Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN)

BACKGROUND

Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury.

METHODS

A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes.

DISCUSSION

The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia.

TRIAL REGISTRATION

ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

Dorsal Column Myelopathy Following Intrathecal Chemotherapy for Leukemia

PURPOSE/OBJECTIVE(S)

Intrathecal (IT) methotrexate (Mtx) and/or cytarabine (AraC) improve CNS disease control in patients (pts) with hematologic malignancies. There are increasing number of case reports of irreversible, primarily dorsal column myelopathy in pts treated with IT chemotherapy. By describing the largest case series of myelopathy following IT chemotherapy, we aim to raise awareness about this devastating albeit rare complication.

MATERIALS/METHODS

We retrospectively reviewed 25 pts with leukemia who developed paraplegia following IT chemotherapy between 2/2006 and 9/2021. Clinical/treatment characteristics, response, and toxicity were extracted from the medical records.

RESULTS

Seventeen pts (68%) were male, 16 had B-cell ALL (64%), 4 had AML (16%), 2 had CML (8%), 2 had T-ALL (8%), and 1 had BPDCN (4%). The median age at diagnosis was 38 years (IQR 30-59). All pts required systemic salvage treatment after induction chemotherapy with a median number of 3 regimens received (IQR 2-5.5). In total, the median number of IT treatments was 19 per pt (IQR 14-27). Most pts (84%, n = 21) received single agent IT Mtx alternating with single agent AraC. Fifteen pts (60%) received triple IT therapy with a median of 3 treatments (IQR 0-8). Prior to the onset of myelopathy, 10 pts (40%) received allogeneic SCT and 9 pts (36%) were treated with radiation therapy. Median follow-up from diagnosis was 1.9 yrs (IQR 1.3-4.1). Myelopathy was progressive and irreversible in all pts (n = 25); 84% (n = 21) experienced sensory loss, and all pts had extremity weakness. Symptoms were ascending in 11 pts (44%) and descending in 4 pts (16%). Irreversible bowel/bladder incontinence developed in 12 pts (48%). CSF analysis at the time of symptom onset was negative for leukemia cells in most pts (n = 21, 84%) and showed malignant cells in 4 pts (16%). CSF studies showed elevated protein in 21 pts (84%). Myelin basic protein was elevated in all 13 assessed pts. On T2 weighted spinal MRI, all pts had enhancement of the dorsal columns, including 80% of pts with this dorsal column abnormality reported at the time of the study and 20% of pts (n = 5) with the dorsal enhancement noted retrospectively. Due to concern for occult disease, 20 pts (80%) received additional CNS-directed therapy after symptom onset. Twenty-two pts (88%) died at last follow-up. The time between neurological symptom onset and death was a median 3.5 months (IQR 2.6 and 5). Three pts (12%) are alive with paraplegia at a median of 4.4 years from symptom onset.

CONCLUSION

Dorsal column myelopathy is a rare but devastating condition that can occur after IT chemotherapy in heavily pre-treated leukemia pts. T2 weighted spinal MRI can be helpful in the evaluation of pts that present with unexplained weakness and sensory changes. We recommend delaying additional CNS-directed therapy until work-up to rule out alternative etiologies is complete. Future strategies are desperately needed to address this irreversible treatment complication.

Estimating Local Cellular Density in Glioma Using MR Imaging Data

BACKGROUND AND PURPOSE

Increased cellular density is a hallmark of gliomas, both in the bulk of the tumor and in areas of tumor infiltration into surrounding brain. Altered cellular density causes altered imaging findings, but the degree to which cellular density can be quantitatively estimated from imaging is unknown. The purpose of this study was to discover the best MR imaging and processing techniques to make quantitative and spatially specific estimates of cellular density.

MATERIALS AND METHODS

We collected stereotactic biopsies in a prospective imaging clinical trial targeting untreated patients with gliomas at our institution undergoing their first resection. The data included preoperative MR imaging with conventional anatomic, diffusion, perfusion, and permeability sequences and quantitative histopathology on biopsy samples. We then used multiple machine learning methodologies to estimate cellular density using local intensity information from the MR images and quantitative cellular density measurements at the biopsy coordinates as the criterion standard.

RESULTS

The random forest methodology estimated cellular density with R 2 = 0.59 between predicted and observed values using 4 input imaging sequences chosen from our full set of imaging data (T2, fractional anisotropy, CBF, and area under the curve from permeability imaging). Limiting input to conventional MR images (T1 pre- and postcontrast, T2, and FLAIR) yielded slightly degraded performance (R2 = 0.52). Outputs were also reported as graphic maps.

