (anterior and posterior teeth; n = 12 for each anterior group, n = 13 for each posterior group) for 2 tissue types (enamel and dentine). The raw 3-dimensional data cloud was subjected to a newly developed rigorous standardization technique to reduce interscanner variability as well as to filter anomalous scanning data. Linear mixed effects (regression) analyses conducted separately for the dependent variables, complexity and anisotropy, showed the following effects of the independent variables: significant interactions between wear type and tissue type ( P = 0.0157 and P = 0.0003, respectively) and significant effects of location ( P < 0.0001 and P = 0.0035, respectively). There were significant associations between complexity and anisotropy when the dependent variable was either complexity ( P = 0.0003) or anisotropy ( P = 0.0014). Our findings of greater complexity in erosion and greater anisotropy in attrition confirm our hypothesis. The greatest geometric means were noted in dentine erosion for complexity and dentine attrition for anisotropy. Dentine also exhibited microwear characteristics that were more consistent with wear types than enamel. Overall, our findings could complement macrowear assessment in dental clinical practice and research and could assist in the early detection and management of pathologic tooth wear.

Abdominal fat ratio - a novel parameter for predicting conversion in laparoscopic colorectal surgery

INTRODUCTION Laparoscopic surgery has become the standard for colorectal cancer resection in the UK but it can be technically challenging in patients who are obese. Patients whose body fat is mainly inside the abdominal cavity are more challenging than those whose fat is mainly outside the abdominal cavity. Abdominal fat ratio (AFR) is a simple parameter proposed by the authors to aid identification of this subgroup. MATERIALS AND METHODS All 195 patients who underwent elective, laparoscopic colorectal cancer resections from March 2010 to November 2013 were included in the study. For patients who were obese (body mass index greater than 30), preoperative staging computed tomography was used to determine AFR. This was assessed by two different, blinded observers and compared with conversion rate. RESULTS Of the 195 patients, 58 (29.7%) fell into the obese group and 137 (70.3%) into the non-obese group. The median AFR of the obese group that were converted to open surgery was significantly higher at 5.9 compared with those completed laparoscopically (3.3, P = 0.0001, Mann-Whitney). There was no significant difference in conversion rate when looking at body mass index, tumour site or size. DISCUSSION Previous studies have found body mass index, age, gender, previous abdominal surgery, site and locally advanced tumours to be associated with an increased risk of conversion. This study adds AFR to the list of risk factors. CONCLUSION AFR is a simple, reproducible parameter which can help to predict conversion risk in obese patients undergoing colorectal cancer resection.

Developing a digital data collection platform to measure the prevalence of sepsis in Wales

OBJECTIVE

To develop a secure, efficient, and easy-to-use data collection platform to measure the prevalence of sepsis in Wales over 24 hours.

MATERIALS AND METHODS

Open Data Kit was used on Android devices with Google App Engine and a digital data collection form.

RESULTS

A total of 184 students participated in the study using 59 devices across 16 hospitals, 1198 datasets were submitted, and 97% of participants found the Open Data Kit form easy to use.

DISCUSSION

We successfully demonstrated that by combining a reliable Android device, a free open-source data collection framework, a scalable cloud-based server, and a team of 184 medical students, we can deliver a low-cost, highly reliable platform that requires little training or maintenance, providing results immediately on completion of data collection.

CONCLUSION

Our platform allowed us to measure, for the first time, the prevalence of sepsis in Wales over 24 hours.

Forehead reflectance photoplethysmography to monitor heart rate: preliminary results from neonatal patients

Around 5%-10% of newborn babies require some form of resuscitation at birth and heart rate (HR) is the best guide of efficacy. We report the development and first trial of a device that continuously monitors neonatal HR, with a view to deployment in the delivery room to guide newborn resuscitation. The device uses forehead reflectance photoplethysmography (PPG) with modulated light and lock-in detection. Forehead fixation has numerous advantages including ease of sensor placement, whilst perfusion at the forehead is better maintained in comparison to the extremities. Green light (525 nm) was used, in preference to the more usual red or infrared wavelengths, to optimize the amplitude of the pulsatile signal. Experimental results are presented showing simultaneous PPG and electrocardiogram (ECG) HRs from babies (n = 77), gestational age 26-42 weeks, on a neonatal intensive care unit. In babies ⩾32 weeks gestation, the median reliability was 97.7% at ±10 bpm and the limits of agreement (LOA) between PPG and ECG were +8.39 bpm and -8.39 bpm. In babies <32 weeks gestation, the median reliability was 94.8% at ±10 bpm and the LOA were +11.53 bpm and -12.01 bpm. Clinical evaluation during newborn deliveries is now underway.

Glue granuloma following laparoscopic hernia repair

Minimal inflammation of tissues can occur following skin closure with a foreign material. This foreign body reaction can lead to granuloma formation. We report the case of a middle-aged man who, having undergone laparoscopic surgery and had the port site wounds closed with skin glue, was detected to have a non-healing wound. A crystal mass protruding from the incision site was confirmed histologically as a chronic granulomatous reaction to skin glue. A foreign body granulomatous reaction to skin glue has not been described in the literature.

