Medical management and surgery versus medical management alone for symptomatic cerebral cavernous malformation (CARE): a feasibility study and randomised, open, pragmatic, pilot phase trial

BACKGROUND

The highest priority uncertainty for people with symptomatic cerebral cavernous malformation is whether to have medical management and surgery or medical management alone. We conducted a pilot phase randomised controlled trial to assess the feasibility of addressing this uncertainty in a definitive trial.

METHODS

The CARE pilot trial was a prospective, randomised, open-label, assessor-blinded, parallel-group trial at neuroscience centres in the UK and Ireland. We aimed to recruit 60 people of any age, sex, and ethnicity who had mental capacity, were resident in the UK or Ireland, and had a symptomatic cerebral cavernous malformation. Computerised, web-based randomisation assigned participants (1:1) to medical management and surgery (neurosurgical resection or stereotactic radiosurgery) or medical management alone, stratified by the neurosurgeon's and participant's consensus about the intended type of surgery before randomisation. Assignment was open to investigators, participants, and carers, but not clinical outcome event adjudicators. Feasibility outcomes included site engagement, recruitment, choice of surgical management, retention, adherence, data quality, clinical outcome event rate, and protocol implementation. The primary clinical outcome was symptomatic intracranial haemorrhage or new persistent or progressive non-haemorrhagic focal neurological deficit due to cerebral cavernous malformation or surgery during at least 6 months of follow-up. We analysed data from all randomly assigned participants according to assigned management. This trial is registered with ISRCTN (ISRCTN41647111) and has been completed.

FINDINGS

Between Sept 27, 2021, and April 28, 2023, 28 (70%) of 40 sites took part, at which investigators screened 511 patients, of whom 322 (63%) were eligible, 202 were approached for recruitment, and 96 had collective uncertainty with their neurosurgeon about whether to have surgery for a symptomatic cerebral cavernous malformation. 72 (22%) of 322 eligible patients were randomly assigned (mean recruitment rate 0·2 [SD 0·25] participants per site per month) at a median of 287 (IQR 67-591) days since the most recent symptomatic presentation. Participants' median age was 50·6 (IQR 38·6-59·2) years, 68 (94%) of 72 participants were adults, 41 (57%) were female, 66 (92%) were White, 56 (78%) had a previous intracranial haemorrhage, and 28 (39%) had a previous epileptic seizure. The intended type of surgery before randomisation was neurosurgical resection for 19 (26%) of 72, stereotactic radiosurgery for 44 (61%), and no preference for nine (13%). Baseline clinical and imaging data were complete for all participants. 36 participants were randomly assigned to medical management and surgery (12 to neurosurgical resection and 24 to stereotactic radiosurgery) and 36 to medical management alone. Three (4%) of 72 participants withdrew, one was lost to follow-up, and one declined face-to-face follow-up, leaving 67 (93%) retained at 6-months' clinical follow-up. 61 (91%) of 67 participants with follow-up adhered to the assigned management strategy. The primary clinical outcome occurred in two (6%) of 33 participants randomly assigned to medical management and surgery (8·0%, 95% CI 2·0-32·1 per year) and in two (6%) of 34 participants randomly assigned to medical management alone (7·5%, 1·9-30·1 per year). Investigators reported no deaths, no serious adverse events, one protocol violation, and 61 protocol deviations.

INTERPRETATION

This pilot phase trial exceeded its recruitment target, but a definitive trial will require extensive international engagement.

FUNDING

National Institute for Health and Care Research.

Diffusion MRI of the facial-vestibulocochlear nerve complex: a prospective clinical validation study

OBJECTIVES

Surgical planning of vestibular schwannoma surgery would benefit greatly from a robust method of delineating the facial-vestibulocochlear nerve complex with respect to the tumour. This study aimed to optimise a multi-shell readout-segmented diffusion-weighted imaging (rs-DWI) protocol and develop a novel post-processing pipeline to delineate the facial-vestibulocochlear complex within the skull base region, evaluating its accuracy intraoperatively using neuronavigation and tracked electrophysiological recordings.

METHODS

In a prospective study of five healthy volunteers and five patients who underwent vestibular schwannoma surgery, rs-DWI was performed and colour tissue maps (CTM) and probabilistic tractography of the cranial nerves were generated. In patients, the average symmetric surface distance (ASSD) and 95% Hausdorff distance (HD-95) were calculated with reference to the neuroradiologist-approved facial nerve segmentation. The accuracy of patient results was assessed intraoperatively using neuronavigation and tracked electrophysiological recordings.

