Effects of a music-based intervention on psychophysiological outcomes of patients undergoing medical imaging procedures: A systematic review and meta-analysis

INTRODUCTION

Musical intervention (MI) is a valuable strategy for addressing the psychological and emotional challenges faced by patients undergoing imaging procedures. This study explores MI's impact on psychophysiological outcomes during imaging procedures, detailing the sound repertoire and technical characteristics employed in MI.

METHODS

A systematic review (SR) and meta-analysis (MA) were conducted. Electronic database searches of PubMed, Web-of-Science, and Scopus were performed encompassing original randomised research and quasi-experimental articles published until June 2023.

RESULTS

Thirteen articles were included in this SR, scoring between 23 and 68 on the Joanna Briggs Institute (JBI) Checklist. Four articles were included to perform a MA concerning anxiety and heart rate (HR) outcomes. Most studies utilised digital playlists as the medium for MI. Headphones were commonly used, with an average volume of 50-60 dB and a musical frequency of 60-80 beats/min. While authors generally preferred selecting musical genres for the repertoire, two articles specifically chose Johann Pachelbel's "Canon in D major" as their musical theme. In terms of psychological parameters, the experimental groups exhibited lower anxiety values than the control groups, with further reductions after MI. However, MA shows that this trend is only marginally significant. Patient comfort and overall examination experience showed improvement with MI. Regarding physiological parameters, HR, especially in the final phase of the examination, was significantly lower in the experimental group compared to the control group.

CONCLUSION

Across multiple studies, MI demonstrated the ability to reduce anxiety and HR. However, no specific music repertoire emerged as the most effective.

IMPLICATIONS FOR PRACTICE

MI arises as a painless, reliable, low-cost, and side-effect-free strategy, presenting imaging departments with a practical means to enhance patient comfort and mitigate anxiety and stress during medical procedures.

Overall survival and central nervous system activity of crizotinib in ROS1-rearranged lung cancer-final results of the EUCROSS trial

BACKGROUND

In 2019, we reported the first efficacy and safety analysis of EUCROSS, a phase II trial investigating crizotinib in ROS1 fusion-positive lung cancer. At that time, overall survival (OS) was immature and the effect of crizotinib on intracranial disease control remained unclear. Here, we present the final analysis of OS, systemic and intracranial activity, and the impact of co-occurring aberrations.

MATERIALS AND METHODS

EUCROSS was a prospective, single-arm, phase II trial. The primary endpoint was best overall response rate (ORR) using RECIST 1.1. Secondary and exploratory endpoints were progression-free survival (PFS), OS, and efficacy in pre-defined subgroups.

RESULTS

Median OS of the intention-to-treat population (N = 34) was 54.8 months [95% confidence interval (CI) 20.3 months-not reached (NR); median follow-up 81.4 months] and median all-cause PFS of the response-evaluable population (N = 30) was 19.4 months (95% CI 10.1-32.2 months). Time on treatment was significantly correlated with OS (R = 0.82; P < 0.0001). Patients with co-occurring TP53 aberrations (28%) had a significantly shorter OS [hazard ratio (HR) 11; 95% CI 2.0-56.0; P = 0.006] and all-cause PFS (HR 4.2; 95% CI 1.2-15; P = 0.025). Patients with central nervous system (CNS) involvement at baseline (N = 6; 20%) had a numerically shorter median OS and all-cause PFS. Median intracranial PFS was 32.2 months (95% CI 23.7 months-NR) and the rate of isolated CNS progression was 24%.

CONCLUSIONS

Our final analysis proves the efficacy of crizotinib in ROS1-positive lung cancer, but also highlights the devastating impact of TP53 mutations on survival and treatment efficacy. Additionally, our data show that CNS disease control is durable and the risk of CNS progression while on crizotinib treatment is low.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

The effect of Zostera noltei recolonization on the sediment mercury vertical profiles of a recovering coastal lagoon

Mercury's extreme toxicity and persistence in the environment justifies a thorough evaluation of its dynamics in ecosystems. Aveiro Lagoon (Portugal) was for decades subject to mercury effluent discharges. A Nature-based Solution (NbS) involving Zostera noltei re-colonization is being tested as an active ecosystem restoration measure. To study the effect of Zostera noltei on the sediment contaminant biogeochemistry, seasonal (summer/winter) sediment, interstitial water and labile mercury vertical profiles were made in vegetated (Transplanted and Natural seagrass meadows) and non-vegetated sites (Bare-bottom area). While no significant differences (p > 0.05) were observed in the sedimentary phase, Zostera noltei presence reduced the reactive/labile mercury concentrations in the top sediment layers by up to 40% when compared to non-vegetated sediment, regardless of season. No differences were found between vegetated meadows, highlighting the fast recovery of the contaminant regulation ecosystem function provided by the plants after re-colonization and its potential for the rehabilitation of historically contaminated ecosystems.

Are we meeting the standards set for informed consent in spinal surgery?

INTRODUCTION

Informed consent empowers patients to exercise their autonomy and actively participate in their medical care. Guidance published by the British Association of Spine Surgeons (BASS) lists three components of consent: provision of information booklets, patient-centred dialogue and completion of appropriate consent forms. The aim of the study was to review the quality of the spinal surgery consent process against the BASS guidance in a single tertiary neurosurgery centre in London.