CONCLUSIONS

Cellular density can be estimated with moderate-to-strong correlations using MR imaging inputs. The random forest machine learning model provided the best estimates. These spatially specific estimates of cellular density will likely be useful in guiding both diagnosis and treatment.

Imaging-Based Algorithm for the Local Grading of Glioma

BACKGROUND AND PURPOSE

Gliomas are highly heterogeneous tumors, and optimal treatment depends on identifying and locating the highest grade disease present. Imaging techniques for doing so are generally not validated against the histopathologic criterion standard. The purpose of this work was to estimate the local glioma grade using a machine learning model trained on preoperative image data and spatially specific tumor samples. The value of imaging in patients with brain tumor can be enhanced if pathologic data can be estimated from imaging input using predictive models.

MATERIALS AND METHODS

Patients with gliomas were enrolled in a prospective clinical imaging trial between 2013 and 2016. MR imaging was performed with anatomic, diffusion, permeability, and perfusion sequences, followed by image-guided stereotactic biopsy before resection. An imaging description was developed for each biopsy, and multiclass machine learning models were built to predict the World Health Organization grade. Models were assessed on classification accuracy, Cohen κ, precision, and recall.

RESULTS

Twenty-three patients (with 7/9/7 grade II/III/IV gliomas) had analyzable imaging-pathologic pairs, yielding 52 biopsy sites. The random forest method was the best algorithm tested. Tumor grade was predicted at 96% accuracy (κ = 0.93) using 4 inputs (T2, ADC, CBV, and transfer constant from dynamic contrast-enhanced imaging). By means of the conventional imaging only, the overall accuracy decreased (89% overall, κ = 0.79) and 43% of high-grade samples were misclassified as lower-grade disease.

CONCLUSIONS

We found that local pathologic grade can be predicted with a high accuracy using clinical imaging data. Advanced imaging data improved this accuracy, adding value to conventional imaging. Confirmatory imaging trials are justified.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

The DiPEP study: an observational study of the diagnostic accuracy of clinical assessment, D-dimer and chest x-ray for suspected pulmonary embolism in pregnancy and postpartum

Objective

To identify clinical features associated with pulmonary embolism (PE) diagnosis and determine the accuracy of decision rules and D‐dimer for diagnosing suspected PE in pregnant/postpartum women

Design

Observational cohort study augmented with additional cases.

Setting

Emergency departments and maternity units at eleven prospectively recruiting sites and maternity units in the United Kingdom Obstetric Surveillance System (UKOSS)

Population

324 pregnant/postpartum women with suspected PE and 198 pregnant/postpartum women with diagnosed PE

Methods

We recorded clinical features, elements of clinical decision rules, D‐dimer measurements, imaging results, treatments and adverse outcomes up to 30 days

Main outcome measures

Women were classified as having PE on the basis of imaging, treatment and adverse outcomes by assessors blind to clinical features and D‐dimer. Primary analysis was limited to women with conclusive imaging to avoid work‐up bias. Secondary analyses included women with clinically diagnosed or ruled out PE.

Results

The only clinical features associated with PE on multivariate analysis were age (odds ratio 1.06; 95% confidence interval 1.01–1.11), previous thrombosis (3.07; 1.05–8.99), family history of thrombosis (0.35; 0.14–0.90), temperature (2.22; 1.26–3.91), systolic blood pressure (0.96; 0.93–0.99), oxygen saturation (0.87; 0.78–0.97) and PE‐related chest x‐ray abnormality (13.4; 1.39–130.2). Clinical decision rules had areas under the receiver‐operator characteristic curve ranging from 0.577 to 0.732 and no clinically useful threshold for decision‐making. Sensitivities and specificities of D‐dimer were 88.4% and 8.8% using a standard threshold and 69.8% and 32.8% using a pregnancy‐specific threshold.

Conclusions

Clinical decision rules and D‐dimer should not be used to select pregnant or postpartum women with suspected PE for further investigation. Clinical features and chest x‐ray appearances may have counter‐intuitive associations with PE in this context.

Tweetable abstract

Clinical decision rules and D‐dimer are not helpful for diagnosing pregnant/postpartum women with suspected PE

Clinical decision rules and D‐dimer are not helpful for diagnosing pregnant/postpartum women with suspected PE.

