[Management of the cut-out of various forms of osteosynthesis for proximal femoral fractures]

Proximal femoral fractures are a common type of injury in older people. A cut-out of the femoral neck screw after initial osteosynthetic surgery of proximal femoral fractures is a frequent and feared complication. There could be different causes for cut-outs. Osteoporosis and necrosis of the femoral head could be biological reasons for cut-outs; however, mechanical factors, such as reduction, implant position and morphological characteristics of fractures also have a major influence on the cut-out rate. The treatment of the cut-out is often complex and depends on the destruction of the femoral head and the acetabulum. If the bone quality is still good and the head is not completely destroyed, a reosteosynthesis can be performed. Conversion to an endoprosthetic replacement is often the only possibility. Endoprosthetic treatment is often complex and associated with a high morbidity.

Atomic diffusion in liquid gallium and gallium-nickel alloys probed by quasielastic neutron scattering and molecular dynamic simulations

The atomic mobility in liquid pure gallium and a gallium-nickel alloy with 2 at% of nickel is studied experimentally by incoherent quasielastic neutron scattering. The integral diffusion coefficients for all-atom diffusion are derived from the experimental data at different temperatures. DFT-basedab-initiomolecular dynamics (MD) is used to find numerically the diffusion coefficient of liquid gallium at different temperatures, and numerical theory results well agree with the experimental findings at temperatures below 500 K. Machine learning force fields derived fromab-initiomolecular dynamics (AIMD) overestimate within a small 6% error the diffusion coefficient of pure gallium within the genuine AIMD. However, they better agree with experiment for pure gallium and enable the numerical finding of the diffusion coefficient of nickel in the considered melted alloy along with the diffusion coefficient of gallium and integral diffusion coefficient, that agrees with the corresponding experimental values within the error bars. The temperature dependence of the gallium diffusion coefficientDGa(T)follows the Arrhenius law experimentally for all studied temperatures and below 500 K also in the numerical simulations. However,DGa(T)can be well described alternatively by an Einstein-Stokes dependence with the metallic liquid viscosity following the Arrhenius law, especially for the MD simulation results at all studied temperatures. Moreover, a novel variant of the excess entropy scaling theory rationalized our findings for gallium diffusion. Obtained values of the Arrhenius activation energies are profoundly different in the competing theoretical descriptions, which is explained by different temperature-dependent prefactors in the corresponding theories. The diffusion coefficient of gallium is significantly reduced (at the same temperature) in a melted alloy with natural nickel, even at a tiny 2 at% concentration of nickel, as compared with its pure gallium value. This highly surprising behavior contradicts the existing excess entropy scaling theories and opens a venue for further research.

The statistical analysis plan for the unification of treatments and interventions for tinnitus patients randomized clinical trial (UNITI-RCT)

BACKGROUND

Tinnitus is a leading cause of disease burden globally. Several therapeutic strategies are recommended in guidelines for the reduction of tinnitus distress; however, little is known about the potentially increased effectiveness of a combination of treatments and personalized treatments for each tinnitus patient.

METHODS

Within the Unification of Treatments and Interventions for Tinnitus Patients project, a multicenter, randomized clinical trial is conducted with the aim to compare the effectiveness of single treatments and combined treatments on tinnitus distress (UNITI-RCT). Five different tinnitus centers across Europe aim to treat chronic tinnitus patients with either cognitive behavioral therapy, sound therapy, structured counseling, or hearing aids alone, or with a combination of two of these treatments, resulting in four treatment arms with single treatment and six treatment arms with combinational treatment. This statistical analysis plan describes the statistical methods to be deployed in the UNITI-RCT.

DISCUSSION

The UNITI-RCT trial will provide important evidence about whether a combination of treatments is superior to a single treatment alone in the management of chronic tinnitus patients. This pre-specified statistical analysis plan details the methodology for the analysis of the UNITI trial results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04663828 . The trial is ongoing. Date of registration: December 11, 2020. All patients that finished their treatment before 19 December 2022 are included in the main RCT analysis.

Self-Assessment of Having COVID-19 With the Corona Check Mhealth App

At the beginning of the COVID-19 pandemic, with a lack of knowledge about the novel virus and a lack of widely available tests, getting first feedback about being infected was not easy. To support all citizens in this respect, we developed the mobile health app Corona Check. Based on a self-reported questionnaire about symptoms and contact history, users get first feedback about a possible corona infection and advice on what to do. We developed Corona Check based on our existing software framework and released the app on Google Play and the Apple App Store on April 4, 2020. Until October 30, 2021, we collected 51,323 assessments from 35,118 users with explicit agreement of the users that their anonymized data may be used for research purposes. For 70.6% of the assessments, the users additionally shared their coarse geolocation with us. To the best of our knowledge, we are the first to report about such a large-scale study in this context of COVID-19 mHealth systems. Although users from some countries reported more symptoms on average than users from other countries, we did not find any statistically significant differences between symptom distributions (regarding country, age, and sex). Overall, the Corona Check app provided easily accessible information on corona symptoms and showed the potential to help overburdened corona telephone hotlines, especially during the beginning of the pandemic. Corona Check thus was able to support fighting the spread of the novel coronavirus. mHealth apps further prove to be valuable tools for longitudinal health data collection.

[E-scooter, e-bike and bicycle injuries in the same period-A prospective analysis of a level 1 trauma center]

BACKGROUND

The actual number of accidents in e‑scooter drivers in Germany seems to be significantly higher than the current figures from the Statistisches Bundesamt suggest. This epidemiological study examines e‑scooter injuries and compares them with e‑bike and bicycle injuries.

OBJECTIVE

In order to create a comparable database on the dangers of e‑scooters, e‑bikes and bicycles, the typical injury patterns were analyzed and prevention options derived from them.

MATERIAL AND METHODS

All accidents involving e‑scooters, e‑bikes and bicycles that were presented via the university emergency room of a level 1 trauma center between 15 June 2019 and 31 October 2020 were prospectively investigated.