METHODS

Retrospective review of clinic letters and consent forms was performed for 100 consecutive cases of elective, non-instrumented spinal decompression surgeries performed in 2019. Documentation was graded for inclusion of the intended benefit (improvement of pain/prevention of neurological deterioration), alternative management options (including no treatment), surgical options and risks (infection, bleeding, paralysis, sphincter disturbances, dural tear and recurrence). Provision of supplementary information booklets was recorded. Two-tailed Fisher exact test was used to calculate statistical significance where appropriate.

RESULTS

Documentation of indications and risks of elective spinal surgery, specifically risk of recurrence (62%) and sphincter disturbance (85%), was suboptimal on the consent forms. Documentation of these risks was also poor in clinic letters (<50%). Alternative treatment options were explained in less than half of the clinic letters, and there was no documentation of information booklet provision prior to elective surgeries.

CONCLUSION

Lack of informed consent plays a major role in medical malpractice claims in spinal surgery. Poor documentation puts the surgeon in a liable position. BASS guidance could be implemented to create a more standardised process of consent in spinal surgery.

At the outer edge of STEMI time: even after 12 hours, the clock keeps ticking

Introduction

Although primary percutaneous coronary intervention (pPCI) is not a class I recommendation in all patients (pts) presenting within 12 to 48h of symptom onset (late ST-segment Elevation Myocardial Infarction, STEMI), there is increasing evidence supporting its routine use in this population. Data on long-term clinical outcomes is sparse.

Objective

To evaluate long-term MACE in late-STEMI pts submitted to pPCI and compare with clinical outcomes of early reperfusion groups.

Methods

Retrospective analysis of consecutive pts submitted to pPCI due to STEMI between 2010 and 2015 in a pPCI centre. Included pts were stratified in 5 groups according to symptom-to-balloon time (SBT): &lt;3h; 3–6h; 6–12h; 12–24h; 24–48h. Of a total of 903 pts, 19 pts were excluded due to SBT &gt;48h. Long-term events were established as 5y mortality and 5y-MACE (a composite endpoint of death, re-infarction, heart failure hospital admission and ischemic stroke). The cumulative incidence of long-term outcomes was calculated by the Cox regression analysis and presented according to the Kaplan-Meier method.

Results

Of the 884 pts included in the study, stratification according to SBT was: pPCI&lt;3h (47.4%), pPCI 3–6h (24.9%), pPCI 6–12h (16.5%), pPCI 12–24h (8.0%), and pPCI 24–48h (3.2%). These groups showed no significant difference in terms of demographic characteristics (age, CV risk factors, previous coronary disease or heart failure), clinical severity (systolic arterial pressure, Killip-Kimball class, left ventricle ejection fraction) and angiography findings (multivessel disease, complete revascularization and PCI success). After a median follow-up of 76 (56; 98) months, 5-year mortality was 20.6% (182 pts) and 5-year MACE was 23.3% (206 pts). MACE was associated with increased median SBT: 5.0 (2.0; 9.0) hours vs 4.0 (2.0; 6.5) hours, p&lt;0.001. Of the MACE components, the only that showed a significant association with higher median SBT was mortality: 5.0 (2.0; 10.0) hours vs 4.0 (2.0; 6.0), p&lt;0.001. Differences in long-term outcomes were significant when considering SBT stratified by revascularization time (Figure 1).

Conclusions

As expected, there is a clinical benefit of early reperfusion for long-term cardiovascular events. Within the late-STEMI group, there seems to be a clear distinction between pPCI&lt;24h and &gt;24h, although the clinical benefit of pPCI timing most probably acts a continuum.

Funding Acknowledgement

Type of funding sources: None.

Predictors for NYHA recovery and 1-year mortality after mitral TEER

Background

Mitral regurgitation (MR) is the second-most frequent valvular heart disease in Europe and frequently aggravates heart failure (HF) symptoms. Mitral transcatheter-edge-to-edge repair (TEER) can be considered in eligible patients, for both primary (in inoperable cases) or secondary severe MR. However, intervention is not advised in severe comorbid patients in whom it is not expected to prolong survival for over 1 year.

Purpose

Evaluate characteristics associated with HF New York Heart Association (NYHA) class recovery, and one-year all-cause mortality after mitral TEER for severe MR.

Methods

All mitral TEER procedures for primary and secondary MR conducted in a single-centre between 2014 and 2020 were retrospectively analyzed. The primary endpoint was defined as a reduction of at least one NYHA class in the first month after intervention, and a secondary endpoint considered a recovery of at least two NYHA classes. Survival status 12 months after mitral TEER was also consulted. Clinical, echocardiographic and blood-analysis data were explored as characteristics associated with the endpoints defined, using Pearson's Chi-squared test, Wilcoxon rank sum test and Fisher's exact test, as appropriate. A p&lt;0.05 was considered statistically significant.

Results

From 103 mitral TEER procedures, 86 (83%) had full information about pre- and post-intervention NYHA class, as well as survival status at 12 months. There was a higher proportion of primary MR among NYHA non-responders (47% versus 25%, p=0.034), but no differences for secondary MR. Higher surgical risk patients (EuroSCORE II) tended to have exhibit more NYHA recovery, though not reaching statistical significance (p=0.068). Both a more advanced NYHA class at baseline and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels were linked to a higher symptomatic recovery (2048 versus 5676pg/ml, p&lt;0.001). Also, persisting MR after TEER of at least grade 3/4 was more frequent in non-NYHA responders. Regarding NYHA improvement of at least two classes, it was observed in 13% patients, and these also had a more advanced NYHA class at baseline and lower NTproBNP basal levels, and exhibited a lower estimated systolic pulmonary artery pressure and inferior vena cava (IVC) diameter. Finally, 10 (11.6%) of mitral TEER patients died in the first 12 months, and no statistically significant associations were found regarding pre-intervention characteristics and survival.