Normosmic idiopathic hypogonadotrophic hypogonadism due to a rare KISS1R gene mutation

Hypogonadotrophic hypogonadism is due to impaired or reduced gonadotrophin secretion from the pituitary gland. In the absence of any anatomical or functional lesions of the pituitary or hypothalamic gland, the hypogonadotrophic hypogonadism is referred to as idiopathic hypogonadotrophic hypogonadism (IHH). We present a case of a young lady born to consanguineous parents who was found to have IHH due to a rare gene mutation.

Neurological Presentations of AIDS-when to Test for HIV

Nine of 122 patients dead from AIDS in central London presented with neurological disease, confirmed pathologically in seven. Seven had no other major systemic manifestations. AIDS needs to be considered in the differential diagnosis of meningitis, dementia, diffuse and focal encephalopathies, brainstem syndromes, myelopathy, visual failure and peripheral nerve syndromes. As AIDS becomes more widespread there will be an increasing need for diagnostic HIV testing in many neurological syndromes.

Parasuicide in Central London 1984-1988

Experience of a central London unit dedicated to the care of patients following parasuicide between 1984 and 1988 is reviewed. There were 1160 admissions, which accounted for 11% of all acute adult medical admissions. The female to male ratio was 1.3, with a peak rate for females below 25 years and for males between 20 and 35. Unemployment was found to be a risk factor for parasuicide in men. Benzodiazepines were the most frequently used drug in parasuicide (35%), followed by paracetamol (13%) and aspirin (9%).

Abstract P6-03-04: Central nervous system miliary metastasis in breast cancer patients

Background: Little is known regarding central nervous system (CNS) miliary metastasis (MiM), which was first described as “carcinomatous encephalitis” by Madow and Alpers in 1951. The majority of reported cases arise from primary lung and gastrointestinal adenocarcinomas, with occasional melanoma primaries and one reported case in breast cancer. Moreover, clinicopathologic correlates, disease outcomes and prognostic factors in these patients are poorly understood. Although identified most frequently on neuroimaging, radiographic criteria to objectively diagnose MiM do not exist. In this analysis of patients with brain metastasis from primary breast cancer, we propose objective, stringent radiographic criteria for CNS MiM diagnosis and identify clinicopathologic factors contributing to disease outcomes.

Methods: Using a prospectively maintained electronic database, 1,002 female patients diagnosed with brain metastasis from primary breast cancer between 2000 and 2015 were identified. Only patients with neuroimaging available for direct review (CT or MRI) were included. Our radiographic criteria for MiM diagnosis were: 1) ≥20 metastatic lesions per image slice on ≥2 noncontiguous image slices by MRI, or 2) ≥10 lesions per image slice on ≥2 noncontiguous image slices by CT, and 3) MiM lesions were required to be present bilaterally and in both the supra- and infratentorial compartments. These criteria were established upon direct review of all neuroimaging by a neuroradiologist. Number and anatomic distribution of metastatic lesions were the patterns best observed to identify cases of CNS MiM on case review; lesion size was not a reliable pattern for MiM identification. Log rank tests were used for statistical analyses.

Results: Using stringent criteria, 486 patients were included in this analysis. Twenty patients with MiM were identified (4.1%). Ten patients were diagnosed with MiM at initial brain metastasis presentation; 10 developed MiM after known brain metastasis. Biomarker based subtype distribution was as follows: HR-/HER2- (TNBC) (n=8), HR+/HER2+ (n=3), HR+/HER2- (n=4), HR-/HER2+ (n=4), unknown (n=1).

Table 1: Disease Outcomes Based on Biomarker SubtypeBiomarker SubtypeMedian Time to MiM (months) (p=0.104)Median Survival after MiM (months) (p=0.008)TNBC (n=8)32.3 (12.1-132.5)1.8 (0.5-4.0)HR+/HER2+ (n=3)44.2 (33.2-71.5)10.8 (10.2-13.3)HR+/HER2- (n=4)110.2 (23.0-156.0)4.8 (0.8-9.8)HR-/HER2+ (n=4)27.1 (3.7-39.4)4.0 (1.8-5.0)All* (n=20)37.4 (3.7-156.0)3.7 (0.4-12.3)Key: BM: Brain metastasis; * Includes 1 patient with unknown subtype.