RESULTS

In our study, 68 accidents in e‑scooter drivers were included, of which only 11.8% (n = 8) were recorded by the police. Significantly more of them were male than female (p = 0.032) with a mean age of 31.1 (±13) years. At the same time, we registered 34 accidents in e‑bike riders and 356 in cyclists. In all three groups, most injuries occurred to the head, followed by injuries to the upper extremities. Significantly more e‑scooter drivers had an ISS ≥ 16 than in the group of injured cyclists (p = 0.016). E‑scooter riders who had an accident had a significantly longer length of stay in hospital, than e‑bike riders (p = 0.003) and cyclists (p = 0.001), 52.9% (n = 18) of e‑bike riders and 53.3% (n = 113) cyclists wore a helmet, compared to only 1.5% (n = 1) of e‑scooter riders. The most common cause of accidents among e‑bike riders (17.7%; n = 6) and cyclists (10.4%; n = 37) was slipping away on tram rails, while for e‑scooter riders it was colliding with a curb (7.4%; n = 5).

CONCLUSION

The three patient collectives examined showed different causes and profiles of injuries. The reasons for an increased proportion of seriously injured people compared to cyclists are electromobility, driving under the influence of alcohol and inadequate wearing of a helmet on e‑scooters when head injuries dominate. 73.5% (n = 50) of the e‑scooter accidents recorded by us were not registered by the police and therefore do not appear in the current statistics of the statistisches Bundesamt. As a result, a much higher number of e‑scooter accidents can be assumed. Preventive measures could include the introduction of compulsory helmets, a higher number of traffic controls and the expansion of bike tracks.

Pilot study of a smartphone-based tinnitus therapy using structured counseling and sound therapy: A multiple-baseline design with ecological momentary assessment

Tinnitus affects a considerable part of the population and develops into a severe disorder in some sufferers. App-based interventions are able to provide low-threshold, cost-effective, and location-independent care for tinnitus patients. Therefore, we developed a smartphone app combining structured counseling with sound therapy and conducted a pilot study to evaluate treatment compliance and symptom improvement (trial registration: DRKS00030007). Outcome variables were Ecological Momentary Assessment (EMA) measured tinnitus distress and loudness and Tinnitus Handicap Inventory (THI) at baseline and final visit. A multiple-baseline design with a baseline phase (only EMA) followed by an intervention phase (EMA and intervention) was applied. 21 patients with chronic tinnitus (≥ 6 months) were included. Overall compliance differed between modules (EMA usage: 79% of days, structured counseling: 72%, sound therapy: 32%). The THI score improved from baseline to final visit indicating a large effect (Cohens d = 1.1). Tinnitus distress and loudness did not improve significantly from baseline phase to the end of intervention phase. However, 5 of 14 (36%) improved clinically meaningful in tinnitus distress (ΔDistress ≥ 10) and 13 of 18 (72%) in THI score (ΔTHI ≥ 7). The positive relationship between tinnitus distress and loudness weakened over the course of the study. A trend but no level effect for tinnitus distress could be demonstrated by a mixed effect model. The improvement in THI was strongly associated with the improvement scores in EMA of tinnitus distress (r = -0.75; 0.86). These results indicate that app-based structured counseling combined with sound therapy is feasible, has an impact on tinnitus symptoms and reduces distress for several patients. In addition, our data suggest that EMA could be used as a measurement tool to detect changes in tinnitus symptoms in clinical trials as has already been shown in other areas of mental health research.

PL01.5.A Towards modernizing intraoperative histopathological assessment in brain and spinal tumors - Comparison of the novel Stimulated Raman Histology with conventional H&E staining

Background

By intraoperative analysis of fresh frozen sections, neuropathologists provide important information of different brain and spinal tumors to the neurosurgeon during surgery. This facilitates characterization of these tumors intraoperatively to optimize the surgical strategy and patient management. However, preparation and staining are time consuming using conventional techniques of intraoperative fresh frozen section. Stimulated Raman Histology (SRH) was introduced as novel technique providing high-resolution digital images of unprocessed tissue samples directly in the operating room comparable to conventional histopathological images. Additionally, SRH images are fast and easily accessible by neuropathologists. Recently, first data showed promising results on the accuracy and feasibility of SRH in comparison to conventional H&E staining.

Material and Methods

In a time period of 4 months, patients with different brain or spinal tumors who underwent neurosurgical resection or open/stereotactic biopsy at the Dept. of Neurosurgery, Medical University Vienna were included in this study. Tumor tissue samples were collected intraoperatively whenever safely possible for analysis with SRH. Subsequently, unprocessed tissue samples were scanned by SRH, and intraoperative histopathological images were created directly in the operating room within a few minutes. All collected tissue samples were then sent for routine neuropathological workup. In an overall analysis, SRH images and H&E staining of all patients were analyzed separately by two board certified neuropathologists. Information on age, localization and suspected diagnosis was provided in each case in order to simulate the situation of intraoperative fresh frozen section. In a next step the technical feasibility and diagnostic accuracy of SRH was calculated.

Results

In this study, tissue samples of 95 patients who underwent neurosurgical resection or open/stereotactic biopsy of different brain and spinal tumors were collected intraoperatively and analyzed by SRH. In total, 31 gliomas, 30 meningiomas, 19 metastases, 7 neurinomas and 8 rare tumors were analyzed. In the present study the use of SRH was technically feasible in all cases and could be easily integrated in the neurosurgical workflow to provide rapid digital histopathological images for the analyzing neuropathologists. According to our data, SRH provided high diagnostic accuracy (>95%) in the investigated different brain and spinal tumors.

Conclusion

Based on our preliminary data the technical use of SRH is feasible and showed a high rate of diagnostic accuracy in a large series of different brain and spinal tumors. By using this promising technique, we intend to modernize intraoperative histopathological assessment by providing rapid digital images of brain and spinal tumors to optimize the management of these patients.

The Impact of Coping Styles and Gender on Situational Coping: An Ecological Momentary Assessment Study With the mHealth Application TrackYourStress

The aim of this study was to investigate the impact of different coping styles on situational coping in everyday life situations and gender differences. An ecological momentary assessment study with the mobile health app TrackYourStress was conducted with 113 participants. The coping styles Positive Thinking, Active Stress Coping, Social Support, Support in Faith, and Alcohol and Cigarette Consumption of the Stress and Coping Inventory were measured at baseline. Situational coping was assessed by the question “How well can you cope with your momentary stress level” over 4 weeks. Multilevel models were conducted to test the effects of the coping styles on situational coping. Additionally, gender differences were evaluated. Positive Thinking (p = 0.03) and Active Stress Coping (p = 0.04) had significant positive impacts on situational coping in the total sample. For women, Social Support had a significant positive effect on situational coping (p = 0.046). For men, Active Stress Coping had a significant positive effect on situational coping (p = 0.001). Women had higher scores on the SCI scale Social Support than men (p = 0.007). These results suggest that different coping styles could be more effective in daily life for women than for men. Taking this into account, interventions tailored to users’ coping styles might lead to better coping outcomes than generalized interventions.