Conclusions

This study suggests that three-fifths of severe MR improve their NYHA class after TEER, but only one-fourth for primary MR. Earlier intervention – with lower NTproBNP levels, less severe pulmonary hypertension, and lower IVC diameters – is associated with more symptomatic HF improvement. All-cause mortality in the first year is still significant, exposing a need for better patient selection. However, these findings represent exploratory deductions of a relatively low number, single-centre, patients.

Funding Acknowledgement

Type of funding sources: None.

Intrathecal baclofen overdose mimicking brainstem death during deep brain stimulation surgery for pain

We describe a unique case of intrathecal baclofen overdose mimicking brainstem death, during bilateral anterior cingulate cortex deep brain stimulation (DBS) for pain. A 37-year-old man with chronic regional pain syndrome requiring an intrathecal baclofen pump underwent DBS under general anaesthesia and experienced an intraoperative generalised tonic-clonic seizure on dural opening. Once the operation was completed, the patient was noted to have fixed, dilated pupils bilaterally and was transferred for an emergency computed tomography scan of the head, which did not reveal any acute intracranial pathology. The patient was transferred to the intensive care unit for management of concurrent hypotension, bradycardia and supportive management of his low Glasgow Coma Scale (GCS) score. A trial of atropine to counter the bradycardia was unsuccessful. Intrathecal baclofen toxicity was suspected as a diagnosis of exclusion, necessitating urgent aspiration of the baclofen pump. The patient's GCS score improved after pump aspiration and he was discharged home several days later. It was noted that the intrathecal baclofen pump had been refilled several days previously and the patient had reported intermittent episodes of somnolence. In perioperative patients with intrathecal baclofen pumps in situ, baclofen toxicity should always be considered as a differential in perioperative complications, even if it is considered a rare event.

Comparative evaluation of physicochemical profile and bioactive properties of red edible seaweed Chondrus crispus subjected to different drying methods

Dehydration of the edible seaweed Chondrus crispus was performed by freeze-drying, conventional oven-drying and emerging microwave hydrodiffusion and gravity (MHG). In this work, the drying kinetics and modelling, estimating specific energy consumption and environmental impact of distinct processes were tested. Color and microstructural features of the dried macroalgae were also evaluated, as well as their nutritive characterization, chemical profile and bioactive potential (antioxidant and antimicrobial activities). Moreover, collected liquid phases from both the defrosted and MHG treated samples were also characterized. All methodologies provided solid phases with an adequate final moisture content. MHG significantly reduced the needed time, specific energy consumption and environmental impact, providing C. crispus with intermediate color and histological structure characteristics. Overall, this trend was also defined to tested chemical parameters and bioactivities. MHG provided aqueous extracts with potential bioactive compounds from this red alga, increasing the efficiency of this drying method.

STEMI around-the-clock: how off-hours admissions impact door-to-balloon time and the long-term prognosis of ST-segment Elevation Myocardial Infarction

Introduction

The outcomes of reperfusion in ST-segment Elevation Myocardial Infarction (STEMI) are time-dependent, and percutaneous coronary intervention (PCI) should be performed within 60 minutes from hospital admission in PCI centers – door-to-balloon time (D2B). The association between Off-Hours Admission (OHA) and long-term outcomes is controversial when considering contemporary organized STEMI networks.

Purpose

This study aims to analyze how OHA influences D2B and long-term mortality.

Methods

Retrospective study of consecutive STEMI patients (pts), admitted in a PCI-centre with a local Emergency Department, between 2010 and 2015. Pts submitted to rescue-PCI were excluded. OHA was defined as admission at night (8p.m. to 8a.m), weekends and nonworking holidays. Predictors of OHA and D2B were studied by logistic regression analysis. Demographic, clinical, angiographic and procedural variables were evaluated using stepwise Cox regression analysis to determine independent predictors of 5-year all-cause mortality (5yM). The cumulative incidence of 5yM stratified by hours of admission was calculated according to the Kaplan-Meier method.

Results

Of 901 pts, 472pts (52.4%) were admitted during off-hours. These pts were younger (61±13 vs 64±12, p=0.002) and had a lower median patient-delay time (128min vs 157min, p=0.014). Clinical severity at presentation, defined by systolic arterial pressure and Killip-Kimball (KK) class, did not differ between groups. OHA did not impact D2B (89 min vs 88 min, p=0.550), which was in turn influenced by age ≥75y (OR 1.85, 95% CI 1.31–2.61, p&lt;0.001). Mean clinical follow-up (FUP) was 68±37 months, with 75.1% of pts achieving a FUP &gt;5 years. 5yM rate was 9.7%. After multivariate cox regression analysis, independent determinants of long-term mortality were age (HR 1.05, 95% CI 1.02–1.08, p&lt;0.001), previous history of heart failure (HR 6.76, 95% CI 1.32–34.72, p=0.022) and pulmonary disease (HR 3.79, 95% CI 1.16–12.33, p=0.027), presentation with KK ≥2 (HR 2.82, 95% CI 1.32–6.01, p=0.007) and radial artery access in catheterization (HR 0.39, 95% CI 0.18–0.83, p=0.014) – figure 1. Although there was an association between a higher D2B time and 5yM (87min vs 101min, p=0.024), neither OHA nor D2B were independent predictors of long-term mortality – figure 2.

