Awareness of social care needs in people with epilepsy and intellectual disability

BACKGROUND

Nearly a quarter of people with intellectual disability (ID) have epilepsy with large numbers experiencing drug-resistant epilepsy, and premature mortality. To mitigate epilepsy risks the environment and social care needs, particularly in professional care settings, need to be met.

PURPOSE

To compare professional care groups as regards their subjective confidence and perceived responsibility when managing the need of people with ID and epilepsy.

METHOD

A multi-agency expert panel developed a questionnaire with embedded case vignettes with quantitative and qualitative elements to understand training and confidence in the health and social determinants of people with ID and epilepsy. The cross-sectional survey was disseminated amongst health and social care professionals working with people with ID in the UK using an exponential non-discriminative snow-balling methodology. Group comparisons were undertaken using suitable statistical tests including Fisher's exact, Kruskal-Wallis, and Mann-Whitney. Bonferroni correction was applied to significant (p < 0.05) results. Content analysis was conducted and relevant categories and themes were identified.

RESULTS

Social and health professionals (n = 54) rated their confidence to manage the needs of people with ID and epilepsy equally. Health professionals showed better awareness (p < 0.001) of the findings/recommendations of the latest evidence on premature deaths and identifying and managing epilepsy-related risks, including the relevance of nocturnal monitoring. The content analysis highlighted the need for clearer roles, improved care pathways, better epilepsy-specific knowledge, increased resources, and better multi-disciplinary work.

CONCLUSIONS

A gap exists between health and social care professionals in awareness of epilepsy needs for people with ID, requiring essential training and national pathways.

Interpreting treatment effect size from single case experimental design data: a preliminary analysis of differential effects of treatments designed to increase or decrease behaviour

BACKGROUND

Estimates of treatment effect size from single case experimental design (SCED) data may be impacted by the direction for treatment effects (i.e. ascending or descending slope for the dependent variable). Estimating effect sizes for treatments designed to decrease behaviour are potentially more restricted because the intended direction for treatment is zero (i.e. an absolute basal). Conversely, effect sizes for interventions that increase behaviour are less restricted due to a relatively unconstrained ceiling from a pure measurement standpoint (i.e. no absolute ceiling). That is, treatments that increase behaviour have a broader range of possible effect size values as the ceiling is only limited by demand characteristics and the learners' skills and motivation to exhibit the behaviour.

METHOD

The current study represents a preliminary analysis of the mean and range of SCED effect sizes for treatments designed to either increase or decrease target behaviour. A within-case Cohen's d measure that was developed for SCED data was used to estimate treatment effect sizes.

RESULTS

Results indicated that the mean and range of effect size values for treatments that increased behaviour were significantly greater compared with treatments that decreased behaviour.

CONCLUSIONS

Results are discussed in terms of developing standards, or best practices, specific to interpreting effect size values and meeting quality control requirements for inclusion of the data set in future SCED meta-analytic studies estimating treatment effect size. Specifically, preliminary results suggest that benchmarks for low, medium and high SCED effect size values need to be developed separately for treatments that increase or decrease levels of the dependent variable.

Comparison of suspected and confirmed internal EVD-related infections: a prospective multi-centre U.K. observational study

Background

Diagnosis of internal external ventricular drain (EVD)-related infections (iERI) is an area of diagnostic difficulty. Empiric treatment is often initiated on clinical suspicion. There is limited guidance around antimicrobial management of confirmed versus suspected iERI.

Methods

Data on patients requiring EVD insertion were collected from 21 neurosurgical units in the United Kingdom from 2014 to 2015. Confirmed iERI was defined as clinical suspicion of infection with positive cerebrospinal fluid (CSF) culture and/or Gram stain. Cerebrospinal fluid, blood, and clinical parameters and antimicrobial management were compared between the 2 groups. Mortality and Modified Rankin Scores were compared at 30 days post-EVD insertion.

Results

Internal EVD-related infection was suspected after 46 of 495 EVD insertions (9.3%), more common after an emergency insertion. Twenty-six of 46 were confirmed iERIs, mostly due to Staphylococci (16 of 26). When confirmed and suspected infections were compared, there were no differences in CSF white cell counts or glucose concentrations, nor peripheral blood white cell counts or C-reactive protein concentrations. The incidence of fever, meningism, and seizures was also similar, although altered consciousness was more common in people with confirmed iERI. Broad-spectrum antimicrobial usage was prevalent in both groups with no difference in median duration of therapy (10 days [interquartile range {IQR}, 7–24.5] for confirmed cases and 9.5 days [IQR, 5.75–14] for suspected, P = 0.3). Despite comparable baseline characteristics, suspected iERI was associated with lower mortality and better neurological outcomes.

Conclusions

Suspected iERI could represent sterile inflammation or lower bacterial load leading to false-negative cultures. There is a need for improved microbiology diagnostics and biomarkers of bacterial infection to permit accurate discrimination and improve antimicrobial stewardship.

