Multidisciplinary neurofibromatosis conference in the management of patients with neurofibromatosis type 1 and schwannomatosis in a single tertiary care institution

OBJECTIVE

To evaluate the role of weekly neurofibromatosis (NF) multi-disciplinary conferences (MDC) on the diagnostic and therapeutic plan for patients with NF type 1 (NF1) and schwannomatosis (SWN).

MATERIALS AND METHODS

This retrospective study reviewed patients with confirmed or suspected NF1 and SWN discussed in weekly MDC from March to July 2021. Demographic data collected included patient age, sex, pre-conference and post-conference diagnosis, radiological studies reviewed, and provider specialties in attendance. Outcomes reported included changes in imaging interpretation and treatment plans, changes in post-conference diagnosis relative to pre-conference diagnosis, and time to completion of the recommended change in treatment.

RESULTS

Data from 17 MDC "pre-conference" lists included 75 patients (38 female, 37 males, mean age (years): 38 (range: 6-80)) with NF1 (52%, 39/75) and SWN (36%, 27/75) discussed over a total of 91 case reviews. 18.7% (14/75) of all patients had NF2-related SWN, and 17.3% (13/75) of all patients had non-NF2 SWN. The MDC led to changes in imaging interpretation in 18.7% and changes in patient management in 74.7% (diagnostic testing (n = 52), surgical plan (n = 24), medical treatment (n = 9), clinical trial status (n = 4), and radiation treatment (n = 1)) of cases. Among patients for whom a change in management was recorded, 91% (62/68) completed at least one recommendation (mean time to completion (days): 41.4 (range: 0-278)).

CONCLUSION

Weekly MDC changes the diagnostic and therapeutic management of the majority of patients discussed (74.7%) and promotes a high adherence rate to recommendations (91%).

Genetic Testing to Inform Epilepsy Treatment Management From an International Study of Clinical Practice

Importance

It is currently unknown how often and in which ways a genetic diagnosis given to a patient with epilepsy is associated with clinical management and outcomes.

Objective

To evaluate how genetic diagnoses in patients with epilepsy are associated with clinical management and outcomes.

Design, Setting, and Participants

This was a retrospective cross-sectional study of patients referred for multigene panel testing between March 18, 2016, and August 3, 2020, with outcomes reported between May and November 2020. The study setting included a commercial genetic testing laboratory and multicenter clinical practices. Patients with epilepsy, regardless of sociodemographic features, who received a pathogenic/likely pathogenic (P/LP) variant were included in the study. Case report forms were completed by all health care professionals.

Exposures

Genetic test results.

Main Outcomes and Measures

Clinical management changes after a genetic diagnosis (ie, 1 P/LP variant in autosomal dominant and X-linked diseases; 2 P/LP variants in autosomal recessive diseases) and subsequent patient outcomes as reported by health care professionals on case report forms.

Results

Among 418 patients, median (IQR) age at the time of testing was 4 (1-10) years, with an age range of 0 to 52 years, and 53.8% (n = 225) were female individuals. The mean (SD) time from a genetic test order to case report form completion was 595 (368) days (range, 27-1673 days). A genetic diagnosis was associated with changes in clinical management for 208 patients (49.8%) and usually (81.7% of the time) within 3 months of receiving the result. The most common clinical management changes were the addition of a new medication (78 [21.7%]), the initiation of medication (51 [14.2%]), the referral of a patient to a specialist (48 [13.4%]), vigilance for subclinical or extraneurological disease features (46 [12.8%]), and the cessation of a medication (42 [11.7%]). Among 167 patients with follow-up clinical information available (mean [SD] time, 584 [365] days), 125 (74.9%) reported positive outcomes, 108 (64.7%) reported reduction or elimination of seizures, 37 (22.2%) had decreases in the severity of other clinical signs, and 11 (6.6%) had reduced medication adverse effects. A few patients reported worsening of outcomes, including a decline in their condition (20 [12.0%]), increased seizure frequency (6 [3.6%]), and adverse medication effects (3 [1.8%]). No clinical management changes were reported for 178 patients (42.6%).

Conclusions and Relevance

Results of this cross-sectional study suggest that genetic testing of individuals with epilepsy may be materially associated with clinical decision-making and improved patient outcomes.

Pharmacists' impact on opportunistic infection prophylaxis in patients with HIV/AIDS

Pharmacists have demonstrated a positive impact on the care of patients with human immunodeficiency virus/acquired immunodeficiency syndrome through enhancing patient outcomes associated with antiretroviral therapy. This pre- and postintervention study assessed the impact of pharmacist intervention on improving the use of prophylactic medications for opportunistic infections (OI). Of the 139 patients screened, 42 patients were included in the prospective intervention group. A total of 27 interventions were made on 15 patients, and 24 recommendations (89%) were accepted by providers. Compared with the retrospective control group, prescribing of OI prophylaxis increased from 58% to 93% (P<0.001) with the addition of pharmacist intervention.

Apolipoprotein E-e4, processing speed, and white matter volume in a genetically enriched sample of midlife adults

Healthy midlife children of a parent with Alzheimer's disease ([AD] N = 23; 9 male) participated in neuropsychological testing, and magnetic resonance imaging (MRI) of brain volumetrics were obtained. In all, 35% of the sample were apolipoprotein E (ApoE)-e4 positive (n = 8; 5 male). The ApoE-e4 group exhibited significantly slower performances on an executive function and processing speed measure and had less white matter volume than the non-ApoE-e4 group. Lesser white matter volume was significantly correlated with slower processing speed. Processing speed and changes in white matter volume might be indicators of preclinical decline in AD.