Conclusions: Reports of MiM consist overwhelmingly of lung and gastrointestinal adenocarcinoma primaries. This retrospective, observational study is the first to establish that CNS MiM occurs in breast cancer with an incidence of roughly 4%. Review of an additional 1,600 patient charts is underway, but this preliminary study is the first to identify clinicopathologic correlates and determine disease outcomes in patients with MiM; it is also the first to propose stringent radiographic criteria for the diagnosis of CNS MiM, and further updated data will be presented at the meeting.

Citation Format: Bashour SI, Ibrahim NK, Schomer DF, Colen RR, Sawaya R, Suki D, Rao G, Murthy RK, Moulder SL, Abugabal Y, Hess KR, Fuller GN. Central nervous system miliary metastasis in breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-03-04.

Glioblastoma stem cells exploit the αvβ8 integrin-TGFβ1 signaling axis to drive tumor initiation and progression

Glioblastoma (GBM) is a primary brain cancer that contains populations of stem-like cancer cells (GSCs) that home to specialized perivascular niches. GSC interactions with their niche influence self-renewal, differentiation and drug resistance, although the pathways underlying these events remain largely unknown. Here, we report that the integrin αvβ8 and its latent transforming growth factor β1 (TGFβ1) protein ligand have central roles in promoting niche co-option and GBM initiation. αvβ8 integrin is highly expressed in GSCs and is essential for self-renewal and lineage commitment in vitro. Fractionation of β8^high cells from freshly resected human GBM samples also reveals a requirement for this integrin in tumorigenesis in vivo. Whole-transcriptome sequencing reveals that αvβ8 integrin regulates tumor development, in part, by driving TGFβ1-induced DNA replication and mitotic checkpoint progression. Collectively, these data identify the αvβ8 integrin-TGFβ1 signaling axis as crucial for exploitation of the perivascular niche and identify potential therapeutic targets for inhibiting tumor growth and progression in patients with GBM.

IGFBP2 potentiates nuclear EGFR-STAT3 signaling

Insulin-like growth factor binding protein 2 (IGFBP2) is a pleiotropic oncogenic protein that has both extracellular and intracellular functions. Despite a clear causal role in cancer development, the tumor-promoting mechanisms of IGFBP2 are poorly understood. The contributions of intracellular IGFBP2 to tumor development and progression are also unclear. Here we present evidence that both exogenous IGFBP2 treatment and cellular IGFBP2 overexpression lead to aberrant activation of EGFR, which subsequently activates STAT3 signaling. Furthermore, we demonstrate that IGFBP2 augments the nuclear accumulation of EGFR to potentiate STAT3 transactivation activities, via activation of the nuclear EGFR signaling pathway. Nuclear IGFBP2 directly influences the invasive and migratory capacities of human glioblastoma cells, providing a direct link between intracellular (and particularly nuclear) IGFBP2 and cancer hallmarks. These activities are also consistent with the strong association between IGFBP2 and STAT3-activated genes derived from the TCGA database for human glioma. A high level of all 3 proteins (IGFBP2, EGFR and STAT3) was strongly correlated with poorer survival in an independent patient dataset. These results identify a novel tumor-promoting function for IGFBP2 of activating EGFR/STAT3 signaling and facilitating EGFR accumulation in the nucleus, thereby deregulating EGFR signaling by 2 distinct mechanisms. As targeting EGFR in glioma has been relatively unsuccessful, this study suggests that IGFBP2 may be a novel therapeutic target.

Dynamic contrast-enhanced perfusion processing for neuroradiologists: model-dependent analysis may not be necessary for determining recurrent high-grade glioma versus treatment effect

BACKGROUND AND PURPOSE

Dynamic contrast-enhanced perfusion MR imaging has proved useful in determining whether a contrast-enhancing lesion is secondary to recurrent glial tumor or is treatment-related. In this article, we explore the best method for dynamic contrast-enhanced data analysis.

MATERIALS AND METHODS

We retrospectively reviewed 24 patients who met the following conditions: 1) had at least an initial treatment of a glioma, 2) underwent a half-dose contrast agent (0.05-mmol/kg) diagnostic-quality dynamic contrast-enhanced perfusion study for an enhancing lesion, and 3) had a diagnosis by pathology within 30 days of imaging. The dynamic contrast-enhanced data were processed by using model-dependent analysis (nordicICE) using a 2-compartment model and model-independent signal intensity with time. Multiple methods of determining the vascular input function and numerous perfusion parameters were tested in comparison with a pathologic diagnosis.