Ponatinib sensitizes myeloma cells to MEK inhibition in the high-risk VQ model

Multiple myeloma (MM) is a malignant plasma cell cancer. Mutations in RAS pathway genes are prevalent in advanced and proteasome inhibitor (PI) refractory MM. As such, we recently developed a VQ MM mouse model recapitulating human advanced/high-risk MM. Using VQ MM cell lines we conducted a repurposing screen of 147 FDA-approved anti-cancer drugs with or without trametinib (Tra), a MEK inhibitor. Consistent with its high-risk molecular feature, VQ MM displayed reduced responses to PIs and de novo resistance to the BCL2 inhibitor, venetoclax. Ponatinib (Pon) is the only tyrosine kinase inhibitor that showed moderate MM killing activity as a single agent and strong synergism with Tra in vitro. Combined Tra and Pon treatment significantly prolonged the survival of VQ MM mice regardless of treatment schemes. However, this survival benefit was moderate compared to that of Tra alone. Further testing of Tra and Pon on cytotoxic CD8+ T cells showed that Pon, but not Tra, blocked T cell function in vitro, suggesting that the negative impact of Pon on T cells may partially counteract its MM-killing synergism with Tra in vivo. Our study provides strong rational to comprehensively evaluate agents on both MM cells and anti-MM immune cells during therapy development.

[18F]NaF PET-MRI provides direct in-vivo evidence of the association between bone metabolic activity and adjacent synovitis in knee osteoarthritis: a cross-sectional study

OBJECTIVE

Synovitis is hypothesized to play a role in the development and growth of osteophytes. Our objectives were to use hybrid positron emission tomography-magnetic resonance imaging (PET-MRI) to (1) determine whether synovitis adjacent to peripheral bone subregions with increased metabolic activity is greater than adjacent to regions without increased metabolic activity and (2) assess the association between subregional bone metabolic activity and adjacent synovitis.

DESIGN

We recruited 11 participants (22 knees) with a diagnosis of OA in at least one knee. Simultaneous bilateral knee PET-MRI was performed. We quantified bone metabolic activity using the radiotracer [18F]sodium fluoride ([18F]NaF) with calculation of maximum standardized uptake values (SUVmax). Synovitis was quantified using dynamic contrast-enhanced MRI with calculation of Ktrans. Bone subregions were coded as osteophyte (OP), focal increased [18F]NaF uptake without osteophyte (FIU), or normal (no osteophyte or FIU). We used robust linear mixed effects models to assess differences in adjacent Ktrans between different subregion types and to assess association between Ktrans and adjacent SUVmax.

RESULTS

94 OPs were detected (59 MOAKS grade 1, 30 grade 2, 5 grade 3), along with 28 FIU and 18 normal subregions. Ktrans was higher adjacent to FIU (adjusted mean [95% CI] = 0.06 [0.03,0.09]) and OPs (0.08 [0.05,0.11]) when compared to normal bone subregions (0.03 [0.00,0.09]). PET SUVmax was positively associated with adjacent Ktrans (β[95% CI] = 0.018 [0.008,0.027]).

CONCLUSIONS

Synovitis is more intense adjacent to peripheral bone regions with increased metabolic activity than those without, although there is some overlap. Subregional bone metabolic activity is positively associated with intensity of adjacent synovitis.

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial

OBJECTIVE

To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage.

DESIGN

Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS).

SETTING

Twenty-eight UK NHS early pregnancy units.

SAMPLE

A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage.

METHODS

Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets.

MAIN OUTCOME MEASURES

Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs).

RESULTS

For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management.

CONCLUSIONS

The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage.

TWEETABLE ABSTRACT

The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Assessment of quantitative [18F]Sodium fluoride PET measures of knee subchondral bone perfusion and mineralization in osteoarthritic and healthy subjects

OBJECTIVE

Molecular information derived from dynamic [18F]sodium fluoride ([18F]NaF) PET imaging holds promise as a quantitative marker of bone metabolism. The objective of this work was to evaluate physiological mechanisms of [18F]NaF uptake in subchondral bone of individuals with and without knee osteoarthritis (OA).

METHODS

Eleven healthy volunteers and twenty OA subjects were included. Both knees of all subjects were scanned simultaneously using a 3T hybrid PET/MRI system. MRI MOAKS assessment was performed to score the presence and size of osteophytes, bone marrow lesions, and cartilage lesions. Subchondral bone kinetic parameters of bone perfusion (K1), tracer extraction fraction, and total tracer uptake into bone (Ki) were evaluated using the Hawkins 3-compartment model. Measures were compared between structurally normal-appearing bone regions and those with structural findings.

RESULTS

Mean and maximum SUV and kinetic parameters Ki, K1, and extraction fraction were significantly different between Healthy subjects and subjects with OA. Between-group differences in metabolic parameters were observed both in regions where the OA group had degenerative changes as well as in regions that appeared structurally normal.

CONCLUSIONS

Results suggest that bone metabolism is altered in OA subjects, including bone regions with and without structural findings, compared to healthy subjects. Kinetic parameters of [18F]NaF uptake in subchondral bone show potential to quantitatively evaluate the role of bone physiology in OA initiation and progression. Objective measures of bone metabolism from [18F]NaF PET imaging can complement assessments of structural abnormalities observed on MRI.

966 Implementation of Regional Scalp Blockade for Painless Removal of ICP Bolts: A Quality Improvement Project

Introduction

Intracranial pressure (ICP) monitoring through insertion of a bolt is a common neurosurgical procedure for diagnosing cerebrospinal fluid disorders. The first step of our quality improvement project identified ICP bolt removal the most painful part of the procedure. We implemented and tested the efficacy of a scalp nerve block for bolt removal.

Method

Two groups were identified: (A) receiving oral analgesia only and (B) receiving ipsilateral supraorbital and supratrochlear nerve blocks. We then retrospectively compared satisfaction ratings of insertion versus removal process for the two bolt types using a telephonic questionnaire

Results

Eighty-five patients had ICP bolts (32M:53F, mean age 42.7±16.0 SD). Fifty-four were removed with oral analgesia (A) and 31 with oral and regional anaesthesia (B). Removal experience was reported as worse for group A than for group B (p &lt; 0.01). Most patients (66%) reported would have preferred local anesthetic during removal. No complications occurred from the block.