RESULTS

Using CTM alone, the facial-vestibulocochlear complex of healthy volunteer subjects was visualised on 9/10 sides. CTM were generated in all 5 patients with vestibular schwannoma enabling the facial nerve to be accurately identified preoperatively. The mean ASSD between the annotators' two segmentations was 1.11 mm (SD 0.40) and the mean HD-95 was 4.62 mm (SD 1.78). The median distance from the nerve segmentation to a positive stimulation point was 1.21 mm (IQR 0.81-3.27 mm) and 2.03 mm (IQR 0.99-3.84 mm) for the two annotators, respectively.

CONCLUSIONS

rs-DWI may be used to acquire dMRI data of the cranial nerves within the posterior fossa.

CLINICAL RELEVANCE STATEMENT

Readout-segmented diffusion-weighted imaging and colour tissue mapping provide 1-2 mm spatially accurate imaging of the facial-vestibulocochlear nerve complex, enabling accurate preoperative localisation of the facial nerve. This study evaluated the technique in 5 healthy volunteers and 5 patients with vestibular schwannoma.

KEY POINTS

• Readout-segmented diffusion-weighted imaging (rs-DWI) with colour tissue mapping (CTM) visualised the facial-vestibulocochlear nerve complex on 9/10 sides in 5 healthy volunteer subjects. • Using rs-DWI and CTM, the facial nerve was visualised in all 5 patients with vestibular schwannoma and within 1.21-2.03 mm of the nerve's true intraoperative location. • Reproducible results were obtained on different scanners.

Generating Operative Workflows for Vestibular Schwannoma Resection: A Two-Stage Delphi's Consensus in Collaboration with the British Skull Base Society. Part 2: The Translabyrinthine Approach

Objective  An operative workflow systematically compartmentalizes operations into hierarchal components of phases, steps, instrument, technique errors, and event errors. Operative workflow provides a foundation for education, training, and understanding of surgical variation. In this Part 2, we present a codified operative workflow for the translabyrinthine approach to vestibular schwannoma resection. Methods  A mixed-method consensus process of literature review, small-group Delphi's consensus, followed by a national Delphi's consensus was performed in collaboration with British Skull Base Society (BSBS). Each Delphi's round was repeated until data saturation and over 90% consensus was reached. Results  Seventeen consultant skull base surgeons (nine neurosurgeons and eight ENT [ear, nose, and throat]) with median of 13.9 years of experience (interquartile range: 18.1 years) of independent practice participated. There was a 100% response rate across both the Delphi rounds. The translabyrinthine approach had the following five phases and 57 unique steps: Phase 1, approach and exposure; Phase 2, mastoidectomy; Phase 3, internal auditory canal and dural opening; Phase 4, tumor debulking and excision; and Phase 5, closure. Conclusion  We present Part 2 of a national, multicenter, consensus-derived, codified operative workflow for the translabyrinthine approach to vestibular schwannomas. The five phases contain the operative, steps, instruments, technique errors, and event errors. The codified translabyrinthine approach presented in this manuscript can serve as foundational research for future work, such as the application of artificial intelligence to vestibular schwannoma resection and comparative surgical research.

Generating Operative Workflows for Vestibular Schwannoma Resection: A Two-Stage Delphi's Consensus in Collaboration with the British Skull Base Society. Part 1: The Retrosigmoid Approach

Objective  An operative workflow systematically compartmentalizes operations into hierarchal components of phases, steps, instrument, technique errors, and event errors. Operative workflow provides a foundation for education, training, and understanding of surgical variation. In this Part 1, we present a codified operative workflow for the retrosigmoid approach to vestibular schwannoma resection. Methods  A mixed-method consensus process of literature review, small-group Delphi's consensus, followed by a national Delphi's consensus, was performed in collaboration with British Skull Base Society (BSBS). Each Delphi's round was repeated until data saturation and over 90% consensus was reached. Results  Eighteen consultant skull base surgeons (10 neurosurgeons and 8 ENT [ear, nose, and throat]) with median 17.9 years of experience (interquartile range: 17.5 years) of independent practice participated. There was a 100% response rate across both Delphi's rounds. The operative workflow for the retrosigmoid approach contained three phases and 40 unique steps as follows: phase 1, approach and exposure; phase 2, tumor debulking and excision; phase 3, closure. For the retrosigmoid approach, technique, and event error for each operative step was also described. Conclusion  We present Part 1 of a national, multicenter, consensus-derived, codified operative workflow for the retrosigmoid approach to vestibular schwannomas that encompasses phases, steps, instruments, technique errors, and event errors. The codified retrosigmoid approach presented in this manuscript can serve as foundational research for future work, such as operative workflow analysis or neurosurgical simulation and education.