Geriatric Proximal Femur Fractures During the Covid-19 Pandemic - Fewer Cases, But More Comorbidities

Background:

The COVID-19 pandemic is challenging healthcare systems worldwide. This study examines geriatric patients with proximal femur fractures during the COVID-19 pandemic, shifts in secondary disease profile, the impact of the pandemic on hospitalization and further treatment.

Methods:

In a retrospective monocentric study, geriatric proximal femur fractures treated in the first six months of 2020 were analyzed and compared with the same period of 2019. Pre-traumatic status (living in a care home, under supervision of a legal guardian), type of trauma, accident mechanism, geriatric risk factors, associated comorbidities, time between hospitalization and surgery, inpatient time and post-operative further treatment of 2 groups of patients, aged 65-80 years (Group 1) and 80+ years (Group 2) were investigated.

Results:

The total number of patients decreased (70 in 2019 vs. 58 in 2020), mostly in Group 1 (25 vs. 16) while the numbers in Group 2 remained almost constant (45 vs. 42). The percentage of patients with pre-existing neurological conditions rose in 2020. This corresponded to an increase in patients under legal supervision (29.3%) and receiving pre-traumatic care in a nursing home (14.7%). Fractures were mostly caused by minor trauma in a home environment. In 2020, total number of inpatient days for Group 2 was lower compared to Group 1 (p = 0.008). Further care differed between the years: fewer Group 1 patients were discharged to geriatric therapy (69.6% vs. 25.0%), whereas in Group 2 the number of patients discharged to a nursing home increased.

Conclusions:

Falling by elderly patients is correlated to geriatric comorbidities, consequently there was no change in the case numbers in this age group. Strategic measures to avoid COVID-19 infection in hospital setting could include reducing the length of hospital stays by transferring elderly patients to a nursing home as soon as possible and discharging independent, mobile patients to return home.

UNITI Mobile-EMI-Apps for a Large-Scale European Study on Tinnitus

More and more observational studies exploit the achievements of mobile technology to ease the overall implementation procedure. Many strategies like digital phenotyping, ecological momentary assessments or mobile crowdsensing are used in this context. Recently, an increasing number of intervention studies makes use of mobile technology as well. For the chronic disorder tinnitus, only few long-running intervention studies exist, which use mobile technology in a larger setting. Tinnitus is characterized by its heterogeneous patient's symptom profiles, which complicates the development of general treatments. In the UNITI project, researchers from different European countries try to unify existing treatments and interventions to cope with this heterogeneity. One study arm (UNITI Mobile) exploits mobile technology to investigate newly implemented interventions types, especially within the pan-European setting. The goals are to learn more about the validity and usefulness of mobile technology in this context. Furthermore, differences among the countries shall be investigated. Practically, two native intervention apps have been developed for UNITI and the mobile study arm, which pose features not presented so far in other apps of the authors. Along the implementation procedure, it is discussed whether these features might leverage similar types of studies in future. Since instruments like the mHealth evidence reporting and assessment checklist (mERA), developed by the WHO mHealth technical evidence review group, indicate that aspects shown for UNITI Mobile are important in the context of health interventions using mobile phones, our findings may be of a more general interest and are therefore being discussed in the work at hand.

Corona Health-A Study- and Sensor-Based Mobile App Platform Exploring Aspects of the COVID-19 Pandemic

Physical and mental well-being during the COVID-19 pandemic is typically assessed via surveys, which might make it difficult to conduct longitudinal studies and might lead to data suffering from recall bias. Ecological momentary assessment (EMA) driven smartphone apps can help alleviate such issues, allowing for in situ recordings. Implementing such an app is not trivial, necessitates strict regulatory and legal requirements, and requires short development cycles to appropriately react to abrupt changes in the pandemic. Based on an existing app framework, we developed Corona Health, an app that serves as a platform for deploying questionnaire-based studies in combination with recordings of mobile sensors. In this paper, we present the technical details of Corona Health and provide first insights into the collected data. Through collaborative efforts from experts from public health, medicine, psychology, and computer science, we released Corona Health publicly on Google Play and the Apple App Store (in July 2020) in eight languages and attracted 7290 installations so far. Currently, five studies related to physical and mental well-being are deployed and 17,241 questionnaires have been filled out. Corona Health proves to be a viable tool for conducting research related to the COVID-19 pandemic and can serve as a blueprint for future EMA-based studies. The data we collected will substantially improve our knowledge on mental and physical health states, traits and trajectories as well as its risk and protective factors over the course of the COVID-19 pandemic and its diverse prevention measures.

Meeting the UK Government's prevention agenda: primary care practitioners can be trained in skills to prevent disease and support self-management

Aims:

The NHS Long Term Plan has a prevention focus and ambition to support patients to self-manage disease through improving health behaviours. An essential requirement of self-management is behaviour change, but many practitioners have not been trained in skills to support behaviour change. ‘Healthy Conversation Skills’ (HCS) training was developed at the University of Southampton for this purpose. This article reports on a pilot study that aimed to assess the feasibility of primary care practitioners adopting HCS in their routine practice. It describes their experiences and level of competence post-training.

Methods:

Health Education England (Wessex) commissioned HCS training for 18 primary care practitioners. Fifteen of these practitioners were subsequently observed in their consultations at one or two time points; face-to-face semi-structured, reflective feedback interviews were conducted immediately following the observations. Practitioners’ HCS competence was assessed from the observations and interviews using a previously developed and published coding rubric. The interview data were analysed thematically to understand practitioners’ experiences of using the new skills.

