British Society for Immunology and United Kingdom Primary Immunodeficiency Network (UKPIN) consensus guideline for the management of immunoglobulin replacement therapy

Currently, there is no guideline to support the use of immunoglobulin replacement therapy (IgRT) in primary and secondary immunodeficiency disorders in UK. The UK Primary Immunodeficiency Network (UK-PIN) and the British Society of Immunology (BSI) joined forces to address this need. Given the paucity of evidence, a modified Delphi approach was used covering statements for the initiation, monitoring, discontinuation of IgRT as well as home therapy programme. A group of six consultant immunologists and three nurse specialists created the statements, reviewed responses and feedback and agreed on final recommendations. This guideline includes 22 statements for initiation, 22 statements for monitoring, 11 statement for home therapy, and 19 statements for discontinuation of IgRT. Further areas of research are proposed to improve future delivery of care.

Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia

DESCRIPTION

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular malformations (VMs). These result in chronic bleeding, acute hemorrhage, and complications from shunting through VMs. The goal of the Second International HHT Guidelines process was to develop evidence-based consensus guidelines for the management and prevention of HHT-related symptoms and complications.

METHODS

The guidelines were developed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) framework and GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The guidelines expert panel included expert physicians (clinical and genetic) in HHT from 15 countries, guidelines methodologists, health care workers, health care administrators, patient advocacy representatives, and persons with HHT. During the preconference process, the expert panel generated clinically relevant questions in 6 priority topic areas. A systematic literature search was done in June 2019, and articles meeting a priori criteria were included to generate evidence tables, which were used as the basis for recommendation development. The expert panel subsequently convened during a guidelines conference to conduct a structured consensus process, during which recommendations reaching at least 80% consensus were discussed and approved.

RECOMMENDATIONS

The expert panel generated and approved 6 new recommendations for each of the following 6 priority topic areas: epistaxis, gastrointestinal bleeding, anemia and iron deficiency, liver VMs, pediatric care, and pregnancy and delivery (36 total). The recommendations highlight new evidence in existing topics from the first International HHT Guidelines and provide guidance in 3 new areas: anemia, pediatrics, and pregnancy and delivery. These recommendations should facilitate implementation of key components of HHT care into clinical practice.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Clinical Significance of Pulmonary Arteriovenous Malformation Reperfusion

The purpose of this study was to assess the clinical significance of reperfused pulmonary arteriovenous malformations (rPAVM) after embolization. This study is a retrospective review of all patients from a single HHT center who underwent pulmonary arteriovenous malformation (PAVM) embolization between January 1, 2006 and December 30, 2007. Clinical history, imaging findings (including reperfusion), and symptoms seen in the setting of PAVMs were reviewed both at the time of embolization and during the subsequent follow-up through December 30, 2013. During the 2-year treatment period, 101 patients underwent PAVM embolization. During the initial embolization, 27 patients were found to have reperfusion of a previously embolized PAVM. During the follow-up period, none of these patients had recurrence of the rPAVM. Three patients who underwent an embolization procedure for the first time at the initial procedure were subsequently found to have rPAVM during the follow-up period. This resulted in a total of 30 patients with rPAVMs. Eighteen (60%) of the 30 patients were found to be symptomatic at the time of presentation with rPAVM. However, 14 had at least one other significant PAVM at the time of diagnosis of reperfusion. Only two symptomatic patients had only rPAVM, both with mild manifestations. Two patients were excluded from the study as their symptoms were attributed to other medical comorbidities. The majority of symptomatic patients with rPAVM had additional PAVMs that required embolization. Neither of the symptomatic patients with an isolated rPAVM had severe manifestations.