Benchtop simulation of the retrosigmoid approach: Validation of a surgical simulator and development of a task-specific outcome measure score

Background

Neurosurgical training is changing globally. Reduced working hours and training opportunities, increased patient safety expectations, and the impact of COVID-19 have reduced operative exposure. Benchtop simulators enable trainees to develop surgical skills in a controlled environment. We aim to validate a high-fidelity simulator model (RetrosigmoidBox, UpSurgeOn) for the retrosigmoid approach to the cerebellopontine angle (CPA).

Methods

Novice and expert Neurosurgeons and Ear, Nose, and Throat surgeons performed a surgical task using the model - identification of the trigeminal nerve. Experts completed a post-task questionnaire examining face and content validity. Construct validity was assessed through scoring of operative videos employing Objective Structured Assessment of Technical Skills (OSATS) and a novel Task-Specific Outcome Measure score.

Results

Fifteen novice and five expert participants were recruited. Forty percent of experts agreed or strongly agreed that the brain tissue looked real. Experts unanimously agreed that the RetrosigmoidBox was appropriate for teaching. Statistically significant differences were noted in task performance between novices and experts, demonstrating construct validity. Median total OSATS score was 14/25 (IQR 10-19) for novices and 22/25 (IQR 20-22) for experts (p < 0.05). Median Task-Specific Outcome Measure score was 10/20 (IQR 7-17) for novices compared to 19/20 (IQR 18.5-19.5) for experts (p < 0.05).

Conclusion

The RetrosigmoidBox benchtop simulator has a high degree of content and construct validity and moderate face validity. The changing landscape of neurosurgical training mean that simulators are likely to become increasingly important in the delivery of high-quality education. We demonstrate the validity of a Task-Specific Outcome Measure score for performance assessment of a simulated approach to the CPA.

Feasibility of comparing medical management and surgery (with neurosurgery or stereotactic radiosurgery) with medical management alone in people with symptomatic brain cavernoma - protocol for the Cavernomas: A Randomised Effectiveness (CARE) pilot trial

INTRODUCTION

The top research priority for cavernoma, identified by a James Lind Alliance Priority setting partnership was 'Does treatment (with neurosurgery or stereotactic radiosurgery) or no treatment improve outcome for people diagnosed with a cavernoma?' This pilot randomised controlled trial (RCT) aims to determine the feasibility of answering this question in a main phase RCT.

METHODS AND ANALYSIS

We will perform a pilot phase, parallel group, pragmatic RCT involving approximately 60 children or adults with mental capacity, resident in the UK or Ireland, with an unresected symptomatic brain cavernoma. Participants will be randomised by web-based randomisation 1:1 to treatment with medical management and with surgery (neurosurgery or stereotactic radiosurgery) versus medical management alone, stratified by prerandomisation preference for type of surgery. In addition to 13 feasibility outcomes, the primary clinical outcome is symptomatic intracranial haemorrhage or new persistent/progressive focal neurological deficit measured at 6 monthly intervals. An integrated QuinteT Recruitment Intervention (QRI) evaluates screening logs, audio recordings of recruitment discussions, and interviews with recruiters and patients/parents/carers to identify and address barriers to participation. A Patient Advisory Group has codesigned the study and will oversee its progress.

ETHICS AND DISSEMINATION

This study was approved by the Yorkshire and The Humber-Leeds East Research Ethics Committee (21/YH/0046). We will submit manuscripts to peer-reviewed journals, describing the findings of the QRI and the Cavernomas: A Randomised Evaluation (CARE) pilot trial. We will present at national specialty meetings. We will disseminate a plain English summary of the findings of the CARE pilot trial to participants and public audiences with input from, and acknowledgement of, the Patient Advisory Group.

TRIAL REGISTRATION NUMBER

ISRCTN41647111.

A synthetic model simulator for intracranial aneurysm clipping: validation of the UpSurgeOn AneurysmBox

Background and objectives

In recent decades, the rise of endovascular management of aneurysms has led to a significant decline in operative training for surgical aneurysm clipping. Simulation has the potential to bridge this gap and benchtop synthetic simulators aim to combine the best of both anatomical realism and haptic feedback. The aim of this study was to validate a synthetic benchtop simulator for aneurysm clipping (AneurysmBox, UpSurgeOn).

Methods

Expert and novice surgeons from multiple neurosurgical centres were asked to clip a terminal internal carotid artery aneurysm using the AneurysmBox. Face and content validity were evaluated using Likert scales by asking experts to complete a post-task questionnaire. Construct validity was evaluated by comparing expert and novice performance using the modified Objective Structured Assessment of Technical Skills (mOSATS), developing a curriculum-derived assessment of Specific Technical Skills (STS), and measuring the forces exerted using a force-sensitive glove.