Results:

Practitioners demonstrated competence in embedding the skills into their routine practice following HCS training. They reflected on how patients liked being asked questions, the usefulness of setting SMARTER (Specific, Measured, Action-oriented, Realistic, Timed, Evaluated and Reviewed) goals and the power of listening. They could also identify facilitators of skill use and ways to overcome challenges such as patients with competing priorities and organisational constraints. They found the skills valuable as a way of empowering patients to make changes to manage their own health.

Conclusions:

HCS are acceptable to primary care practitioners, can be readily adopted into their routine consultations and are a helpful strategy for supporting patients to make changes. HCS training has the potential to be a sustainable, scalable and effective way of contributing to the prevention agenda by supporting disease self-management, and hence of addressing today’s epidemic of lifestyle-related conditions.

Towards a unification of treatments and interventions for tinnitus patients: The EU research and innovation action UNITI

Tinnitus is the perception of a phantom sound and the patient's reaction to it. Although much progress has been made, tinnitus remains a scientific and clinical enigma of high prevalence and high economic burden, with an estimated prevalence of 10%-20% among the adult population. The EU is funding a new collaborative project entitled "Unification of Treatments and Interventions for Tinnitus Patients" (UNITI, grant no. 848261) under its Horizon 2020 framework. The main goal of the UNITI project is to set the ground for a predictive computational model based on existing and longitudinal data attempting to address the question of which treatment or combination of treatments is optimal for a specific patient group based on certain parameters. Clinical, epidemiological, genetic and audiological data, including signals reflecting ear-brain communication, as well as patients' medical history, will be analyzed making use of existing databases. Predictive factors for different patient groups will be extracted and their prognostic relevance validated through a Randomized Clinical Trial (RCT) in which different patient groups will undergo a combination of tinnitus therapies targeting both auditory and central nervous systems. From a scientific point of view, the UNITI project can be summarized into the following research goals: (1) Analysis of existing data: Results of existing clinical studies will be analyzed to identify subgroups of patients with specific treatment responses and to identify systematic differences between the patient groups at the participating clinical centers. (2) Genetic and blood biomarker analysis: High throughput Whole Exome Sequencing (WES) will be performed in well-characterized chronic tinnitus cases, together with Proximity Extension Assays (PEA) for the identification of blood biomarkers for tinnitus. (3) RCT: A total of 500 patients will be recruited at five clinical centers across Europe comparing single treatments against combinational treatments. The four main treatments are Cognitive Behavioral Therapy (CBT), hearing aids, sound stimulation, and structured counseling. The consortium will also make use of e/m-health applications for the treatment and assessment of tinnitus. (4) Decision Support System: An innovative Decision Support System will be implemented, integrating all available parameters (epidemiological, clinical, audiometry, genetics, socioeconomic and medical history) to suggest specific examinations and the optimal intervention strategy based on the collected data. (5) Financial estimation analysis: A cost-effectiveness analysis for the respective interventions will be calculated to investigate the economic effects of the interventions based on quality-adjusted life years. In this paper, we will present the UNITI project, the scientific questions that it aims to address, the research consortium, and the organizational structure.

Bioactive glass S53P4 vs. autologous bone graft for filling defects in patients with chronic osteomyelitis and infected non-unions - a single center experience

Introduction: The goals of osteomyelitis therapy are successful control of infection and reconstruction of the bone. The gold standard for filling defects is the autologous bone graft. Bioactive glass S53P4 is an inorganic bone substitute. We compared the outcome of using bioactive glass (BAG) versus autologous bone graft (AB) in patients with infected non-union. Methods: Patients with chronic osteomyelitis and infected non-union who received either bioactive glass or autologous bone grafts between 2013 and 2017 were analyzed retrospectively. The primary endpoint was successful control of infection during follow-up. Secondary endpoints were bone healing, functional outcome, and occurrence of complications. Results: Eighty-three patients were analyzed (BAG n=51, AB n=32). Twenty-one patients experienced reinfection (BAG n=15, 29 %; AB n=6, 19 %). Seventy-eight patients achieved full weight bearing (BAG n=47, 92 %; AB n=31, 97 %). Sixty-four patients had complete bone healing at the end of the follow-up period (BAG n=39, 77 %; AB n=25, 78 %). There were no significant differences between the groups with respect to the primary or secondary endpoints. Patients with multidrug-resistant pathogens had a significantly higher rate of incomplete bone healing (p=0.033) and a 3-fold higher risk of complications in both groups. Conclusions: Bioactive glass appears to be a suitable bone substitute not only for successful control of infection and defect filling but also for bone healing in cases of infected non-union. In our study, bioactive glass was neither superior nor inferior to autologous bone graft with regard to the primary and secondary endpoints. Further studies with larger numbers of patients are required.

Improving pregnant women's diet and physical activity behaviours: the emergent role of health identity

Background

Women who gain too much weight in pregnancy are at increased risk of disease and of having children with increased risk. Interventions to improve health behaviours are usually designed for a general population of pregnant women, and trial outcomes show an average impact that does not represent the differences between individuals. To inform the development of future interventions, this study explored the factors that influenced women’s diet and physical activity during pregnancy and aimed to identify the needs of these women with regards to lifestyle support.

Methods

Women who completed a trial of vitamin D supplementation and nurse support in pregnancy were invited to take part in an interview. Seventeen women were interviewed about their lifestyles during pregnancy, the support they had, and the support they wanted. Interview transcripts were coded thematically and analysed to understand the factors that influenced the diets and physical activity levels of these women and their engagement with resources that could provide support.

Results

Women identified barriers to eating well or being physically active, and pregnancy-specific issues like nausea and pain were common. Women’s interest in maintaining a healthy lifestyle and their engagement with lifestyle support was related to the extent to which they self-identified as healthy people. Health-disengaged women were disinterested in talking about their lifestyles while health-focused women did not feel that they needed extra support. Women between these ends of the ‘health identity’ spectrum were interested in improving their health, and were able to identify barriers as well as sources of support.

Conclusions

Lifestyle interventions in pregnancy should be adapted to meet the needs of individuals with different health identities, and encouraging a change in health identity may be one way of supporting sustained change in health behaviours.