Conclusion

OHA did not seem to influence D2B and long-term STEMI outcomes in our PCI-centre. 5yM was mostly influenced by patient characteristics and clinical severity at presentation.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Predictors of long-term mortalityFigure 2. 5-year survival stratified by OHA

Indirect effects of COVID-19 Pandemic in ST-segment elevation myocardial infarction: insights from a multicentric national survey

Objective

Coronavirus disease 2019 (COVID-19) pandemic may have indirect consequences in ST-segment elevation myocardial infarction (STEMI) outcomes due to difficulties in healthcare access, but also due to reperfusion delays. The objective of this study was to evaluate the performance indicators in STEMI during the early phase of the lockdown following the COVID-19 pandemic.

Methods

The “patient delay” and the “system delay” were evaluated in 312 patients with suspected STEMI, in the period of the first State of Emergency in Portugal, through a survey called “Moment COVID” implemented within 18th March to 2 May 2020, in 18 national centers of Interventional Cardiology where PPCI is carried out 24/7. These patients were compared with a historical cohort of 267 patients from the 5th year after integration of SFL Initiative in Portugal (Moment 2015) in which the same survey was applied. Patients with late presentation of STEMI (&gt;12 hours of symptoms onset) were excluded from this analysis.

Results

In “Moment COVID” there was a trend towards a longer “patient delay” (incremental median 20 min; p=0.059) and a significant longer system-delay (incremental median 17 min; p=0.033) compared to the historical cohort of “Moment 2015”. Consequently, times to revascularization tended to be longer (incremental median 26 min; p=0.074). Indeed, in “Moment COVID” patients were less compliant with the times recommended by the European guidelines: door-to-balloon time &lt;60 min was achieved in 47.6% of patients compared to 57.0% (p=0.052) in “Moment 2015” and system-delay &lt;90 min in 13.9% compared to 21.8% (p=0.033).

Conclusion

These results from a multicentric national analysis demonstrated a trend to longer time from symptom onset to request healthcare system assistance and a significantly longer time from first medical contact to revascularization among patients with STEMI during COVID-19 pandemic. This delay for treatment could negatively impact the STEMI prognosis at the long-term.

Funding Acknowledgement

Type of funding sources: None.

Thalamic deep brain stimulation for post-traumatic neuropathic limb pain: Efficacy at five years' follow-up and effective volume of activated brain tissue

Chronic neuropathic pain affects 7%-10% of the population. Deep brain stimulation (DBS) has shown variable but promising results in its treatment. This study prospectively assessed the long-term effectiveness of DBS in a series of patients with chronic neuropathic pain, correlating clinical results with neuroimaging. Sixteen patients received 5 years' post-surgical follow-up in a single center. Six had phantom limb pain after amputation and 10 had deafferentation pain after traumatic brachial plexus injury. Patient-reported outcome measures were completed before and after surgery, using VAS, UWNPS, BPI and SF-36 scores. Neuroimaging evaluated electrode location and effective volumes of activated tissue (VAT). Two subgroups were created based on the percentage of VAT superimposed upon the ventroposterolateral thalamic nucleus (eVAT), and clinical outcomes were compared. Analgesic effect was assessed at 5 years and compared to preoperative pain, with an improvement on VAS of 76.4% (p=0.0001), on UW-NPS of 35.2% (p=0.3582), on BPI of 65.1% (p=0.0505) and on SF-36 of 5% (p=0.7406). Eight patients with higher eVAT showed improvement on VAS of 67.5% (p=0.0017) while the remaining patients, with lower eVAT, improved by 50.6% (p=0.03607). DBS remained effective in improving chronic neuropathic pain after 5 years. While VPL-targeting contributes to success, analgesia is also obtained by stimulating surrounding posterior ventrobasal thalamic structures and related spinothalamocortical tracts.

307 Improving Compliance with Standard of Care Guidelines for Suspected Cauda Equina Syndrome Across A District General Hospital Network

Introduction

Cauda equina syndrome (CES) is a spinal emergency that cannot be reliably detected through clinical examination alone and as a result requires prompt MR imaging to provide a diagnosis. This audit examined compliance to standard of care following service improvements in line with the updated SBNS/BASS national guidelines for CES.

Method

A retrospective analysis of 200 patients referred to neurosurgery for suspected CES: 100 pre- and 100 post-service improvement SBNS guideline implementation.

The online neurosurgical database was reviewed, cases assessed for completeness of referral information (including appropriate exam and pre-referral MRI) with patient demographics, referring hospital and outcome also recorded.

Results

Prior to the SBNS guidelines only 19 patients received MRI prior to referral, 70% of all referrals were incomplete or contained erroneous clinical information. Post-service improvements there was a 68% increase of pre-referral MRI (32 cases), and an improvement in quality of clinical information with only 19% of referrals providing insufficient or unreliable information.

Conclusions

Through relatively simple changes to local policy, patient care flow and education of emergency department clinicians we have significantly improved pre-referral MRI rates as well as overall referral quality across the whole DGH network.

Fulminant intracranial hypertension secondary to oxytetracycline requiring urgent ventriculo-peritoneal shunt insertion

Idiopathic intracranial hypertension is a syndrome that presents with headaches and visual loss. Its pathogenesis is unknown. Treatment options include acetazolamide, therapeutic lumbar punctures or permanent CSF diversion. We present the only reported case of acute drug-induced intracranial hypertension secondary to oxytetracycline requiring urgent cerebrospinal fluid diversion. The patient's rapid visual failure progressed daily despite discontinuation of the drug and required an urgent ventriculo-peritoneal (VP) shunt insertion. Patients should be counselled about the rare potential risk of developing intracranial hypertension when commencing oxytetracycline. Rapid visual failure in IIH is a neurosurgical emergency necessitating urgent ventriculoperitoneal shunt insertion.