Conclusions

Regional nerve blocks are a safe and effective adjuvant for the painless removal of frontal ICP monitoring bolts. The final stage of the project was to implement nerve blocks as standard practice for bolt removal, to improve patient experience.

The cost-effectiveness of progesterone in preventing miscarriages in women with early pregnancy bleeding: an economic evaluation based on the PRISM trial

OBJECTIVES

To assess the cost-effectiveness of progesterone compared with placebo in preventing pregnancy loss in women with early pregnancy vaginal bleeding.

DESIGN

Economic evaluation alongside a large multi-centre randomised placebo-controlled trial.

SETTING

Forty-eight UK NHS early pregnancy units.

POPULATION

Four thousand one hundred and fifty-three women aged 16-39 years with bleeding in early pregnancy and ultrasound evidence of an intrauterine sac.

METHODS

An incremental cost-effectiveness analysis was performed from National Health Service (NHS) and NHS and Personal Social Services perspectives. Subgroup analyses were carried out on women with one or more and three or more previous miscarriages.

MAIN OUTCOME MEASURES

Cost per additional live birth at ≥34 weeks of gestation.

RESULTS

Progesterone intervention led to an effect difference of 0.022 (95% CI -0.004 to 0.050) in the trial. The mean cost per woman in the progesterone group was £76 (95% CI -£559 to £711) more than the mean cost in the placebo group. The incremental cost-effectiveness ratio for progesterone compared with placebo was £3305 per additional live birth. For women with at least one previous miscarriage, progesterone was more effective than placebo with an effect difference of 0.055 (95% CI 0.014-0.096) and this was associated with a cost saving of £322 (95% CI -£1318 to £673).

CONCLUSIONS

The results suggest that progesterone is associated with a small positive impact and a small additional cost. Both subgroup analyses were more favourable, especially for women who had one or more previous miscarriages. Given available evidence, progesterone is likely to be a cost-effective intervention, particularly for women with previous miscarriage(s).

TWEETABLE ABSTRACT

Progesterone treatment is likely to be cost-effective in women with early pregnancy bleeding and a history of miscarriage.

TM2-2 Analysis of adverse events in the management of chronic headache by occipital nerve stimulation

Objectives

To analyse long-term adverse events of occipital nerve stimulation (ONS).

Design

Prospective open-label observational study.

Subjects

134 patients with refractory headaches implanted between 2007–2014 in a single specialised centre.

Methods

Information was collected on ONS device, implantable pulse generator (IPG) site and adverse event rates. The impact of implanter experience and the association between IPG site and adverse event rates was also explored.

Results

Mean follow up was 46 months (6–108 months). A total of 139 adverse events were recorded in 75 patients (56%). A total of 59 additional surgeries were needed in 39 patients. A significant difference was seen in the rates of adverse events recorded between 2007–2010 and 2011–2014 (60.7% vs 42.6%, p=0.002). A significant reduction in ONS revision was seen over time (25.7% vs 5.9%, p=0.002). Analysis of adverse events with IPG site showed those with abdominal implants recorded higher adverse event rate that those with an IPG in the chest (65.8% vs 40.3%, p=0.004).

Conclusions

In specialist centres, adverse event rates of ONS can be much lower than reported in the literature. Our results suggest implanter experience and IPG site both have an effect on adverse event rate.

WP1-6 The syndrome of the trephined

Objectives

Syndrome of the Trephined (SoT) or sinking skin flap syndrome is characterised by neurological deterioration occurring after a delay post-craniectomy, with or without a significant postural component, that may improve with cranioplasty. The symptoms and signs seen are heterogeneous and can be readily missed. With increasing numbers of patients surviving after decompressive craniectomies, and often a long delay before cranioplasty, we think it important that awareness of this potentially lethal but reversible condition is raised.

Design

Case Series.

Subjects

Cases with suspected SoT were identified retrospectively from all admissions to a Level 1 Neurorehabilitation Unit over 2 years.

Methods

Cases were identified by their treating clinicians. Their clinical features are described, and outcomes after cranioplasty are discussed.

Results

From 36 patients admitted after craniectomy over 2 years, 4 patients with suspected SoT were identified, with a latency of 4–12 months post-injury. Late neurological deterioriation included reduced alertness and mobility, cognitive decline and headache. Two patients had a clear postural component to their symptoms. Coexisting hydrocephalus was sometimes seen, and complicated neurosurgical management. All cases improved after cranioplasty.

Conclusions

SoT is an under-reported and under-recognised complication of craniectomy. It is a potentially reversible cause of significant late deterioration following craniectomy. Further research into the optimal timing for cranioplasty is needed.

TM3-5 Venous sinus stenting for IIH: what are the long-term outcomes?

Objectives

Idiopathic intracranial hypertension (IIH) is associated with dural venous sinus stenosis (DVSS). This is increasingly treated with endovascular insertion of stents. Clinical and manometric improvements after stent placement have been described. However, there is little data reporting further need for CSF diversion, complication rates and sustained improvements in ICP.

Design

Single centre case series.

Subjects

Twenty-four IIH patients underwent stent insertion on discovery of DVSS with medical management ongoing.

Methods

Clinical notes, radiographic reports and 24 hour ICP monitoring data before and after stent placement was collected.