RESULTS

The best accuracy (88%) with good correlation compared with pathology (P = .005) was obtained by using a novel, model-independent signal-intensity measurement derived from a brief integration beginning after the initial washout and by using the vascular input function from the superior sagittal sinus for normalization. Modeled parameters, such as mean endothelial transfer constant > 0.05 minutes(-1), correlated (P = .002) but did not reach a diagnostic accuracy equivalent to the model-independent parameter.

CONCLUSIONS

A novel model-independent dynamic contrast-enhanced analysis method showed diagnostic equivalency to more complex model-dependent methods. Having a brief integration after the first pass of contrast may diminish the effects of partial volume macroscopic vessels and slow progressive enhancement characteristic of necrosis. The simple modeling is technique- and observer-dependent but is less time-consuming.

Pilot trial of sunitinib therapy in patients with von Hippel-Lindau disease

BACKGROUND

Von Hippel-Lindau (VHL) disease induces vascular neoplasms in multiple organs. We evaluated the safety and efficacy of sunitinib in VHL patients and examined the expression of candidate receptors in archived tissue.

METHODS

Patients with VHL were given four cycles of 50 mg sunitinib daily for 28 days, followed by 14 days off. Primary end point was toxicity. Modified RECIST were used for efficacy assessment. We evaluated 20 archival renal cell carcinomas (RCCs) and 20 hemangioblastomas (HBs) for biomarker expression levels using laser-scanning cytometry (LSC).

RESULTS

Fifteen patients were treated. Grade 3 toxicity included fatigue in five patients. Dose reductions were needed in 10 patients. Eighteen RCC and 21 HB lesions were evaluable. Six of the RCCs (33%) responded partially, versus none of the HBs (P = 0.014). LSC revealed that mean levels of phosphorylated vascular endothelial growth factor receptor-2 were lower in HB than in RCC endothelium (P = 0.003) and mean phosphorylated fibroblast growth factor receptor substrate-2 (pFRS2) levels were higher in HB (P = 0.003).

CONCLUSIONS

Sunitinib treatment in VHL patients showed acceptable toxicity. Significant response was observed in RCC but not in HB. Greater expression of pFRS2 in HB tissue than in RCC raises the hypothesis that treatment with fibroblast growth factor pathway-blocking agents may benefit patients with HB.

Multifocal epithelioid glioblastoma mimicking cerebral metastasis: case report

OBJECTIVE

Epithelioid glioblastoma is a rare morphologic subtype of glioblastoma that closely mimics metastatic carcinoma or metastatic melanoma histologically. All previous case reports of this unusual glioblastoma variant have been solitary lesions. We report here the first case to our knowledge of multifocal epithelioid glioblastoma mimicking cerebral metastasis.

CLINICAL PRESENTATION

A 67-year-old man with a prior history of mycosis fungoides, a common form of cutaneous T-cell lymphoma, presented with memory loss and impaired peripheral vision. Two discrete brain lesions highly suspicious for metastases were identified by magnetic resonance imaging (MRI).

INTERVENTION

The patient underwent two separate craniotomies; both lesions were successfully resected in toto with an excellent post-surgical outcome.

CONCLUSION

Epithelioid glioblastoma is one of the rarest morphologic subtypes of glioblastoma. Here we describe the first case to our knowledge of multifocal epithelioid glioblastoma that convincingly mimicked a secondary metastatic process. Multifocal epithelioid glioblastoma should be included in the differential diagnosis of patients who present with multiple discrete brain lesions. An attempt at gross total resection is recommended when anatomically feasible for definitive histopathological diagnosis and to improve progression free survival of patients who present with similarly ambiguous and potentially misleading multiple lesions.

An audit of the quality of care of traumatic brain injury at a busy regional hospital in South Africa

Access to care by a dedicated neurosurgical unit is limited in the developing world, and the vast majority of patients who sustain a head injury are managed by general surgeons. Prevention of secondary brain injury is paramount. While the principles of management are relatively straightforward, delivering this care may be difficult. This audit looks at the spectrum of head injuries presenting to a busy regional hospital and attempts to measure the quality of care offered to these patients.

PATIENTS AND METHODS

The audit includes three separate sections. The first is a prospective audit of all patients with a traumatic brain injury presenting to the Accident and Emergency (AE) department at Edendale Hospital, Pietermaritzburg, over a 2-month period. The next two sub-audits consist of a random review of referral letters and AE clerking notes to assess the quality of care received by these patients. A total of 25 referral letters and 28 AE inpatient notes were randomly chosen for review and compared with agreed standardised markers for quality of care.