Spinal subarachnoid haematoma after neuraxial anaesthesia in a patient with polycythaemia vera

Polycythaemia vera is a common haematological proliferative disorder. It is characterised by uncontrolled red cell production with ensuing peri-operative vaso-occlusive and haemorrhagic complications. Spinal haematoma after neuraxial anaesthesia is rare; most cases are associated with technical difficulties or bleeding disorders. Current consensus opinion suggests that neuraxial anaesthesia in patients with polycythaemia vera is safe due to a lower risk of thrombotic events and hypoxaemia compared with general anaesthesia. We report a case of a spinal subarachnoid haematoma after uneventful neuraxial anaesthesia in a patient with optimised polycythaemia vera. Despite an emergent laminectomy, the patient developed permanent motor deficits. This report highlights that although neuraxial anaesthesia is recommended by many authors, patients with polycythaemia vera can paradoxically have an increased haemorrhagic risk from platelet dysfunction and acquired von Willebrand disease. Clinicians proceeding with surgery under neuraxial anaesthesia should appreciate these risks even in patients with normal or apparently elevated thrombotic states. This case also demonstrates that traditional coagulation tests may need to be complemented by pre-operative platelet function tests and screening for von Willebrand disease. Finally, the importance of the patient participation in the choice of the anaesthesia technique cannot be understated, with specific attention paid to this frequently unrecognised risk.

Neuroablative surgical treatments for pain due to cancer

Cancer pain is common and challenging to manage - it is estimated that approximately 30% of cancer patients have pain that is not adequately controlled by analgesia. This paper discusses safe and effective neuroablative treatment options for refractory cancer pain. Current management of cancer pain predominantly focuses on the use of medications, resulting in a relative loss of knowledge of these surgical techniques and the erosion of the skills required to perform them. Here, we review surgical methods of modulating various points of the neural axis with the aim to expand the knowledge base of those managing cancer pain. Integration of neuroablative approaches may lead to higher rates of pain relief, and the opportunity to dose reduce analgesic agents with potential deleterious side effects. With an ever-increasing population of cancer patients, it is essential that neurosurgeons maintain or train in these techniques in tandem with the oncological multi-disciplinary team.

Advances on assessing nanotoxicity in marine fish - the pros and cons of combining an ex vivo approach and histopathological analysis in gills

The need to overcome logistic and ethical limitations of in vivo nanotoxicity evaluation in marine organisms is essential, mostly when dealing with fish. It is well established that medium/solvent conditions affect dispersion and agglomeration of nanoparticles (NPs), which represents a constraint towards a solid and realistic toxicity appraisal. In this way the pros and cons of an ex vivo approach, using a simplified exposure medium (seawater) and addressing gills histopathology, were explored. The nanotoxic potential of environmentally realistic concentrations of titanium dioxide NPs (TiO₂ NPs) was also assessed, disclosing the morpho-functional effects on the gills and the possible uptake/elimination processes. Excised gills of the Senegalese sole (Solea senegalensis) were directly exposed in artificial seawater to 20 and 200 μg L^-1 TiO₂ NPs, for 2 h and 4 h. Semi-quantitative and quantitative histological analyses were applied. The normal morphology of the gill's epithelia was only slightly altered in the control, reflecting protective mechanisms against the artificiality of the experimental conditions, which, together with the absence of differences in the global histopathological index (I_h), corroborated that the gill's morpho-functional features were not compromised, thereby validating the proposed ex vivo approach. TiO₂ NPs induced moderate severity and dissemination of histopathological lesions. After 2 h, a series of compensatory mechanisms occurred in NP treatments, implying an efficient response of the innate defense system (increasing number of goblet cells) and effective osmoregulatory ability (chloride cells proliferation). After 4 h, gills revealed signs of recovery (normalization of the number of chloride and goblet cells; similar I_h), highlighting the tissue viability and effective elimination and/or neutralization of NPs. The uptake of the TiO₂ NPs seemed to be favored by the higher particle sizes. Overall, the proposed approach emerged as a high-throughput, reliable, accurate and ethically commendable methodology for nanotoxicity assessment in marine fish.

P975Safety and clinical outcomes of rotational atherectomy: an eleven-year centre experience

Introduction

Rotational atherectomy (RA) is an adjunctive tool for the management of heavily calcified coronary lesions during percutaneous coronary intervention (PCI), but the clinical outcomes remain unclear. Access site choice is also poorly defined and there is growing evidence that transradial approach (TRA) is associated with lower complications and lower mortality.

Objectives

To assess the safety and long-term outcomes of RA for calcified coronary lesions and to investigate the influence of vascular access site in the efficacy and safety of the procedure.

Methods

Retrospective single-centre study that included consecutive PCI with RA performed from January 2006 to December 2017. Endpoint was a composite of major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and target vessel revascularization, at 1- and 5-year.