Results

After 1089.2±107.1 days, 6 patients remained symptomatic and went onto require CSF diversion, 75.0% did not require CSF diversion. One patient developed stent thrombosis requiring VKA anticoagulation for 3 months, this patient also developed new stenosis proximal to the stent at 2 years. A second patient developed in-stent stenosis requiring balloon angioplasty at 2 years and subsequent repeat stenting at 3 years. Eleven patients had 24 hour ICP monitoring at baseline and a mean of 231.9±129.5 days after DVSS stent placement. The mean reduction in ICP was 7.92±1.80 mmHg (p<0.01) and PA was 2.84±0.84 mmHg (p<0.01).

Conclusions

DVSS stenting is a viable endovascular therapy for IIH with modest long-term patency and ICP reduction. However, a quarter of stented patients required subsequent CSF diversion to manage their symptoms.

TM3-4 The effect of acetazolamide on intracranial pressure: primary study with prolonged continuous intracranial pressure monitoring

Objectives

Acetazolamide has frequently been used as a first-line treatment for idiopathic Intracranial Hypertension (IIH) and other disorders which lead to a non-acute rise in intracranial pressure (ICP). The effect of acetazolamide has been observed through lumbar puncture, however the effect of acetazolamide on ICP has not been studied in continuous ICP measurement.

Design

A retrospective study of a prospectively built ICP database

Subjects

All patients with continuous ICP monitoring demonstrating 24 hours on and 24 hours off acetazolamide were included in the study.

Methods

Patients median ICP and median pulse amplitude over 24 hour monitoring period on and off Diamox was assessed.

Results

12 patients (9F, 3M) underwent ICP monitoring with data collected during the same admission. 8 patients had IIH, 1 Chiari Malformation, 3 new diagnostic ICP procedures. 10 patients saw a reduction in ICP while on acetazolamide. Overall, patients experienced a Median reduction of 1.14 mmHg (Mean 1.16 mmHg, Range 4.24 to −4.445 mmHg). Patients (n9) who were on ≥1 g of acetazolamide per day experienced a median reduction in ICP of 1.595 mmHg (Mean 1.91 mmHg, Range 4.24–0.5 mmHg).

Conclusions

Our data suggests acetazolamide can reduce ICP quickly following commencement, however this reduction was relatively small. The effect seems greater with a higher dose. Larger numbers of patients are required to gain a greater understanding into the significance of acetazolamide on ICP, particularly the affect at larger doses.

WP1-8 Radiographic markers of disturbances in CSF dynamics: correlating imaging with 24-hour ICP monitoring

Objectives

Disorders with chronically elevated ICP have salient imaging findings associated with the sella turcica and optic nerves. We aim to quantify the degree of correlation between imaging features and ICP.

Design

Prospective case-cohort study.

Subjects

One-hundred and twenty-six patients (35M:91F) underwent ICPM with recent MR imaging.

Methods

T1-saggital views for sella volume, optic nerve vertical tortuosity, then T2-axial views for optic nerve sheath distension were blindly reviewed against respective median ICP and pulse amplitudes (PA). Imaging was triple reviewed for discordant values.

Results

The mean ICP of four sella morphologies (full/flat/concave/empty) were 1.2, 4.8, 8.4 and 16.7 mmHg respectively (p<0.01). AUROC for sella morphology predicting ICP was 0.81. This measurement was able to detect minimum ICP of 5.3 mmHg with 73.0% sensitivity and specificity, 73.0% PPV and 69.8% NPV. The mean PA values were 4.0, 5.2, 6.1 and 9.6 mmHg respectively (p<0.01). AUROC for sella morphology predicting PA was 0.78. This measurement was able to detect minimum PA of 5.47 mmHg with 76.3% sensitivity, 79.5% specificity, 63.5% PPV and 81.0% NPV. Mean PA values for vertical tortuosity (nil/uni/bi) were 5.2, 7.1 and 7.0 mmHg respectively (p<0.05). Mean ICP values for rail tracking (nil/uni/bi) were 4.5, 7.5 and 15.7 mmHg respectively (p<0.01). Mean PA values were 5.2, 5.8 and 8.0 mmHg respectively (p<0.0001).

Conclusions

Combined radiological features of ICP are promising non-invasive markers for raised ICP.

WP1-10 Prevalence of normal pressure hydrocephalus in falls clinic patients

Objectives

Patients with idiopathic Normal Pressure Hydrocephalus (iNPH) present with Hakim Adams triad and radiological findings suggestive of iNPH. We compare the presence of clinical and radiological signs of iNPH present in patients presenting to falls clinic at a District General Hospital with the general population.

Design

Retrospective analysis of patients referred to falls clinic (January 2017 to December 2017) and interpretation of CT or MRI head imaging with Evans index.

Subjects

Falls clinic patients presenting to a District General Hospital outpatient clinic.

Methods

Retrospective cohort of patients admitted to a single District General Hospital with falls and recent CT or MRI head. An Evans Index above 0.35 was used as an indicator of hydrocephalic ventricular enlargement.

Results

371 patients were seen in one year. 216 had previous CT or MRI head. 6.75% of all patients seen in falls clinic (11.6% who have had brain imaging) have hydrocephalic ventricular enlargement. This is compared to 4.5% in a study of patients aged 70 and over in a normal population.1

Conclusions

Patients seen in Falls clinic have an increased probability of having radiological signs consistent with idiopathic normal pressure hydrocephalus.

Reference

Jaraj D, Marlow T, Jensen C, Skoog I, Wikkelso C. Prevalence of idiopathic normal-pressure hydrocephalus. Neurology2014April 22;82(16):1449–1454.