Chemical chaperones reverse early suppression of regulatory circuits during unfolded protein response in B cells from common variable immunodeficiency patients

B cells orchestrate pro-survival and pro-apoptotic inputs during unfolded protein response (UPR) to translate, fold, sort, secrete and recycle immunoglobulins. In common variable immunodeficiency (CVID) patients, activated B cells are predisposed to an overload of abnormally processed, misfolded immunoglobulins. Using highly accurate transcript measurements, we show that expression of UPR genes and immunoglobulin chains differs qualitatively and quantitatively during the first 4 h of chemically induced UPR in B cells from CVID patients and a healthy subject. We tested thapsigargin or tunicamycin as stressors and 4-phenylbutyrate, dimethyl sulfoxide and tauroursodeoxycholic acid as chemical chaperones. We found an early and robust decrease of the UPR upon endoplasmic reticulum (ER) stress in CVID patient cells compared to the healthy control consistent with the disease phenotype. The chemical chaperones increased the UPR in the CVID patient cells in response to the stressors, suggesting that misfolded immunoglobulins were stabilized. We suggest that the AMP-dependent transcription factor alpha branch of the UPR is disturbed in CVID patients, underlying the observed expression behavior.

Abstract P4-01-07: A comprehensive liquid biopsy in patients undergoing neoadjuvant therapy

Background: Precision medicine is revolutionizing breast cancer (BC) care. Comprehensive liquid biopsies are a tool for personalized care in patients with locally advanced breast cancer (LABC). Identifying robust biomarkers as part of a comprehensive liquid biopsy to predict response to treatment is of immense clinical interest.

Methods: After obtaining IRB approval, serial blood samples were collected from patients with LABC undergoing neoadjuvant therapy. Paired biopsies were collected prior to treatment and were sent to Foundation Medicine for next-generation sequencing (NGS). We used a sized-base microfilter technology to capture circulating tumor cells (CTCs) and circulating cancer associated fibroblasts (cCAFs). Patients with one or more CTCs or cCAFs were deemed positive for these tests. Additionally, in collaboration with Foundation Medicine, we extracted circulating tumor DNA (ctDNA) and we analyzed it using the FoundationACT platform. Patients with a detectable genomic alteration in their plasma were considered as having a positive ctDNA test. Our primary objective is to determine if a comprehensive liquid biopsy can serve as a prognostic marker of pathologic complete response (pCR).

Results: For this analysis we describe our findings in the initial blood draw of the first 18 patients enrolled. The mean age is 54 years (38-70). All patients who had their tumors sequenced had a detectable mutation. Consistent with the findings of others, we found TP53 mutations to be the most prevalent at 83.3%. We found that 44% of patients had ctDNA, 68.4% had cCAFs and 78.9% had CTCs. Many patients also had clusters of cells, consisting of one cell type, or co-clusters, consisting of both. 38.9% had CTC clusters, 16.7% had cCAF clusters and 16.7% had co-clusters (CTCs and cCAFs together). Some patients with CTCs did not have cCAFs and vice versa. The number of CTCs and cCAFS did not correlate with stage of disease or receptor status.

Conclusions: We describe a comprehensive liquid biopsy combining a sized-based microfilter technology for CTC and cCAFs identification and the FoundationACT platform for ctDNA analysis is feasible and these biomarkers can be detected in patients with LABC prior to the initiation of neoadjuvant therapy. Our study is accruing rapidly, and we will update our results with the longitudinal collection and the prognostic value of a comprehensive liquid biopsy at the time of the meeting.

Citation Format: Sandoval Leon AC, Medina Saenz K, Miller P, Benson A, Calfa C, Mahtani R, Slingerland J, Perez A, Vogel C, Valdes-Albini F, El-Ashry D, Lippman M. A comprehensive liquid biopsy in patients undergoing neoadjuvant therapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-07.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Implications of Nondifferential Misclassification on Estimates of Attributable Risk

Objectives: Only the effects of isolated nondifferential misclassification of exposure or disease on the estimates of attributable risk have been discussed in the literature. The aim of this paper is to broaden the spectrum of scenarios for which implications of misclassification are available.

Methods: For this purpose, a matrix-based approach allowing a comprehensive, unified analysis of various structures of misclassification is introduced. The relative bias or – in the situation of covariate misclassification – the relative adjustment are presented for the different misclassification scenarios.

Results: Under nondifferential misclassification of exposure or disease, the attributable risk is biased towards the null with the only exception of perfect sensitivity of exposure classification or perfect specificity of disease classification both leading to an unbiased attributable risk. From these two marginal effects, the consequences of simultaneous nondifferential independent misclassification of exposure and disease on the attributable risk are derived in the matrix-based approach. Misclassification of a dichotomous covariate leads to partial adjustment.

Conclusions: To a large extent, the results for the attributable risk are in accordance with the well-known results for the relative risk. The algebraic differences between the two risk measures, however, make it necessary to repeat the methodological considerations for the attributable risk.

Abstract P6-11-03: A phase 2 open-label study of lucitanib in patients (pts) with FGF aberrant metastatic breast cancer (MBC)

BACKGROUND: Lucitanib is a potent, oral antiangiogenic tyrosine kinase inhibitor of Vascular Endothelial Growth Factor Receptors 1-3 (VEGFR1-3), Platelet-Derived Growth Factor Receptors alpha and beta (PDGFRα/β), and Fibroblast Growth Factor Receptors 1-3 (FGFR1-3). FGF aberrancies (amplification of FGFR1,or 11q[amplicon containing FGF ligands 3, 4, and 19]), are genomic alterations observed in over 20% of breast cancer pts and promote cancer proliferation and survival.

METHODS: MBC pts who had received at least 1 metastatic line of therapy were randomized 1:1 to 10 or 15 mg QD of lucitanib. Stratification was based on local assessment of FGF aberrancy; pts with both FGFR1 and 11q-amplified tumors were stratified as FGFR1 amplified. Central confirmation of FGFR1 or 11q amplification was done using Abbott FISH probes (FGFR1 or 11q copy number ≥ 6 and a ratio of FGFR1 or 11q to centromere ≥ 2). Investigator-assessed progression-free survival (PFS) was the primary endpoint. Secondary endpoints included objective response rate (ORR) per RECIST 1.1, disease control rate (DCR), duration of response (DR), and incidence of treatment-emergent adverse events (TEAE).