Three-year clinical outcome after chondrocyte transplantation using a hyaluronan matrix for cartilage repair

Repair of articular cartilage represents a significant clinical problem and although various new techniques - including the use of autologous chondrocytes - have been developed within the last century the clinical efficacy of these procedures is still discussed controversially. Although autologous chondrocyte transplantation (ACT) has been widely used with success, it has several inherent limitations, including its invasive nature and problems related to the use of the periosteal flap. To overcome these problems autologous chondrocytes transplantation combined with the use of biodegradable scaffolds has received wide attention. Among these, a hyaluronan-based scaffold has been found useful for inducing hyaline cartilage regeneration. In the present study, we have investigated the mid-term efficacy and safety of Hyalograft C grafts in a group of 36 patients undergoing surgery for chronic cartilage lesions of the knee. Clinical Outcome was assessed prospectively before and at 12, 24, and 36 months after surgery. No major adverse events have been reported during the 3-year follow-up. Significant improvements of the evaluated scores were observed (P < 0.02) at 1 year and a continued increase of clinical performance was evident at 2 and 3 years follow-up. Patients under 30 years of age with single lesions showed statistically significant improvements at all follow-up visits compared to those over 30 with multiple defects (P < 0.01). Hyalograft C compares favorably with classic ACT and is particularly indicated in younger patients with single lesions. The graft can be implanted through a miniarthrotomy and needs no additional fixation with sutures except optional fibrin gluing at the defect borders. These results suggest that Hyalograft C is a valid alternative to ACT.

[Physical activity after total knee replacement]

AIM

The aim of the study is to find out to what extent patients can do sports after total knee replacement and how patients change their activities compared to the preoperative situation.

METHOD

167 patients, not older than 65 years at time of surgery, who had total knee replacement during the years 1988 to 1998 were asked about their physical activity habits before and after surgery and 112 of them were seen for follow-up examination.

RESULTS

138 (83%) patients correctly answered the questionnaire about their activities. The average age at time of surgery was 55.3 years (21 - 65 yrs), at time of follow-up examination or questioning it was 63.8 years (24 - 78 yrs). The preoperative activity rate was 80.4%. Postoperatively it sank to 75.4%. 99 of the 111 (89.2%) patients returned to some kind of activity after surgery. Walking proved to be the most popular activity (92.8%), followed by swimming (34.2%) and cycling (18.0%). Follow-up examination was done after an average of 74 months (24 - 156) postoperatively and revealed an average Knee Society Knee Score for all patients of 84/70. With a score of 83.4/55.7 the less active group lay under the more active group with a score of 85.2/72.3.

CONCLUSION

A tendency towards low impact physical activities could be seen after total knee replacement. Even so, the percentage of patients participating in physical activities was not reduced in a strong way by surgery.

Subcutaneous low-dose epoetin beta for the avoidance of transfusion in patients scheduled for elective surgery not eligible for autologous blood donation

This randomized, multicentre, parallel-group study assessed the efficacy of epoetin beta in reducing the transfusion frequency in patients ineligible for autologous blood donation prior to surgery. The patients (n = 194) received either epoetin beta (125 or 250 IU/kg, once weekly) or no therapy for 3-4 weeks before surgery. The pre-operation haemoglobin levels were markedly increased in the epoetin beta groups (125 IU/kg: +1.1 g/dl; 250 IU/kg: +1.6 g/dl), but not in the control group. The transfusion frequency was significantly reduced in both epoetin groups as compared with the control group (p = 0.046). Epoetin beta was well tolerated, and no serious adverse events were observed. Low-dose administration of epoetin beta before elective surgery reduces the transfusion frequencies in patients not eligible for autologous blood donation.

Osteoarthrosis after the Max Lange procedure for unstable shoulders

Thirty-four patients were followed for a mean of 14.4 years after the Max Lange operation for instability of the shoulder. This procedure consists of an anterior capsulorraphy with lateralisation of the subscapularis tendon and the insertion of a bone block at the inferior and anterior part of the glenoid. The Rowe score showed 87% good and excellent results. External rotation and abduction were significantly limited as compared to the normal side. Radiographs revealed osteoarthrosis in 47%. Double contrast computed tomography in 18 cases showed a bony defect in the anterior and inferior part of the humeral head in 12 who had significantly limited external rotation as compared to those without the defect. Lateralisation of the subscapularis tendon with limitation of external rotation may lead to increased contact stress and shear forces at the anterior rim of the glenoid which contributes to the development of osteoarthrosis.

Endoscopic and videofluoroscopic evaluations of swallowing and aspiration

A new procedure for evaluating oropharyngeal dysphagia utilizing fiberoptic laryngoscopy was compared to the videofluoroscopy procedure. Twenty-one subjects were given both examinations within a 48-hour period. Results of the fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy examinations were compared for presence or absence of abnormal events. Good agreement was found, especially for the finding of aspiration (90% agreement). The FEES was then measured against the videofluoroscopy study for sensitivity, specificity, positive predictive value, and negative predictive value. Sensitivity was 0.88 or greater for three of the four parameters measured. Specificity was lower overall, but was still 0.92 for detection of aspiration. It was concluded that the FEES is a valid and valuable tool for evaluating oropharyngeal dysphagia. Some specific patients and conditions that lend themselves to this procedure are discussed.