Neonatal lung ultrasound exam guidelines

Point-of-care ultrasound (POC-US) is increasingly used especially in emergency and critical-care medicine. It is focused, quick and does not expose patients to ionizing radiation. It encompasses all organ systems and has well-defined indications. Lung ultrasound (LUS) represents one of the most exciting applications in the field of POC-US. It is particularly important to emphasize the role of LUS in neonatology due to the specific pathology inherent in lung immaturity as well as in the particular sensitivity of neonates to repeated radiation exposure. One of the main barriers to the more extensive use of the ultrasound technology is a lack of efficient and attractive training solutions followed by the structured quality-check assurance. In an effort to help bridge this gap, based on the most current literature, we developed creative and intuitive neonatal LUS algorithms. We hope they can serve as a clinical imaging guidelines and a valuable complement to the history and physical exam.

Pomalidomide, bortezomib and low-dose dexamethasone in lenalidomide-refractory and proteasome inhibitor-exposed myeloma

This phase 1 dose-escalation study evaluated pomalidomide, bortezomib (subcutaneous (SC) or intravenous (IV)) and low-dose dexamethasone (LoDEX) in lenalidomide-refractory and proteasome inhibitor-exposed relapsed or relapsed and refractory multiple myeloma (RRMM). In 21-day cycles, patients received pomalidomide (1-4 mg days 1-14), bortezomib (1-1.3 mg/m2 days 1, 4, 8 and 11 for cycles 1-8; days 1 and 8 for cycle ⩾9) and LoDEX. Primary endpoint was to determine the maximum tolerated dose (MTD). Thirty-four patients enrolled: 12 during escalation, 10 in the MTD IV bortezomib cohort and 12 in the MTD SC bortezomib cohort. Patients received a median of 2 prior lines of therapy; 97% bortezomib exposed. With no dose-limiting toxicities, MTD was defined as the maximum planned dose: pomalidomide 4 mg, bortezomib 1.3 mg/m2 and LoDEX. All patients discontinued treatment by data cutoff (2 April 2015). The most common grade 3/4 treatment-emergent adverse events were neutropenia (44%) and thrombocytopenia (26%), which occurred more frequently with IV than SC bortezomib. No grade 3/4 peripheral neuropathy or deep vein thrombosis was reported. Overall response rate was 65%. Median duration of response was 7.4 months. Pomalidomide, bortezomib and LoDEX was well tolerated and effective in lenalidomide-refractory and bortezomib-exposed patients with RRMM.

Predicting preterm birth in women with previous preterm birth and cervical length ≥ 25 mm

OBJECTIVE

To identify risk factors predicting subsequent spontaneous preterm birth or preterm prelabor rupture of membranes (PPROM) in a cohort of women with a history of spontaneous preterm birth and a cervical length of ≥ 25 mm at 20-24 weeks' gestation.

METHODS

We identified all pregnant women who attended our preterm labor clinic between January 2010 and December 2012 because of previous spontaneous preterm birth or PPROM before 34 weeks. Women with a normal cervical length (defined as ≥ 25 mm) between 20 and 24 weeks' gestation were identified and included in the analysis. Maternal characteristics, obstetric history, shortest cervical length and gestational age at shortest cervical length of women who delivered preterm (before 37 weeks) were compared with those who delivered at or after 37 weeks in the index pregnancy. Multiple regression analysis was planned to examine the relationship between significant clinical and cervical-length variables to identify significant clinical predictors of spontaneous preterm birth among high-risk patients with a normal cervix between 20 and 24 weeks' gestation.

RESULTS

Of 134 women with a normal cervix at 20-24 weeks, 28 (20.9%) delivered spontaneously or had PPROM before 37 weeks; of these 12 (9.0%) delivered before 34 weeks. None of the selected explanatory variables was predictive of recurrent preterm birth in this cohort. No correlation between absolute cervical length and gestational age at delivery was found (R = 0.01).

CONCLUSION

In high-risk women with a cervical length of ≥ 25 mm at 20-24 weeks' gestation, demographic characteristics and absolute cervical length are not useful in predicting subsequent spontaneous preterm birth.

Neural stimulators: a guide to imaging and postoperative appearances

Implantable neural stimulators have been developed to aid patients with debilitating neurological conditions that are not amenable to other therapies. The aim of this article is to improve understanding of correct anatomical placement as well as the relevant imaging methods used to assess these devices. Potential complications following their insertion and an overview of the current indications and potential mechanism of action of these devices is provided.

MDM2 overexpression in benign and malignant lesions of the human breast

MDM2 overexpression has been detected in women with benign or cancerous lesions of the breast. Immunohistochemical methods were used to identify overexpression in 11 of 27 benign cases (41%) and 15 of 22 (68%) cancer cases. MDM2 overexpression correlated well with immunohistochemically detected estrogen receptor (ER), suggesting that expression of these proteins was coordinately regulated. To test this, the MCF-10A human breast cell line, negative for both ER and MDM2 expression, was transfected with a wild-type ER. Following transfection, both ER and MDM2 were strongly expressed in two independent clones. Expression of both was reduced in the presence of increasing concentrations of estradiol (10(-10)-10(-8) M) thus, estrogen may be involved in regulation of MDM2 expression in proliferative breast lesions.

[Intravenous uterine leiomyomatosis with heart extension: a report of one case]

Uterine intravenous leiomyomatosis is a rare benign tumor, whose diagnosis of certainty is histological. It is characterized by its potential of intravascular extension with possibility of cardiac localisation imposing a complete surgical removal and a suitable imagery postoperatively. We report the case of a 63-year-old patient, presenting a cardiac extension complicating a LIV, by which we will discuss the diagnosis aspects, prognosis and therapeutic of this pathology.