RESULTS: Enrollment completed in 3/2016; 178 pts that received at least 1 dose of lucitanib are included in this analysis (baseline characteristics in Table 1). Due to grade 3 hypertension in the 15 mg group (46% vs 37% in 10 mg group), enrollment to the 15 mg group was halted. Overall, most pts (97%) experienced at least 1 TEAE, with the most frequently (≥ 30%) occurring events being hypertension (73%), fatigue (48%), nausea (43%), hypothyroidism (40%), and headache (33%). Grade ≥ 3 TEAEs occurred in 66% of pts, with hypertension as the most frequent event (40%) followed by proteinuria and hyponatremia (both 6%). AEs were manageable with dose interruption or reduction, with approximately 8% of pts ending treatment due to an AE. Current median PFS is 3.5 mos (95% CI 2.8-4.6; range 0.62-12.95) and 2.6 mos (95% CI 1.8-2.9; range 0.82-18.87) respectively for the 10 mg and 15 mg treatment groups. No differences in clinical activity were observed by treatment group, FGF aberrancy, hormone receptor or HER2 status. Of the 168 evaluable pts, confirmed ORR was 3%; overall DCR was 27% (32% for pts in the 10 mg group compared to 20% for the 15 mg group); overall mean (standard deviation) DR of 3.3 (1.8) mos.

Baseline Characteristics 10 mg QD15 mg QD N=109N=69Age (years)Median5653Range27-8227-80SexFemale109 (100%)67 (97%)Male02 (3%)ECOG PSmissing5 (5%)2 (3%)051 (47%)30 (43%)153 (49%)37 (54%)Number of prior anticancer therapies in the metastatic setting&gt; 332 (29%)21 (30%)3-648 (44%)32 (46%)&gt; 629 (27%)16 (23%)Endocrine/HER2 statusmissing7 (6%)1 (1%)ER+ or PR+74 (68%)50 (73%)HER2+12 (11%)7 (10%)TNBC16 (15%)11 (16%)FGFR aberrancyFGFR1 amplified54 (49%)29 (42%)11q amplified31 (28%)24 (35%)FGFR1 and 11q amplified13 (12%)9 (13%)FGFR1 and 11q non-amplified11 (10%)7 (10%)

CONCLUSION: At 10 mg QD, lucitanib has modest activity with manageable toxicity in this heavily pretreated pt population. Future clinical development for lucitanib may focus on alternative biomarkers to identify sensitive tumors and rational combinations with other anti-cancer drugs.

Citation Format: Mayer IA, Arteaga CL, Nanda R, Miller KD, Jhaveri K, Brufsky AM, Rugo H, Yardley DA, Vahdat LT, Sadeghi S, Audeh MW, Rolfe L, Litten J, Knox A, Raponi M, Tankersley C, Isaacson J, Wride K, Morganstern DE, Vogel C, Connolly RM, Gradishar WJ, Patel R, Pusztai L, Abu-Khalaf M. A phase 2 open-label study of lucitanib in patients (pts) with FGF aberrant metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-11-03.

The relationship between maternal self-efficacy, compliance and outcome in a trial of vitamin D supplementation in pregnancy

In a randomised controlled trial of vitamin D during pregnancy, we demonstrated that women with lower self-efficacy were more likely to experience practical problems with taking the trial medication and that this was associated with lower compliance and achieved 25(OH)-vitamin D concentrations.

INTRODUCTION

The relationship between self-efficacy (the belief that one can carry out a behaviour), compliance with study protocol and outcome was explored within a randomised, double-blind, placebo-controlled trial of vitamin D supplementation in pregnancy.

METHODS

In the Maternal Vitamin D Osteoporosis Study (MAVIDOS) trial, women with circulating plasma 25(OH)-vitamin D of 25-100 nmol/l in early pregnancy were randomised to either 1000 IU cholecalciferol/day or matched placebo from 14 weeks until delivery. Circulating 25(OH)-vitamin D concentrations were assessed at 14 and 34 weeks' gestation. A sequential sub-sample completed Schwarzer's General Self-Efficacy Scale at 14 and 34 weeks and the Problematic Experiences of Therapy Scale at 34 weeks. Women were interviewed about their experiences of the trial and interview transcripts analysed thematically.

RESULTS

In 203 women, those with higher self-efficacy were less likely to experience practical problems taking the study medication (odds ratio (OR) 0.81 (95 % confidence interval (CI) 0.69-0.95), p = 0.01). Over half reported practical problems associated with poorer compliance with the protocol requiring women to take the medication daily. Compliance in women who experienced practical problems was 94 % compared with 98 % for those with no problems (p < 0.001). Poorer compliance was also associated with lower concentrations of 25(OH)-D in late pregnancy in the treatment group (β = 0.54 nmol/l (95 % CI 0.18-0.89), p = 0.003). Thematic analysis suggested common difficulties were remembering to take the medication every day and swallowing the large capsules.

CONCLUSIONS

These findings suggest that differences in self-efficacy influence trial outcomes. Such information may help clinicians anticipate responses to routine vitamin D supplementation in pregnancy and identify those who may need more support to comply.

TRIAL REGISTRATION

ISRCTN82927713, registered 11/04/2008.

Current practice of diabetes education in children and adolescents with type 1 diabetes in Germany and Austria: analysis based on the German/Austrian DPV database

BACKGROUND

Diabetes education of patients and/or parents is an essential part of diabetes care with effects on diabetes outcome. The objective of our study was to describe the current practice of diabetes education in Germany and Austria with regard to training frequency, patient age, migration background and diabetes therapy in a large cohort of pediatric patients with diabetes mellitus type 1 (T1DM).

METHODS

We analyzed data from pediatric T1DM patients with diabetes training in 2013 and complete data available for treatment year in the multicenter Diabetes Patienten Verlaufsdokumentation (DPV) registry using sas 9.4.

RESULTS

In 2013 21 871 pediatric patients with T1DM were documented [52.4% male, age: 12.70 (9.35-15.30) yr (median (interquartile range)], diabetes duration: 3.80 (1.45-7.00) yr, migration background: 21.4%, twice daily injections: 5.5%, multiple daily injections: 52.5%, insulin-pump therapy: 42%. Of these 32.31% were trained in 2013. Younger patients and their parents were trained more intensely and more frequently as inpatients compared with older patients (0-6 vs. 6-12 and 12-18 yr: teaching units: 13.07 vs. 12.05 and 9.79; inpatient: 79% vs. 72% and 70%). There was also a difference in training frequency with regard to migration background. Severe hypoglycemia or ketoacidosis resulted in intensification of training (4.0 vs. 2.0%; 7.8 vs. 3.1%). Centre-specific education tools were used frequently alone or in combination with published, standardized education programs.