Emergency readmissions to paediatric surgery and urology: The impact of inappropriate coding

Introduction In England, emergency readmissions within 30 days of hospital discharge after an elective admission are not reimbursed if they do not meet Payment by Results (PbR) exclusion criteria. However, coding errors could inappropriately penalise hospitals. We aimed to assess the accuracy of coding for emergency readmissions. Methods Emergency readmissions attributed to paediatric surgery and urology between September 2012 and August 2014 to our tertiary referral centre were retrospectively reviewed. Payment by Results (PbR) coding data were obtained from the hospital's Family Health Directorate. Clinical details were obtained from contemporaneous records. All readmissions were categorised as appropriately coded (postoperative or nonoperative) or inappropriately coded (planned surgical readmission, unrelated surgical admission, unrelated medical admission or coding error). Results Over the 24-month period, 241 patients were coded as 30-day readmissions, with 143 (59%) meeting the PbR exclusion criteria. Of the remaining 98 (41%) patients, 24 (25%) were inappropriately coded as emergency readmissions. These readmissions resulted in 352 extra bed days, of which 117 (33%) were attributable to inappropriately coded cases. Conclusions One-quarter of non-excluded emergency readmissions were inappropriately coded, accounting for one-third of additional bed days. As a stay on a paediatric ward costs up to £500 a day, the potential cost to our institution due to inappropriate readmission coding was over £50,000. Diagnoses and the reason for admission for each care episode should be accurately documented and coded, and readmission data should be reviewed at a senior clinician level.

The United Kingdom Primary Immune Deficiency (UKPID) Registry: report of the first 4 years' activity 2008-2012

This report summarizes the establishment of the first national online registry of primary immune deficency in the United Kingdom, the United Kingdom Primary Immunodeficiency (UKPID Registry). This UKPID Registry is based on the European Society for Immune Deficiency (ESID) registry platform, hosted on servers at the Royal Free site of University College, London. It is accessible to users through the website of the United Kingdom Primary Immunodeficiency Network (www.ukpin.org.uk). Twenty-seven centres in the United Kingdom are actively contributing data, with an additional nine centres completing their ethical and governance approvals to participate. This indicates that 36 of 38 (95%) of recognized centres in the United Kingdom have engaged with this project. To date, 2229 patients have been enrolled, with a notable increasing rate of recruitment in the past 12 months. Data are presented on the range of diagnoses recorded, estimated minimum disease prevalence, geographical distribution of patients across the United Kingdom, age at presentation, diagnostic delay, treatment modalities used and evidence of their monitoring and effectiveness.

A framework to aid adoption of automated rehabilitation devices into clinical practice: synthesising and Interpreting Language for Clinical Kinematics (SILCK)

The Synthesising and Interpreting Language for Clinical Kinematics (SILCK) is an informatic framework for developing software to control automated rehabilitation devices. It aids adoption of devices into rehabilitation practice, by bridging the gap between clinical practice and internal device operation. SILCK defines data entities and processes for capturing clinical observations of patients and their rehabilitation goals in formats which can be used to direct the tailoring of device parameters to the individual patient's needs.

Abstract PD08-02: Disparities in the Utilization of Reconstruction after Mastectomy: The California Teachers Study

Background: For breast cancer patients undergoing mastectomy, factors such as insurance status, race/ethnicity, age, and type of hospital influence whether post-mastectomy reconstruction (PMR) is performed. This study was undertaken to determine if additional patient variables and clinicopathologic features also influence the utilization of PMR using the California Teachers Study (CTS).

Methods: Patients were identified from the CTS, a cohort of approximately 133,000 female public school teachers and administrators, followed prospectively from 1995 forward to investigate exposures associated with incident cancer and other outcomes. All in situ and invasive breast cancers were identified through linkage with the California Cancer Registry, as well as with the California Office of Statewide Health Planning and Development (OSHPD) hospital discharge database to determine the rates of mastectomy with and without reconstruction. Patterns in PMR rates were examined by calendar year, age, race/ethnicity, type of insurance, type of hospital, tumor stage, body mass index (BMI), family history of breast cancer (FH), smoking history, physical activity, and prior breast implant status using a chi-square test. Univariable and multivariable-adjusted odds ratios (OR) with 95% confidence intervals (CI) were estimated for relative odds of immediate reconstruction vs. mastectomy only.