14 mmHg: a case of raised intracranial pressure?

A 40-year-old woman presented with chronic headaches. She had undergone ventriculo-peritoneal (VP) shunt 7 years previously for treatment of hydrocephalus secondary to aqueduct stenosis. Intracranial pressure (ICP) monitoring revealed a resting ICP of less than 5 mmHg. Headaches were thought to be due to low ICP and the shunt tubing was ligated. Over the next 4 h there was an increase in ICP to 14 mmHg, decrease in GCS to 13 and ventriculomegaly on CT. These changes were reversed by the removal of the ligature. This unusual case highlights the fact that, in some shunted patients with over drainage of ventricles and a low resting ICP, small increases in ICP are poorly tolerated. This may be due to altered visco-elastic properties of the ventricles and the brain parenchyma.

The effect of ball carrying method on sprint speed in rugby union football players

Different methods of ball carrying can be used when a player runs with the ball in rugby union. We examined how three methods of ball carrying influenced sprinting speed: using both hands, under the left arm and under the right arm. These methods were compared with running without the ball. Our aim was to determine which method of ball carrying optimizes sprinting speed. Altogether, 48 rugby union players (age 21 +/- 2 years, height 1.83 +/- 0.1 m, body mass 85.3 +/- 12 kg, body fat 14 +/- 5%; mean +/- s) were recruited. The players performed twelve 30-m sprints in total (each player performed three trials under each of three methods of carrying the ball and sprinting without the ball). The design of the study was a form of Latin rectangle, balanced across the trial order for each of the methods and for pairwise combinations of the methods in blocks of four per trial. Each sprint consisted of a 10-m rolling start, followed by a 20-m timed section using electronic timing gates. Compared with sprinting 20 m without the ball (2.58 +/- 0.16 s), using both hands (2.62 +/- 0.16 s) led to a significantly slower time (P < 0.05). Sprinting 20 m with the ball under the left arm (2.61 +/- 0.15 s) or under the right arm (2.60 +/- 0.17 s) was significantly quicker than when using 'both hands' (P < 0.05), and both these methods were significantly slower than when running without the ball (P < 0.05). Accordingly, running with the ball in both hands led to the greatest decrement in sprinting performance, although carrying the ball under one arm also reduced the players' sprinting ability. Our results indicate that to gain a speed advantage players should carry the ball under one arm.

Bilateral sensorineural hearing loss complicating basal skull fracture

Otological damage is well-recognized following head injury. The commonest complication is hearing loss. We present a case of bilateral sensorineural hearing loss due to bilateral temporal bone fractures following an epileptic seizure, which is unique in the literature and illustrates the importance of this complication of head injury.

Dual technique for obliteration of small arteriovenous malformations

A 17-year-old man underwent an incomplete excision of a left fronto-parietal arterio-venous malformation (AVM), under image guidance. An initial attempt to treat the residual AVM by embolization was unsuccessful. The craniotomy was then re-opened in the angiography suite and the residual AVM was excised by, first, following the microcatheter within the arterial feeding vessel to the AVM and, secondly, by using metallic clips as radiographic markers to locate the position of the AVM during superselective angiography. The dual technique described is likely to be useful in selected cases with small residual AVMs and AVMs near eloquent areas of the brain, where the extent of surgical dissection and postoperative morbidity can be minimized by the precise localization of the AVM.

Depression, heart rate variability, and acute myocardial infarction

BACKGROUND

Clinical depression is associated with an increased risk for mortality in patients with a recent myocardial infarction (MI). Reduced heart rate variability (HRV) has been suggested as a possible explanation for this association. The purpose of this study was to determine if depression is associated with reduced HRV in patients with a recent MI.

METHODS AND RESULTS

Three hundred eighty acute MI patients with depression and 424 acute MI patients without depression were recruited. All underwent 24-hour ambulatory electrocardiographic monitoring after hospital discharge. In univariate analyses, 4 indices of HRV were significantly lower in patients with depression than in patients without depression. Variables associated with HRV were then compared between patients with and without depression, and potential confounds were identified. These variables (age, sex, diabetes, and present cigarette smoking) were entered into an analysis of covariance model, followed by depression status. In the final model, all but one HRV index (high-frequency power) remained significantly lower in patients with depression than in patients without depression.

CONCLUSIONS

We conclude that greater autonomic dysfunction, as reflected by decreased HRV, is a plausible mechanism linking depression to increased cardiac mortality in post-MI patients.

Infarction of solid Hodgkin's tumors in mice by antibody-directed targeting of tissue factor to tumor vasculature

We demonstrated previously that selective thrombosis of the blood vessels of solid tumors in mice can be achieved by targeting the extracellular domain of tissue factor by means of an antibody to an experimentally induced marker on tumor vascular endothelium. In the present study, we extend this finding to a naturally occurring marker of tumor vascular endothelium, vascular cell adhesion molecule-1 (VCAM-1). VCAM-1 is expressed by vascular endothelial cells in Hodgkin's disease and various solid tumors in mice and humans. It is absent from vascular endothelial cells in normal tissues in mice, with the exception of the heart and lungs, where it is present on venules. A monoclonal antibody to murine VCAM-1 was covalently linked to the extracellular domain of human tissue factor to create a "coaguligand." After i.v. administration to severe combined immunodeficient mice bearing human Hodgkin's tumors, the coaguligand localized selectively to VCAM-1-expressing vessels, caused thrombosis of those vessels, and retarded tumor growth. The coaguligand also localized to VCAM-1-expressing vessels in the heart and lungs of the mice but did not induce thrombosis in these sites. An immunohistochemical evaluation of the distribution of a monoclonal anti-phosphatidylserine (PS) antibody in the mice showed that the VCAM-1-expressing vessels in the tumor expressed PS, whereas the VCAM-1-expressing vessels in the heart and lungs lacked PS. The lack of thrombotic effect of the coaguligand on heart and lung vessels may be because PS is needed to provide the procoagulant surface upon which coagulation complexes can assemble. The requirement for coincident expression of the targeted marker and PS on tumor endothelium probably contributes to the selectivity of thrombotic action and the safety of coaguligands.