Management of atrial fibrillation in the Emergency Department: current approach and future expectations

Atrial fibrillation (AF) is the most common cardiac dysrhythmia and occurs in 3.3%-10% of emergency admissions. It is frequently quoted for people over the age of 75, but the cases of AF in young subjects without structural heart disease are also increasing, therefore, leading to the evaluation of "lonely atrial fibrillation" as a new challenge for the clinician. The first diagnosis and treatment often occur in the emergency room and the emergency physician has therefore to evaluate the initial step towards the therapeutic decisions. Although international standard guidelines are available, AF treatment in the Emergency Department (ED) is still heterogeneous in terms of the management strategy chosen. There are two main strategies for the management of AF: rate and rhythm control. Moreover, antithrombotic treatment is pivotal in AF to prevent cardioembolic stroke and it is considered a primary objective after an accurate assessment of antithrombotic treatment risks and benefits. The introduction of innovative echocardiographic approach, directly in ED, seems to improve the management and risk stratification of patients with AF. This review aims to provide an overview about the current approach and the future expectations in the management of AF in ED. This manuscript represents a synopsis of the lectures on AF management in the ED of the Third Italian GREAT Network Congress, that was hold in Rome, 15-19 October 2012. We decided to use only the most relevant references for each contribution as suggested by each participant at this review.

Salt or sugar for your injured brain? A meta-analysis of randomised controlled trials of mannitol versus hypertonic sodium solutions to manage raised intracranial pressure in traumatic brain injury

BACKGROUND

Rising intracranial pressure (ICP) is a poor prognostic indicator in traumatic brain injury (TBI). Both mannitol and hypertonic sodium solutions are used to treat raised ICP in patients with TBI.

OBJECTIVE

This meta-analysis compares the use of mannitol versus hypertonic sodium solutions for ICP control in patients with TBI.

DATA SOURCES AND STUDY ELIGIBILITY

Randomised clinical trials in adults with TBI and evidence of raised ICP, which compare the effect on ICP of hypertonic sodium solutions and mannitol.

METHODS

The primary outcome measure is the pooled mean reduction in ICP. Studies were combined using a Forest plot.

RESULTS

Six studies were included, comprising 171 patients (599 episodes of raised ICP). The weighted mean difference in ICP reduction, using hypertonic sodium solutions compared with mannitol, was 1.39 mm Hg (95% CI -0.74 to 3.53).

LIMITATIONS

Methodological differences between studies limit the conclusions of this meta-analysis.

CONCLUSIONS

The evidence shows that both agents effectively lower ICP. There is a trend favouring the use of hypertonic sodium solutions in patients with TBI.

Jejunal diverticulitis in a child

Jejunal diverticular disease is rare and few cases have been documented in the literature. Here we report the first case of a child presenting with a perforated congenital jejunal diverticulum.

High-dose glycine impairs the prepulse inhibition measure of sensorimotor gating in humans

An impaired capacity to filter or 'gate' sensory information is a core deficit in cognitive function associated with schizophrenia. These deficits have been linked in part to N-methyl-d-aspartate (NMDA) receptor dysfunction. An association between high levels of glycine, a positive allosteric modulator of the NMDA receptor, and sensorimotor gating impairments (i.e. prepulse inhibition (PPI) deficit) have been reported in animal models of schizophrenia as well as patients with schizophrenia. This study examined the acute effects of modulating the glycine site of the NMDA receptor (with high-dose glycine) on sensory gating as measured by PPI. Sixteen healthy male subjects (final sample size of 12) participated in a double-blind, placebo-controlled, crossover design in which each subject was tested under two acute treatment conditions separated by at least a 5-day washout period; placebo and 0.8 g/kg glycine. PPI was recorded 45 min post treatment using electromyography of the eye-blink response. Relative to placebo, high-dose glycine significantly impaired sensorimotor gating as demonstrated by a decrease in PPI (t(11) = -2.983, p < 0.05). Administration of a high dose of glycine is associated with impairments in PPI supporting earlier observations in animals and patients with schizophrenia. This result, when taken together with findings in patients, suggests that high synaptic levels of glycine may have some clinically relevant detrimental effects and suggests a potential dissociation of clinical symptomatology and sensory information processing as a function of NMDA receptor modulation in schizophrenia.

Parallel pathways in RAF-induced senescence and conditions for its reversion

We developed a clonal WI-38hTERT/GFP-RAF1-ER immortal cell line to study RAF-induced senescence of human fibroblasts. Activation of the GFP-RAF1-ER kinase by addition of 4-hydroxy-tamoxifen led to a robust induction of senescence within one population doubling, accompanied by the assembly of heterochromatic foci. At least two pathways contribute in parallel to this senescence leading to the accumulation of p15, p16, p21 and p27 inhibitors of cyclin-dependent kinases (CKIs). Cells that traversed S phase after RAF1 kinase activation experienced a replicative stress manifested by phosphorylation of H2AX and Chk2 and synthesis of p21. However, about half the cells in the population were blocked without passing through S phase and did not show activation of DNA-damage checkpoints. When the cells were cultivated in 5% oxygen, RAF1 activation generated minimal reactive oxygen species, but RAF-induced senescence occurred efficiently in these conditions even in the presence of anti-oxidants or inhibitors of DNA checkpoint pathways. Despite the presence of heterochromatic foci, simultaneous knockdown of p16 and p21 with inactivation of the GFP-RAF1-ER kinase led to rapid reversion of the senescent state with the majority of cells becoming competent for long-term proliferation. These results demonstrate that replicative and oxidative stresses are not required for RAF-induced senescence, and this senescence is readily reversed upon loss of CKIs.