Results

246 procedures were included in a total of 236 patients (pts): mean age 70.1±9.7 years, 73.6% male; 36.2% had previous PCI, 12.2% vascular peripheral disease (VPD), 24% reduced left ventricle ejection fraction (LVEF) and 6.9% were under hemodialysis. PCI with RA was mostly performed due to stable angina (48.9%) and via TRA (55.3%), with a total of 371 treated segments and a median number of 1 vessel treated per intervention. The left anterior descending artery was the most frequently treated artery (67.5%). Single burr was used in 76% of cases (mean number of burrs 1.23; mean burr size 1.5 mm). Procedural success rate was 94.7%. Complications were recorded in 9.3%, with no procedure related death. Clinical follow-up was complete in 98.8% of pts at 1-year and 81.3% at 5-year (mean time 62.3±41.8 months). Survival free of MACE at 1- and 5-year were 83.7% and 73.2%, respectively. Multivariate Cox regression identified 6 independent predictors (only 1 protector) for 1-year MACE (Fig. A) and 6 independent predictors (all of increased risk) for 5-year MACE (Fig. B). TRA was protector of 1-year MACE and Kaplan-Meier curves showed benefit for both 1- and 5-year MACE occurrence (Fig. C and D), without significant difference in procedural success (p=0.92) and complications (p=0.45) rate comparing to transfemoral approach.

Conclusions

RA followed by stenting was a safe procedure with a high immediate success rate but an increased number of long-term cardiovascular events. Some clinical conditions, such as previous PCI, VPD and reduced LVEF, seems to adversely influence the long-term outcome while TRA appears to be protective.

P117 Predictive factors of outcome in poor grade subarachnoid haemorrhage (SAH)

Objectives

To study the factors associated with outcome in poor grade SAH in a busy tertiary centre.

Design

Retrospective records review.

Subjects

All Patients with SAH WFNS grades IV and V admitted Jan 2016-Dec 2017.

Methods

We admitted 379 SAH patients, 84 (22%) were poor grade (n=84, 33M/51F mean age 60.7±1.4 y). Outcome was assessed by Modified Rankin Scale (mRS) scores before surgery and at latest follow up (3–6 months). mRS was dichotomised as good (0–3) and poor (4–6).Spearman’s rank-order test evaluated correlation between latest mRS and all other variables (WFNS grade, GCS, Motor score of GCS, age, sex, smoking, hypertension, intraventricular haemorrhage (IVH) and intracerebral haemorrhages (ICH)).

Results

63 patients (75%) had poor outcome, of which 46 (55%) died (44 with 30 days), versus 21 (25%) had good outcome. Spearman’s correlation analysis revealed that patients with smaller aneurysms (3.3±0.4 mm in good outcome patients vs 11.3±1.2 mm in poor outcome) (rs=0.37, p=0.009), who are younger (rs=0.24, p=0.03), have higher GCS (rs=−0.24, p=0.03), higher motor score (rs=0.25, p=0.02), lower WFNS grade (rs=0.3, p=0.007) and received coiling of aneurysms vs no treatment (rs=−0.39, p<0.0001) had better outcome. There was no significant correlation in outcome with ICH, IVH, external ventricular drain insertion, location of aneurysms, smoking, hypertension, other co-morbidities or sex.

Conclusions

In poor grade SAH, younger patients with smaller aneurysms, higher GCS and higher motor score who received endovascular coiling had better outcome.

WP1-23 Vascular collagen 4A1 in subcortical white matter of older people and primates

Objectives

To test whether collagen 4A1 in cerebral small arteries associated with age, hypertension or small vessel disease (SVD).

Design

Neuropathology cohort study.

Subjects

Older people age >65 years with minimal Alzheimer’s Disease.

Methods

We examined subcortical white matter in archived brain tissue from older people (n=34, 15F/19M, median age 84, range 65–99 y) and from experimental non-human primates (NHP, Macaca mulatta) that were young adults (n=9, age 6.2–8.3 y) or older adults (n=8, age 17.0–22.7 y). Some of the primates (5 young, 3 older) were chronically hypertensive. Vascular collagen 4A1 immunohistochemical labelling was examined qualitatively and quantified as percent area fraction.

Results

Collagen 4A1 labelling was common in arterial myocytes and in the adventitial layer in human and primate brain arteries, as well as in basement membrane, which frequently exhibited replication. Among older people, collagen 4A1 associated with neuropathological SVD severity (sclerotic index; r=−0.461, p=0.0409, least squares) and with radiological SVD severity (leukoaraiosis; p=0.0455, 1-way ANOVA) but not with age or clinical history of hypertension. In NHP, age but not hypertension was significantly associated with collagen-4A1 labelling (p=0.0396, 0.232 respectively, 2-way ANOVA).

Conclusions

In this small cohort, vascular collagen 4A1 was related to SVD severity in older humans, in accord with genetic associations of COL4A1 with SVD phenotypes.

P112 Management and outcome of subarachnoid haemorrhage (SAH) in older people: a centre series

Objectives

To study the management and factors associated with outcomes in SAH in elderly over 80 years of age.

Design

Retrospective records review.

Subjects

All Patients with SAH confirmed on head CT admitted Jan 2012-Dec 2017.

Methods

We admitted 1079 patients with SAH, 32 were aged ≥80 y (3%). We subdivided the patients into a poor outcome group (POG) (Modified Rankin Scale (mRS) 4–6), (n=24, 14F/10M, mean age 83.7±0.7 y) and good outcome group (GOG) (mRS 0–3) (n=8, 7F/1M, mean age 82.6±0.6 y). Spearman’s rank-order test evaluated correlation between outcome (mRS) and all other variables (WFNS grade, GCS, Motor score of GCS, age, sex, smoking, hypertension, intraventricular haemorrhage (IVH) and intracerebral haemorrhages (ICH)).