CONCLUSION

Training frequency was highest in younger patients and during the first year of diabetes. Acute complications resulted in more frequent diabetes training, indicating that currently many education sessions take place in consequence to these complications.

Preconception and pregnancy: opportunities to intervene to improve women's diets and lifestyles

Recently, large-scale trials of behavioural interventions have failed to show improvements in pregnancy outcomes. They have, however, shown that lifestyle support improves maternal diet and physical activity during pregnancy, and can reduce weight gain. This suggests that pregnancy, and possibly the whole periconceptional period, represents a 'teachable moment' for changes in diet and lifestyle, an idea that was made much of in the recent report of the Chief Medical Officer for England. The greatest challenge with all trials of diet and lifestyle interventions is to engage people and to sustain this engagement. With this in mind, we propose a design of intervention that aims simultaneously to engage women through motivational conversations and to offer access to a digital platform that provides structured support for diet and lifestyle change. This intervention design therefore makes best use of learning from the trials described above and from recent advances in digital intervention design.

Progression-free survival as surrogate end point for overall survival in clinical trials of HER2-targeted agents in HER2-positive metastatic breast cancer

BACKGROUND

The gold standard end point in randomized clinical trials in metastatic breast cancer (MBC) is overall survival (OS). Although therapeutics have been approved based on progression-free survival (PFS), its use as a primary end point is controversial. We aimed to assess to what extent PFS may be used as a surrogate for OS in randomized trials of anti-HER2 agents in HER2+ MBC.

METHODS

Eligible trials accrued HER2+ MBC patients in 1992-2008. A correlation approach was used: at the individual level, to estimate the association between investigator-assessed PFS and OS using a bivariate model and at the trial level, to estimate the association between treatment effects on PFS and OS. Correlation values close to 1.0 would indicate strong surrogacy.

RESULTS

We identified 2545 eligible patients in 13 randomized trials testing trastuzumab or lapatinib. We collected individual patient data from 1963 patients and retained 1839 patients from 9 trials for analysis (7 first-line trials). During follow-up, 1072 deaths and 1462 progression or deaths occurred. The median survival time was 22 months [95% confidence interval (CI) 21-23 months] and the median PFS was 5.7 months (95% CI 5.5-6.1 months). At the individual level, the Spearman correlation was equal to ρ = 0.67 (95% CI 0.66-0.67) corresponding to a squared correlation value of 0.45. At the trial level, the squared correlation between treatment effects (log hazard ratios) on PFS and OS was provided by R(2) = 0.51 (95% CI 0.22-0.81).

CONCLUSIONS

In trials of HER2-targeted agents in HER2+ MBC, PFS moderately correlates with OS at the individual level and treatment effects on PFS correlate moderately with those on overall mortality, providing only modest support for considering PFS as a surrogate. PFS does not completely substitute for OS in this setting.

Greater access to fast-food outlets is associated with poorer bone health in young children

SUMMARY

A healthy diet positively influences childhood bone health, but how the food environment relates to bone development is unknown. Greater neighbourhood access to fast-food outlets was associated with lower bone mass among infants, while greater access to healthy speciality stores was associated with higher bone mass at 4 years.

INTRODUCTION

Identifying factors that contribute to optimal childhood bone development could help pinpoint strategies to improve long-term bone health. A healthy diet positively influences bone health from before birth and during childhood. This study addressed a gap in the literature by examining the relationship between residential neighbourhood food environment and bone mass in infants and children.

METHODS

One thousand one hundred and seven children participating in the Southampton Women's Survey, UK, underwent measurement of bone mineral density (BMD) and bone mineral content (BMC) at birth and 4 and/or 6 years by dual-energy X-ray absorptiometry (DXA). Cross-sectional observational data describing food outlets within the boundary of each participant's neighbourhood were used to derive three measures of the food environment: the counts of fast-food outlets, healthy speciality stores and supermarkets.

RESULTS

Neighbourhood exposure to fast-food outlets was associated with lower BMD in infancy (β = -0.23 (z-score): 95% CI -0.38, -0.08) and lower BMC after adjustment for bone area and confounding variables (β = -0.17 (z-score): 95% CI -0.32, -0.02). Increasing neighbourhood exposure to healthy speciality stores was associated with higher BMD at 4 and 6 years (β = 0.16(z-score): 95% CI 0.00, 0.32 and β = 0.13(z-score): 95% CI -0.01, 0.26 respectively). The relationship with BMC after adjustment for bone area and confounding variables was statistically significant at 4 years, but not at 6 years.

CONCLUSIONS

The neighbourhood food environment that pregnant mothers and young children are exposed may affect bone development during early childhood. If confirmed in future studies, action to reduce access to fast-food outlets could have benefits for childhood development and long-term bone health.

Color Doppler sonographic dynamic tissue perfusion measurement demonstrates significantly reduced cortical perfusion in children with diabetes mellitus type 1 without microalbuminuria and apparently healthy kidneys

MOTIVATION

With respect to the devastating consequences of the increasing prevalence of diabetes mellitus, the main reason for end stage renal disease and dialysis in industrialized countries, and the very limited diagnostic and therapeutic possibilities to predict, monitor and prevent diabetic nephropathy (DN), new concepts for early recognition and quantification of the prevailing microvascular changes in DN are urgently needed.

MATERIALS AND METHODS

We present the first study of renal cortical tissue perfusion measurement by means of standardized color Doppler sonographic videos evaluated with the PixelFlux software 1 for Dynamic Tissue Perfusion Measurement (DTPM) in 92 patients with DM1 without MA compared to 71 healthy probands.

RESULTS

DTPM reveals a highly significant diminution of cortical perfusion in patients with DM1 compared to healthy probands by 31 %, most pronounced in the distal hemicortex (reduction by 50 %) compared to 21 % within the proximal hemicortex.