RESULTS

Over the 2 months October and November 2007, 150 patients with a head injury were seen in the AE department. Of these 117 were male. A total of 76 were discharged home after investigation with a head injury warning chart, 49 were admitted to the general wards, 11 were admitted to the surgical intensive care unit, 10 were referred to the neurosurgical centre in Durban, and 4 died in the AE department. Of the 10 who needed advanced neurosurgical care, 3 required urgent burr-holes before referral. One of these patients died. All the remaining 9 patients who were transferred to the neurosurgery unit survived. The referral letters and AE clerking notes revealed major deficits.

CONCLUSION

Traumatic brain injury is a common problem. Only a small subset of patients require specialised neurosurgical care. Although many patients with intracranial injury can tolerate the delay associated with transfer, some cases are acute and urgent intervention by non-neurosurgeons is needed. Prevention of secondary brain injury is poorly understood and not prioritised. This situation needs to be improved. The introduction of formalised standard referral and management sheets may help to improve care.

Treatment of VHL patients with sunitinib: Clinical observations and translational studies

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Background: Von Hippel Lindau (VHL) disease induces vascular lesions in multiple organs. Surgical intervention is the treatment of choice. Effective, safe systemic therapy will greatly improve the quality of life of these individuals. Methods: Patients with genetically confirmed VHL were enrolled on an IRB approved trial. Eligibility criteria included retinal angiomas, hemangioblastomas (HBs) measuring at least 5mm, renal cell carcinoma (RCC) 1 to 3 cm and pancreatic neuroendocrine tumors (NETs) 1 to 3 cm. Patients received sunitinib 50mg/day for 28 days/14 days off for four cycles. Scans were performed at baseline, and after cycles two and four. A separate set of 20 formalin-fixed paraffin embedded HBs and 20 RCCs were used for laser scanning cytometry (LSC) analysis of total and phospho vascular endothelial growth factor receptor (pVEGFR) and phospho platelet derived growth factor receptor (pPDGFR) levels in tumor endothelium. Results: Twelve patients were evaluable for response and toxicity. Eight had RCCs, nine had CNS lesions, and three had pancreatic NETs. Tumor size reduction was seen in 16/19 evaluable RCC lesions (95%CI 0.60, 0.97), 3/5 NETs (95%CI 0.15, 0.95) and 6/19 HBs (95%CI 0.13, 0.57). Two patients came off study for treatment related side effects, one patient progressed on study, and two patients did not complete the scheduled course of therapy. LSC analysis demonstrated significantly lower phospho VEGFR levels in HBs when compared with RCC. The mean (SD) of pVEGFR levels in log-transformation were 11.27 (0.49) and 11.75 (0.37) for HBs and RCC respectively (p = 0.003). The mean (SD) of pVEGFR to VEGFR ratio was .21 (0.12) versus 0.37 (0.43), for HBs and RCC respsectively (p = 0.043). Conclusions: Sunitinib treatment of patients with VHL resulted in consistent decrease of RCC and NET tumor size. The discrepant response to sunitinib in RCC and HBs may be explained by differential dependence on VEGFR activation in tumor endothelium.

[Table: see text]

Dental injury during seizures associated with juvenile myoclonic epilepsy

BACKGROUND

Patients can sustain injuries during seizures and the pattern and type of injury (eg, tongue biting) can be a useful silent witness in the diagnosis of seizures. In addition, the seizure type potentially influences the type of injury.

METHODS

Patients with dental injury were identified from the Gloucestershire Epilepsy Database (n = 1673). These patients' notes were reviewed and the following data collected: demographic data; seizure types and age of onset; injury; EEG; and MRI.

RESULTS

14 people had dental injuries: 10 incisors (seven had >1 incisor) and five other teeth. Eight had juvenile myoclonic epilepsy (JME), two other primary generalised epilepsy and four focal onset epilepsy. Compared with the rest of the database population (JME; n = 81) there was a highly significant association of dental injury with JME (p<0.0001).

CONCLUSIONS

Incisor injury is rare but appears to be associated with JME in patients with epilepsy, presumably reflecting the pattern of seizure onset. This pattern of injury should prompt consideration of this diagnosis. It is hoped that recognition of this can both facilitate earlier diagnosis and help educate patients to protect their teeth.