Results

9 patients (38%) of POG were WFNS grades IV – V versus 1 patient (13%) in GOG. More POG than GOG patients had IVH (83% vs 38%, rs=−0.44 p=0.011). 20% of POG had ICH vs none in GOG. GOG patients had better GCS (rs=−0.37, p=0.04), lower WFNS grade (rs=0.43, p=0.01) and did not need external ventricular drain (EVD) (rs=0.51, p=0.003). There was no significant correlation between outcome and sex, smoking, hypertension, size of aneurysm (4.9 mm ±1.0 in GOG vs 5.4 mm ±1.1 in POG, rs=−0.29, p=0.28), percentage receiving coiling or clipping, GCS motor score, procedure complications and general medical complications.

Conclusions

75% of patients’ aged ≥80 y with SAH had poor outcome. WFNS grade (I-III), higher GCS patients who did not need EVD had better outcome.

TM3-6 Symptomatic intracranial arachnoid cysts: a centre series

Objectives

To study the presentation, management and outcomes of symptomatic intracranial arachnoid cysts.

Design

Retrospective records review.

Subjects

All cases coded as intracranial cysts.

Methods

Patients admitted between Jan-2012 and Sep 2017. Of 56 cases, only 24 were arachnoid cysts. Median age 57 (range 8–81). Mean 49.1±5.0 years, 8 males and 16 females.

Results

Males were significantly younger (34.3±9.1 vs 56.5±5.2 year-old, p=0.03) and outnumbered females. Mean size of cysts was 58.8±6.1 mm (range 18.5–126 mm). Five were located frontally, one fronto-temporal and another fronto-parietal, two parietal and two parieto-occipital, two within third ventricle, one intraventricular, one supra sellar and one intra sellar while eight were posterior fossa. 12 patients had headache, five presented with cognitive and memory issues, five had visual problems, four with limb weakness and two had cerebellar signs. Eight had open fenestration, five endoscopic fenestration, four had aspiration with reservoir, two aspiration only, two marsupialisation, two received ICP monitor and one had no treatment. One reservoir was aspirated three times and another open fenestration had another surgical fenestration. Two had transient infection, two needed VP shunts and one had cysto-peritoneal shunt. mRS (0–2) improved significantly after the treatment (62.5% pre-surgery to 91.7% post-surgery, p=0.016).

Conclusions

Symptomatic arachnoid cysts are more common in young males. In the literature, the most common location is middle cranial fossa which is not the case in symptomatic arachnoid cysts as in our series. Although intervention is variable, they are associated with very good outcomes.

WM1-4 Decompressive craniectomy versus strokectomy for malignant middle cerebral artery (MCA) infarction

Objectives

To compare the outcomes of decompressive craniectomy (DC) with craniotomy and debulikng of stroke tissue (Strokectomy (SC)) for malignant MCA infarction at our centre.

Design

Retrospective records review.

Subjects

All Patients with malignant MCA infraction that underwent DC and SC between Jan 2012 and Sep 2017.

Methods

20 patients had DC (11F/9M, mean age 44.7±1.8 y) and four patients had SC (1F/3M) 51.5±5.9 7 y). Outcomes were assessed by Modified Rankin Scale (mRS) scores before surgery and at latest follow up (3–6 months). mRS was dichotomised as good (0–3) and poor (4–6). Craniotomy size was measured by antero-posterior (AP) diameter and compared between the groups.

Results

18 patients (90%) of the DC group had mRS 4–6 before surgery versus 100% in the SC group. Post-surgery 15 patients (75%) of the DC group had poor outcome with 7 mortalities (35%) in comparison to one patient (25%) with poor outcome in the SC group and no mortalities. The average craniotomy size in DC was 120.1±4.1 mm versus 85.5±13.1 mm in the SC, p=0.003 students t test). Six patients of the DC group underwent cranioplasty where two developed post-operative seizures. There was no significant difference in age, sex and side of craniotomy (7 Left/13 Right in DC vs 2 Left/2 Right in SC).

Conclusions

Strokectomy is comparable to decompressive craniectomy in outcomes without taking the extra risks and costs of cranioplasty. Further studies are required to promote this approach.

Evaluation of a single extraction test to estimate the human oral bioaccessibility of potentially toxic elements in soils: Towards more robust risk assessment

Intake of soil by children and adults is a major exposure pathway to contaminants including potentially toxic elements (PTEs). However, only the fraction of PTEs released in stomach and intestine are considered as bioaccessible and results from routine analyses of the total PTE content in soils, therefore, are not necessarily related to the degree of bioaccessibility. Experimental methods to determine bioaccessibility usually are time-consuming and relatively complicated in terms of analytical procedures which limits application in first tier assessments. In this study we evaluated the potential suitability of a recently developed single extract method (ISO-17586:2016) using dilute (0.43M) nitric acid (HNO₃) to mimic the bioaccessible fraction of PTEs in soils. Results from 204 soils from Portugal, Brazil and the Netherlands including all major soil types and a wide range of PTEs' concentrations showed that the extraction efficiency using 0.43M HNO₃ of Ba, Cd, Cu, Ni, Pb and Zn in soils is related to that of in vitro methods including the Simple Bioaccessibility Extraction Test (SBET) and Unified BARGE Method (UBM). Also, differences in the degree of bioaccessibility resulting from differences in parent material, geology and climate conditions did not affect the response of the 0.43M HNO₃ extraction which is a prerequisite to be able to compare results from different soils. The use of 0.43M HNO₃ as a first screening of bioaccessibility therefore offers a robust and representative way to be included in first tier standard soil tests to estimate the oral bioaccessibility.