CONCLUSION

Thus, DTPM offers a novel means of numerically describing the state of the renal microvasculature in DM in a patient-friendly, non-invasive, non-ionizing manner.

[Unequal social participation in later life]

The concept of active ageing comprises the maintenance of societal participation throughout the life span into old age. "Good" ageing in line with this activity paradigm develops into a starting point of social inequality rather than being its result. Based on the German Ageing Survey (DEAS) we investigated access to volunteering and to educational activities depending on social and spatial aspects of inequality. Societal participation is socially and spatially structured. Individuals from a lower social class are less often involved in educational activities or in volunteering. Moreover, individuals living in economically disadvantaged regions are less likely to participate than in economically strong regions. Disadvantages cumulate if low individual resources overlap with poor economic conditions in the living area. Measures to facilitate participation should be taken on the local level to enhance opportunities for volunteering and educational activities. This should help to sustainably increase the participation of individuals from lower social classes.

Abstract OT2-3-11: Tivozanib in combination with paclitaxel vs placebo with paclitaxel in patients with locally advanced or metastatic triple-negative breast cancer

Background: Triple-negative breast cancer (TNBC) is an aggressive cancer with inferior survival outcomes. Although weekly paclitaxel (WP) is effective in the treatment (tx) of metastatic breast cancer (MBC), optimization of therapies for patients (pts) with TNBC is essential. Angiogenesis is a hallmark of advanced cancer, with subset analyses suggesting activity of angiogenesis inhibitors in TNBC. Tivozanib (TIVO) is a potent and selective inhibitor of vascular endothelial growth factor receptors (VEGFR) 1, 2, and 3 with a promising role in metastatic renal cell carcinoma, and established safety in Phase I combination with WP in MBC.

Purpose: This Phase II trial will assess the efficacy and safety of TIVO + WP in the first-line setting for pts with advanced or metastatic TNBC and evaluate the performance of candidate angiogenesis biomarkers.

Objectives: The primary objective of this study is to compare progression-free survival (PFS) of pts treated with TIVO + WP vs pts treated with placebo (PB) + WP. Secondary objectives include objective response rate (ORR), overall survival (OS), safety and tolerability, quality of life, and correlative candidate biomarker endpoints. The pharmacokinetics of TIVO + WP also will be characterized.

Study Design and Methods: This multicenter, randomized, PB-controlled, two-arm study will enroll pts with metastatic or unresectable TNBC (evaluable per RECIST) and no prior systemic therapy. Pts must have confirmed available archival tumor tissue. Pts will be stratified by ECOG performance score and number of metastatic sites, then randomized to receive either oral TIVO 1.5 mg once daily for 3 weeks (wks) on/1 wk off and intravenous WP 90 mg/m2 for 3 wks on/1 wk off, or PB + WP. One cycle will be 4 wks; tx will continue until disease progression or unacceptable toxicity. Archival tumor tissue and blood samples will be evaluated for response biomarkers, including a hypoxia sensitivity gene signature, a myeloid resistance gene signature, and angiogenic ligands. All pts will be followed for survival until death. Adverse events will be monitored throughout the study. Pharmacokinetic samples will be collected during cycles 1 and 2. PAM-50–defined intrinsic molecular subtype populations also will be evaluated retrospectively.

Recruitment of 130 patients is planned, with an interim analysis after 80 pts to measure ORR (130 pts with a total of 82 investigator-assessed PFS events provides 80% power to detect statistically significant PFS differences between tx arms). Endpoint analyses will use the intent-to-treat population. The primary efficacy analysis will use investigator assessments of response and a two-sided 95% confidence interval for the hazard ratio produced using Cox proportional hazards regression models. OS will be compared using the log-rank test. Analyses of candidate biomarkers and determination of an optimal predictive cutoff for response also are planned. Trial enrollment will commence in fall 2012.

Conclusion: This study will determine whether TIVO, a selective and potent VEGFR inhibitor, combined with WP improves clinical outcomes in pts with TNBC, and whether clinical activity is associated with candidate angiogenesis biomarkers.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT2-3-11.

Treatment of diabetic ketoacidosis (DKA) with 2 different regimens regarding fluid substitution and insulin dosage (0.025 vs. 0.1 units/kg/h)

Diabetic ketoacidosis (DKA) is still the most dangerous acute complication in type 1 diabetes. The aim of this study was to compare treatment of DKA with a regimen of a low insulin dose (0.025 units/kg/h) vs. a standard insulin dose (0.1 units/kg/h).We retrospectively analysed all cases of children and adolescents (age 0-18 years) with type 1 diabetes and DKA who needed treatment in the ICU in the time period of 1998-2005 in 2 pediatric diabetes centers. In a chart review of the first 48 h after onset of DKA the following parameters where evaluated: pH, blood glucose, sodium, potassium, and ketones in urine. Consciousness, neurological status and complications such as cerebral edema, hypoglycaemia or hypokalemia were also recorded.23 children were treated in center A (low insulin dose) whereas 41 where treated in center B (standard insulin dose). Mean age of the patients was 8.9 (range 1.58-17.7) and 13.5 years (1.25-17.7) respectively (p=0.134). Mean pH was 7.1 and HCO3 was 9.05 and 7.79 respectively (p=0.122). Initial blood glucose was 26 mmol/l (no difference between the 2 centres). Treatment with the standard insulin dose resulted in a slightly shorter duration of acidosis (8 h in center A, 6.5 h in center B) and a significantly faster normalization of blood glucose (18 h in A, vs. 10.5 h in B) (p<0.005). During the first day we found similar and very low rates of hypoglycaemia. In center B one case of suspected cerebral edema and cerebral infarction occurred.Low dose insulin substitution is as safe as the recommended standard dose in respect to the occurrence of acute complications. Acidosis is broken slightly earlier with the standard dose. Implications of this earlier normalisation of pH remain unclear.

[Tumour of the endolymphatic sac in a 12-year-old child]

We present the case of a 12-year-old boy with right-sided pantonal sensorineural hearing loss. With the help of imaging diagnostics a tumour of the right temporal bone was detected. It was resected using a transmastoid approach. Histopathological study showed a low-grade adenocarcinoma of the endolymphatic sac, known as Heffner tumour. An association with the von-Hippel-Lindau complex - as often reported in the medical literature - could not be proven.