Results: During follow-up, 1,253 CTS participants with incident breast cancer underwent mastectomy with (N = 368) and without (N = 885) reconstruction. In multivariable stepwise logistic regression analyses, calendar year, age, type of insurance, tumor stage, and prior breast implant were statistically significantly associated with use of reconstruction. The proportion of patients undergoing immediate PMR increased from 21.8% during 1995–1999 to 26.4% during 2005–2009. A statistically significant dose-response was apparent between older age at surgery and decreased likelihood of post-mastectomy reconstruction (Ptrend&lt;0.001). Race/ethnicity was not significantly associated with the use of PMR because the majority of patients were non-Hispanic white (89.5%). Most participants either had private insurance (56.8%) or Medicare (42.4%); those with private insurance were twice as likely to undergo PMR compared to patients with Medicare (OR 2.23: 95%CI 1.25–4.00, p = 0.01). Compared to participants with in situ and stage I breast cancer combined, participants with stage II or stage III breast cancer had one-third to one-half lower odds of postmastectomy reconstruction relative to mastectomy only (ORstageII = 0.67, 95% CI = 0.49–0.90, p = 0.01; ORstageIII=0.47, 95% CI=0.29–0.77, p = 0.002). Participants with a prior history of a breast implant were 7 times more likely to undergo PMR than participants with no such history (OR 7.14: 95%CI 2.38–21.41, p &lt; 0.001).

Conclusions: In the CTS population, having a prior breast implant and lower tumor stage were additional variables associated with increased odds of PMR. This study validates previous studies which have shown that private insurance and younger age are associated with the use of reconstruction after mastectomy. Patient and health care provider education is warranted to ensure that all patients undergoing mastectomy are offered and have access to PMR.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD08-02.

Overlapping spectra of SMAD4 mutations in juvenile polyposis (JP) and JP-HHT syndrome

Juvenile polyposis (JP) and hereditary hemorrhagic telangiectasia (HHT) are clinically distinct diseases caused by mutations in SMAD4 and BMPR1A (for JP) and endoglin and ALK1 (for HHT). Recently, a combined syndrome of JP-HHT was described that is also caused by mutations in SMAD4. Although both JP and JP-HHT are caused by SMAD4 mutations, a possible genotype:phenotype correlation was noted as all of the SMAD4 mutations in the JP-HHT patients were clustered in the COOH-terminal MH2 domain of the protein. If valid, this correlation would provide a molecular explanation for the phenotypic differences, as well as a pre-symptomatic diagnostic test to distinguish patients at risk for the overlapping but different clinical features of the disorders. In this study, we collected 19 new JP-HHT patients from which we identified 15 additional SMAD4 mutations. We also reviewed the literature for other reports of JP patients with HHT symptoms with confirmed SMAD4 mutations. Our combined results show that although the SMAD4 mutations in JP-HHT patients do show a tendency to cluster in the MH2 domain, mutations in other parts of the gene also cause the combined syndrome. Thus, any mutation in SMAD4 can cause JP-HHT. Any JP patient with a SMAD4 mutation is, therefore, at risk for the visceral manifestations of HHT and any HHT patient with SMAD4 mutation is at risk for early onset gastrointestinal cancer. In conclusion, a patient who tests positive for any SMAD4 mutation must be considered at risk for the combined syndrome of JP-HHT and monitored accordingly.

Family history of haematopoietic malignancies and non-Hodgkin's lymphoma risk in the California Teachers Study

Family history of haematopoietic malignancies appears to be a risk factor for non-Hodgkin's lymphoma (NHL), but whether risk varies by family member's gender is unclear. Among 121 216 women participating in the prospective California Teachers Study, NHL risk varied by type of haematopoietic malignancy and gender of the relative.

Unanticipated discovery of vascular anomalies by hemodialysis catheter placement. Case report

This case report describes an unexpected finding post hemodialysis catheter placement in a child scheduled for living-relation renal transplant. Moreover, the unusual appearance of the catheter on a chest X-ray prompted further investigation of the patient's vascular anatomy, resulting in the discovery of an aberrant iliac artery course that significantly affected the surgical approach to this planned procedure.