Results

Ten experts and eighteen novices completed the task. Most experts agreed that the brain looked realistic (8/10), but far fewer agreed that the brain felt realistic (2/10). Half the expert participants (5/10) agreed that the aneurysm clip application task was realistic. When compared to novices, experts had a significantly higher median mOSATS (27 vs. 14.5; p < 0.01) and STS score (18 vs. 9; p < 0.01); the STS score was strongly correlated with the previously validated mOSATS score (p < 0.01). Overall, there was a trend towards experts exerting a lower median force than novices, however, these differences were not statistically significant (3.8 N vs. 4.0 N; p = 0.77). Suggested improvements for the model included reduced stiffness and the addition of cerebrospinal fluid (CSF) and arachnoid mater.

Conclusion

At present, the AneurysmBox has equivocal face and content validity, and future versions may benefit from materials that allow for improved haptic feedback. Nonetheless, it has good construct validity, suggesting it is a promising adjunct to training.

Risk of Aneurysm Rupture (ROAR) study: protocol for a long-term, longitudinal, UK multicentre study of unruptured intracranial aneurysms

INTRODUCTION

Unruptured intracranial aneurysms (UIA) are common in the adult population, but only a relatively small proportion will rupture. It is therefore essential to have accurate estimates of rupture risk to target treatment towards those who stand to benefit and avoid exposing patients to the risks of unnecessary treatment. The best available UIA natural history data are the PHASES study. However, this has never been validated and given the known heterogeneity in the populations, methods and biases of the constituent studies, there is a need to do so. There are also many potential predictors not considered in PHASES that require evaluation, and the estimated rupture risk is largely based on short-term follow-up (mostly 1 year). The aims of this study are to: (1) test the accuracy of PHASES in a UK population, (2) evaluate additional predictors of rupture and (3) assess long-term UIA rupture rates.

METHODS AND ANALYSIS

The Risk of Aneurysm Rupture study is a longitudinal multicentre study that will identify patients with known UIA seen in neurosurgery units. Patients will have baseline demographics and aneurysm characteristics collected by their neurosurgery unit and then a single aggregated national cohort will be linked to databases of hospital admissions and deaths to identify all patients who may have subsequently suffered a subarachnoid haemorrhage. All matched admissions and deaths will be checked against medical records to confirm the diagnosis of aneurysmal subarachnoid haemorrhage. The target sample size is 20 000 patients. The primary outcome will be aneurysm rupture resulting in hospital admission or death. Cox regression models will be built to test each of the study's aims.

ETHICS AND DISSEMINATION

Ethical approval has been given by South Central Hampshire A Research Ethics Committee (21SC0064) and Confidentiality Advisory Group support (21CAG0033) provided under Section 251 of the NHS Act 2006. The results will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN17658526.

Radiological follow-up of endovascularly treated intracranial aneurysms: a survey of current practice in the UK and Ireland

PURPOSE

Due to the risk of intracranial aneurysm (IA) recurrence and the potential requirement for re-treatment following endovascular treatment (EVT), radiological follow-up of these aneurysms is necessary. There is little evidence to guide the duration and frequency of this follow-up. The aim of this study was to establish the current practice in neurosurgical units in the UK and Ireland.

METHODS

A survey was designed with input from interventional neuroradiologists and neurosurgeons. Neurovascular consultants in each of the 30 neurosurgical units providing a neurovascular service in the UK and Ireland were contacted and asked to respond to questions regarding the follow-up practice for IA treated with EVT in their department.

RESULTS

Responses were obtained from 28/30 (94%) of departments. There was evidence of wide variations in the duration and frequency of follow-up, with a minimum follow-up duration for ruptured IA that varied from 18 months in 5/28 (18%) units to 5 years in 11/28 (39%) of units. Young patient age, previous subarachnoid haemorrhage and incomplete IA occlusion were cited as factors that would prompt more intensive surveillance, although larger and broad-necked IA were not followed-up more closely in the majority of departments.

CONCLUSIONS

There is a wide variation in the radiological follow-up of IA treated with EVT in the UK and Ireland. Further standardisation of this aspect of patient care is likely to be beneficial, but further evidence on the behaviour of IA following EVT is required in order to inform this process.