Coupling of the PTH/PTHrP receptor to multiple G-proteins. Direct demonstration of receptor activation of Gs, Gq/11, and Gi(1) by [alpha-32P]GTP-gamma-azidoanilide photoaffinity labeling

Parathyroid hormone (PTH) elicits many of its physiological effects by activating distinct, G-protein-coupled signaling cascades that lead to synthesis of cyclic AMP and hydrolysis of phosphatidylinositol 4,5-bisphosphate. Using the nonhydrolyzable photo-reactive GTP analog [alpha-32P]GTP-gamma-azidoanilide (GTP-AA) and peptide antisera raised against G-protein alpha-subunits, we studied coupling of the PTH receptor to G-proteins in rat osteoblast-like cells (ROS 17/2.8), and in human embryonal kidney cells expressing the cloned human PTH/parathyroid hormone-related peptide (PTHrP) receptor at 40,000 receptors/cell (C20) or 400,000 receptors/cell (C21). Incubation of C21 membranes (but not C20 membranes) with [Nle8,18, Tyr34]-bovine PTH(1-34) amide (bPTH[1-34]) led to concentration-dependent incorporation of GTP-AA into the two isoforms of G alpha s, into G alpha q/11, and to a much lesser extent into G alpha i(1). In ROS 17/2.8 cells, bPTH(1-34) increased the incorporation of GTP-AA into G alpha s, but not into G alpha q/11 or G alpha i. The ability of bPTH(1-34) to increase labeling of G alpha s and G alpha q/11 was correlated with the receptor-dependent sensitivity of the adenylyl cyclase and phospholipase C signaling pathways to the hormone.

Is blood pressure related to kidney size and shape?

OBJECTIVE

To examine the relationship between blood pressure and the size and shape of the kidneys in healthy volunteers from the community.

DESIGN

A cross-sectional community-based study of normal volunteers in Portsmouth City, Hampshire, UK.

SUBJECTS

Subjects numbered 185 (99 female), aged 19-66 years.

RESULTS

Blood pressure was higher in men, and in those with higher body mass index. Both systolic and diastolic blood pressure were correlated with the derived kidney volume. However, when corrected for age, sex and BMI the relationship was not statistically significant. Blood pressure correlated inversely with the width : length ratio of the left kidney.

CONCLUSIONS

Blood pressure was not correlated with kidney size in this group of adults.

Aortic valve replacement in the elderly. Risk factors and long-term results

OBJECTIVE

The current study was undertaken to determine long-term results of aortic valve replacement (AVR) in the elderly, to ascertain predictors of poor outcome, and to assess quality of life.

SUMMARY BACKGROUND DATA

Aortic valve replacement is the procedure of choice for elderly patients with aortic valve disease. The number of patients aged 70 and older requiring AVR continues to increase. However, controversy exists as to whether surgery devoted to this subset reflect a cost-effective approach to attaining a meaningful quality of life.

METHODS

This study reviews data on 247 patients aged 70 to 89 years who underwent isolated AVR between 1980 and 1995; there were 126 men (51%) and 121 women (49%). Follow-up was 97% complete (239/247 patients) for a total of 974.9 patient-years. Mean age was 76.2 +/- 4.8 years. Operative mortality and actuarial survival were determined. Patient age, gender, symptoms, associated diseases, prior conditions, New York Health Association class congestive heart failure, native valve disease, prosthetic valve type, preoperative catheterization data, and early postoperative conditions were analyzed as possible predictors of outcome. Functional recovery was evaluated using the SF-36 quality assessment tool.

RESULTS

Operative mortality was 6.1% (15/247). Multivariate logistic regression showed that poor left ventricular function and preoperative pacemaker insertion were independent predictors of early mortality. After surgery, infection was predictive of early mortality. Overall actuarial survival at 1, 5, and 10 years was 89.5 +/- 2% (198 patients at risk), 69.3 +/- 3.4% (89 patients at risk), and 41.2 +/- 6% (13 patients at risk), respectively. Cox proportional hazards model showed that chronic obstructive pulmonary disease and urgency of operation were independent predictors of poor long-term survival. Postoperative renal failure also was predictive of poor outcome. Using the SF-36 quality assessment tool, elderly patients who underwent AVR scored comparably to their age-matched population norms in seven of eight dimensions of overall health. The exception is mental health.

CONCLUSIONS

Aortic valve replacement in the elderly can be performed with acceptable mortality. Significant preoperative risk factors for early mortality include poor left ventricular function and preoperative pacemaker insertion. Predictors of late mortality include chronic obstructive pulmonary disease and urgency of operation. These results stress the importance of operating on the elderly with aortic valve disease; both long-term survival and functional recovery are excellent.