Genetic aberrations and survival in plasma cell leukemia

Plasma cell leukemia (PCL) is an aggressive and rare hematological malignancy that originates either as primary disease (pPCL) or as a secondary leukemic transformation (sPCL) of multiple myeloma (MM). We report here the genetic aberrations and survival of 80 patients with pPCL or sPCL and make comparisons with 439 cases of MM. pPCL presents a decade earlier than sPCL (54.7 vs 65.3 years) and is associated with longer median overall survival (11.1 vs 1.3 months; P<0.001). 14q32 (IgH) translocations are highly prevalent in both sPCL and pPCL (82-87%); in pPCL IgH translocations almost exclusively involve 11q13 (CCND1), supporting a central etiological role, while in sPCL multiple partner oncogenes are involved, including 11q13, 4p16 (FGFR3/MMSET) and 16q23 (MAF), recapitulating MM. Both show ubiquitous inactivation of TP53 (pPCL 56%; sPCL 83%) by coding mutation or 17p13 deletion; complemented by p14ARF epigenetic silencing in sPCL (29%). Both show frequent N-RAS or K-RAS mutation. Poor survival in pPCL was predicted by MYC translocation (P=0.006). Survival in sPCL was consistently short. Overall pPCL and sPCL are different disorders with distinct natural histories, genetics and survival.

Prognostic factors for hyperdiploid-myeloma: effects of chromosome 13 deletions and IgH translocations

Chromosomal hyperdiploidy is the defining genetic signature in 40-50% of myeloma (MM) patients. We characterize hyperdiploid-MM (H-MM) in terms of its clinical and prognostic features in a cohort of 220 H-MM patients entered into clinical trials. Hyperdiploid-myeloma is associated with male sex, kappa immunoglobulin subtype, symptomatic bone disease and better survival compared to nonhyperdiploid-MM (median overall survival 48 vs 35 months, log-rank P = 0.023), despite similar response to treatment. Among 108 H-MM cases with FISH studies for common genetic abnormalities, survival is negatively affected by the existence of immunoglobulin heavy chain (IgH) translocations, especially those involving unknown partners, while the presence of chromosome 13 deletion by FISH did not significantly affect survival (median overall survival 50 vs 47 months, log-rank P = 0.47). Hyperdiploid-myeloma is therefore a unique genetic subtype of MM associated with improved outcome with distinct clinical features. The existence of IgH translocations but not chromosome 13 deletion by FISH negatively impacts survival and may allow further risk stratification of this population of MM patients.

Clinical and biological implication of defective p53 pathway in multiple myeloma (MM)

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Background: The p53 tumor suppressor is commonly inactivated by mutations. Even in tumors without mutations, there are defects in the response to p53 activation. In MM, the prognostic significance of p53 mutation is unknown, while there has been no systematic study of p53 function. We seek to address these issues in this study. Methods: p53 mutation was studied by conformation sensitive gel electrophoresis with primers encompassing exons 1 to 10 followed by sequencing of DNA fragments with altered electrophoretic pattern in newly diagnosed MM patients entered into ECOG E9486 trial where patients were randomized to receive variations of melphalan-based conventional chemotherapy (VBMCP). Fisher’s exact tests were used to compare variables between patients. Kaplan-Meier survival curves were compared using the log-rank test. To investigate p53 function, we analyzed the expression of p53, and 3 of its transcriptional targets, APAF1, p21 and MDM2, in a separate cohort of 15 normal plasma cells (PC), 14 MGUS, 13 smoldering myeloma (SMM) and 101 MM (73 new and 28 relapsed) from the Mayo Clinic who had gene expression profiling performed on the Affymetrix U133A chip (Santa Clara, Ca). Results: Two hundred and sixty-eight patients had enough materials for study and were included in the analysis. The prevalence of p53 mutation was 3% (n = 9). Five of the 9 patients (56%, p = 0.001) with mutations also had p53 deletion (studied by fluorescent in-situ hybridization) resulting in bi-allelic loss of p53. Soft tissue plasmacytomas (37% v 7%, p = 0.018), and among the common translocations, t(4;14) and t(14;16) (50% v 18%) were more common in patients with p53 mutations. Despite similar response to treatment, those with p53 mutation had very short OS (16.7 v 41.4 months, p < 0.001). There was induction of p53 expression in MGUS and SMM with concurrent induction of APAF1, p21 and MDM2 whereas loss of this pattern was frequent in MM (45% in new MM and 60% in relapse MM compared to 15% in MGUS/SMM (p = 0.03)). Conclusions: p53 mutations are relatively rare in newly diagnosed MM patients but portend a short survival. However, functional abnormalities of p53 are prevalent and may be important in progression from MGUS/SMM to MM.

[Table: see text]