CAPSULE

The single dilute (0.43M) nitric acid extraction can be used in first tier soil risk assessment to assess both geochemical reactivity and oral bioaccessibility of PTEs.

Epidemiologic Profile of Transplant Patients Treated by the Physiotherapy

Transplant candidates have advanced chronic disease, which often leads to muscular and respiratory impairment contributing to reduced quality of life and daily life activities, and these patients are therefore referred to physiotherapy service. Because of this, it is necessary to know the epidemiologic and functional profile for a better physiotherapeutic approach. Inpatients of kidney, liver, heart, lung and multivisceral transplantation programs were followed up for 1 year. A comparative analysis between groups was performed, taking into account hospital stay time and functional independence measure (FIM). In all, 157 patients (88 post-transplant) were evaluated, with mean age of 54 years, and 99 were men. Prevalence of transplantation included liver: 87 (56%); kidney: 51 (32%); heart: 10 (6%); lung: 8 (5%); multivisceral: 1 (1%). The average length of hospital stay was 23 days for kidney patients, 19 days for lung patients, 18 days for heart patients, 15 days for liver patients, and the 15 days for multivisceral patients. The mean of FIM score was 94 for heart patients; 95 for liver patients, 96 for kidney patients, 99 for lung patients, and 120 for multivisceral patients. The highest incidence of hospitalization was of liver patients, although renal patients had a longer time of hospitalization. FIM score was higher at hospital discharge, if compared with the values at the moment of evaluation, but through the comparison of FIM previous with FIM final scores, the patients still presented functional limitation at the time of hospital discharge. Specific protocols for each transplant group, focused on the improvement of the functionality, are necessary.

Removal and recovery of Critical Rare Elements from contaminated waters by living Gracilaria gracilis

The experiments performed in this work proved the ability of Gracilaria gracilis to concentrate and recover Critical Rare Elements (CRE) from contaminated waters. The importance of recycling these elements is related to their very limited sources in Nature and progressive use in technologies. Moreover, their mining exploitation has negative environmental impact, and recent studies point them as new emerging pollutants. To the best of our knowledge, this is the first report on the application of living macroalgae for the removal and recovery of CRE. G. gracilis (2.5gL^-1, fresh weight) was exposed to mono- and multi-element saline solutions of 500μgL^-1 of Y, Ce, Nd, Eu and La. Removal was up to 70% in 48h, with bioaccumulation following Elovich kinetic model. In multi-element solutions, selectivity was not observed although removal of lanthanides improved comparatively to single-element solutions. No mortality or adverse effect on growth was registered. The subsequent macroalgae digestion allowed collecting virtually 100% of all elements in a 300-fold more concentrated solution. The overall results suggest the application of living macroalgae as a simple and effective alternative technology for removing and recovering CRE from wastewaters, contributing to an improvement of water quality and CRE recycling.

Addressing the impact of mercury estuarine contamination in the European eel (Anguilla anguilla L., 1758) - An early diagnosis in glass eel stage based on erythrocytic nuclear morphology

The decline of the European eel (Anguilla anguilla L., 1758) population throughout Europe has been partially attributed to pollution. As glass eel estuarine migration may represent a considerable threat, the impact of mercury (Hg) contamination at this stage was evaluated through an in situ experiment (7days). Total Hg (tHg) bioaccumulation was evaluated concomitantly with erythrocytic nuclear morphology alterations: erythrocytic nuclear abnormalities assay (ENA), frequency of immature erythrocytes (IE) and the erythrocytic maturity index (EMI). The ENA results suggested a genotoxic pressure at the most contaminated sites, in line with the tHg increase. The EMI data, together with IE frequency, showed that fish exposed to high levels of Hg exhibited alterations of haematological dynamics, translated into an erythropoiesis increment. Despite the presence of these compensatory mechanisms, the present findings suggest a harmful impact of Hg on genome integrity at this early development stage, potentially affecting eels' condition and ultimately the population sustainability.

Highly efficient upconversion of Er3+ in Yb3+ codoped non-cytotoxic strontium lanthanum aluminate phosphor for low temperature sensors

Er³⁺ and Er³⁺/Yb³⁺ melilite-based SrLaAl₃O₇ (SLA) phosphors were synthesized by a facile Pechine method. The differences in emission intensities of ⁴I_13/2 → ⁴I_15/2 transition in NIR region when excited with Ar⁺ and 980 nm lasers were explained in terms of energy transfer mechanisms. Temperature and power dependence of upconversion bands in the visible region centered at 528, 548 and 660 nm pertaining to ²H_11/2, ⁴S_3/2 and ⁴F_9/2 → ⁴I_15/2 transitions were investigated. Fluorescence intensity ratio (FIR) technique was used to explore temperature sensing behaviour of the thermally coupled levels ²H_11/2/⁴S_3/2 of Er³⁺ ions in the phosphors within the temperature range 14–300 K and the results were extrapolated up to 600 K. Anomalous intensity trend observed in Er³⁺ doped SLA phosphor was discussed using energy level structure. Cytotoxicity of phosphors has been evaluated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay in Bluegill sunfish cells (BF-2). The non-cytotoxic nature and high sensitivity of the present phosphors pay a way for their use in vitro studies and provide potential interest as a thermo graphic phosphor at the contact of biological products.