Tumor infarction in mice by antibody-directed targeting of tissue factor to tumor vasculature

Selective occlusion of tumor vasculature was tested as a therapy for solid tumors in a mouse model. The formation of blood clots (thrombosis) within the tumor vessels was initiated by targeting the cell surface domain of human tissue factor, by means of a bispecific antibody, to an experimentally induced marker on tumor vascular endothelial cells. This truncated form of tissue factor (tTF) had limited ability to initiate thrombosis when free in the circulation, but became an effective and selective thrombogen when targeted to tumor endothelial cells. Intravenous administration of the antibody-tTF complex to mice with large neuroblastomas resulted in complete tumor regressions in 38 percent of the mice.

Bioprosthetic versus mechanical prostheses for aortic valve replacement in the elderly

BACKGROUND

Many centers advocate bioprosthetic valves in the elderly to avoid anticoagulation, in particular when patient survival is less than the expected valve durability. Because expected survival in the elderly is increasing and age-specific risk of anticoagulation in the elderly is not known, we examined valve- and anticoagulation-related morbidity in elderly patients after aortic valve replacement (AVR) with bioprostheses or mechanical prostheses.

METHODS AND RESULTS

Between January 1980 and June 1994, 211 patients age > or = 70 years underwent isolated AVR; there were 109 men (52%) and 102 women (48%). Mean age was 75.9 +/- 4.8 years. Aortic stenosis was present in 194 (92%) patients. Bioprostheses were used in 145 (69%) and mechanical prostheses were used in 66 (31%). Chronic anticoagulation was maintained in all patients with a mechanical valve and in 18 patients (12%) with a bioprosthetic valve. Follow-up data were obtained for 98% (194 of 197) of hospital survivors at a mean follow-up of 3.8 years. Operative mortality was 6.6%; survival at 3 and 5 years was 75.3 +/- 3% and 64.6 +/- 4%, respectively. There was no significant difference in operative or late mortality between patient groups. Rates of freedom from thromboembolic events, endocarditis and anticoagulant-related hemorrhage for bioprosthetic and mechanical valve patients were similar. Prosthetic failure was identified in three bioprosthetic valves (2%); furthermore, the 4 patients in the series who required reoperation had received bioprostheses at the first operation.

CONCLUSIONS

In conclusion, (1) elderly patients undergoing isolated AVR can be managed with either mechanical or bioprosthetic valves with similar early and late risk, as long as there are no specific contraindications to anticoagulation; (2) anticoagulation-related risk of hemorrhage is low in this group of elderly patients; and (3) the low but significant risk of reoperation following the use of bioprostheses suggests that mechanical valves may be underused in the elderly.

Neurologic injury in cardiac surgical patients with a history of stroke

BACKGROUND

Controversy still exists as to whether patients with previous stroke are at increased risk for neurologic complications after heart operations.

METHODS

We performed a prospective analysis of 1,000 consecutive patients undergoing cardiac operations requiring cardiopulmonary bypass, without hypothermic circulatory arrest. Of the 1,000 patients, 71 had previously documented stroke (study group); 2 control patients with no history of stroke were selected for each of these patients (control group, n = 142). There were no significant differences between the study and control patients with respect to established risk factors for neurologic complications.

RESULTS

Compared with controls, study patients took longer to awaken (12.6 +/- 10.9 versus 3.5 +/- 2.1 hours; p < 0.0001) and longer to extubate (29.5 +/- 29.3 versus 9.1 +/- 5.2 hours; p < 0.001), and had a greater incidence of reintubation (7 of 71, 9.9% versus 2 of 142, 1.4%; p < 0.01) and postoperative confusion (26 of 71, 36.6% versus 7 of 142, 4.9%; p < 0.001). There was a higher incidence of focal neurologic deficit among study patients (31 of 71, 43.7% versus 2 of 142, 1.4%; p < 0.001). These deficits included new stroke (6 of 71, 8.5%) as well as the reappearance of previous deficits (19 of 71, 26.8%) or worsening of previous deficits (6 of 71, 8.5%), without new abnormalities on head computed tomography or magnetic resonance imaging. Study patients with neurologic deficit had longer cardiopulmonary bypass times than did study patients without deficit (146 +/- 48.5 versus 110 +/- 43.3 minutes; p < 0.001). The 30-day mortality rate was greater in study patients than in controls (5 of 71, 7% versus 1 of 142, 0.7%; p < 0.02), with four deaths among the 6 study patients with a new stroke (66.7%).

CONCLUSION

This analysis identifies a group of patients at high risk for neurologic sequelae and confirms the vulnerability of the previously injured brain to cardiopulmonary bypass, as evidenced by reappearance or exacerbation of focal deficits in such patients.

The effect of hypoxia on baroreflexes and pressor sensitivity in sleep apnea and hypertension

Many persons with sleep apnea are hypertensive. Forty-two subjects of similar age and weight were divided into four groups of hypertensives and normotensives with and without sleep apnea. All subjects had heart rate, blood pressure (BP), baroreflex sensitivity and pressor sensitivity to phenylephrine measured while breathing room air or 15% oxygen. Hypoxia raised heart rate and lowered BP in all groups (p < 0.001), with the greatest hypotensive effect among hypertensives. Hypertensives had blunted baroreflex sensitivity, and breathing a hypoxic mixture lowered baroreflex sensitivity of all four groups (p = 0.008). The apneic subjects tended to lower their baroreflex sensitivity more in response to hypoxia and also had an enhanced pressor response to phenylephrine, whether breathing room air or 15% oxygen. Episodes of sleep apnea lead to hypoxia, an initial period of hypotension and a subsequent increase in sympathetic nervous activity. Our studies suggest that apneics could have an exaggerated pressor sensitivity to norepinephrine. They might also have difficulty returning BP to normal levels, because hypoxia impaired baroreflexes.