Role of power distance phenomena in blended learning in higher education post-Covid-19

COVID has posed several challenges for higher education. There is a rise in blended teaching and learning models that can improve the quality of education, observed Raman. Classroom interaction vital in quality of education is affected by power distance between the teacher and students, states Kasuya. Much research has been done on blended learning but hardly any on the role of power distance in blended learning in higher education, specifically post COVID. Keeping in mind the growing significance of blended learning shortly, it becomes strategically important to understand the role of power distance in blended learning in higher education post-COVID-19. This research paper tries to address the research gap. The study is exploratory, exploring the role of power distancing in blended learning formats during post-COVID-19. The findings indicate that there is a relationship between power distance and the autonomy of an individual. The higher the power distance between a teacher and a student from the teacher’s perspective, it becomes teacher-centred learning. So blended learning with the best of low power distances in terms of the media and delivery mechanism of offline and online ensures the mitigation of power between the teacher and the taught. The research will help the universities create a perfect blended learning format that enhances the quality of higher education. Due to the paucity of time and resources and a ban on respondent interaction due to pandemics, this research is based on secondary data analysis.

Optical properties of human brain and tumour tissue: An ex vivo study spanning the visible range to beyond the second near-infrared window

Neuro-oncology surgery would benefit from detailed intraoperative tissue characterization provided by noncontact, contrast-agent-free, noninvasive optical imaging methods. In-depth knowledge of target tissue optical properties across a wide-wavelength spectrum could inform the design of optical imaging and computational methods to enable robust tissue analysis during surgery. We adapted a dual-beam integrating sphere to analyse small tissue samples and investigated ex vivo optical properties of five types of human brain tumour (meningioma, pituitary adenoma, schwannoma, low- and high-grade glioma) and nine different types of healthy brain tissue across a wavelength spectrum of 400 to 1800 nm. Fresh and frozen tissue samples were analysed. All tissue types demonstrated similar absorption spectra, but the reduced scattering coefficients of tumours show visible differences in the obtained optical spectrum compared to those of surrounding normal tissue. These results underline the potential of optical imaging technologies for intraoperative tissue characterization.

Surgery for cerebral cavernous malformations: a systematic review and meta-analysis

BACKGROUND

We sought to quantify the risks of neurosurgical excision of cerebral cavernous malformations (CCMs) in a systematic review of cohort studies.

METHODS

We updated our previous systematic review by searching OVID Medline, OVID EMBASE, and the Cochrane Library from 1 January 2013 to 30 April 2019. The primary outcome was a composite of death attributed to CCM or surgery, non-fatal symptomatic intracerebral haemorrhage (ICH), or new or worsened persistent non-haemorrhagic focal neurological deficit (FND).

RESULTS

We included 70 cohorts, 67 reporting surgery alone, and three compared surgery to conservative management. A total of 5,089 patients (median age 36 years, 52% female) underwent surgery (total follow-up 19,404 patient-years). The annual rate of the composite outcome was 4.2% (95% CI 2.9 to 5.7; 46 cohorts; I² = 93%), which was higher in cohorts reporting exclusively brainstem CCM (6.0%, 95% CI 4.1-8.3; 25 cohorts, I² = 92%) versus predominantly supratentorial CCM (2.4%, 95% CI 1.3-3.8, 21 cohorts, I² = 86%, p_het = 0.001). The annual rate of the composite outcome was higher in cohorts with > 95% presenting with ICH (6.1%, 95% CI 4.2-8.4; 23 cohorts, I² = 93%) versus others (2.3%, 95% CI 1.2-3.7; 23 cohorts, I² = 83%, p_het = 0.001). The incidence of the composite outcome did not change over time in cohorts of exclusively brainstem CCM (p = 0.7) or predominantly supratentorial CCM (p = 0.5).

CONCLUSIONS

The risk of death, ICH, or FND after CCM excision is ~ 4%. This risk is higher for brainstem CCM and CCM that have caused ICH but has not changed over time.

TRIAL REGISTRATION

This systematic review was registered (PROSPERO CRD42019131246).

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

Implementation of the Vinehealth application, a digital health tool, into the care of patients living with brain cancer

e13582

Background: Cancers of the brain lead to significant neurocognitive, physical and psychological morbidities. Digital technologies provide a novel platform to capture and evaluate these needs. Mobile health (mHealth) applications typically focus on one aspect of care rather than addressing the multimodal needs of the demographic of these patients. The Vinehealth application aims to address this by tracking symptoms, delivering machine learning-based personalised educational content, and facilitating reminders for medications and appointments. Where mHealth interventions traditionally lack the evidence-based approach of pharmaceuticals, this study acts as an initial step in the rigorous assessment of a new digital health tool. Methods: A mixed methodology approach was applied to evaluate the Vinehealth application as a care delivery adjunct. Patients with brain cancer were recruited from the day of their procedure ± 7 days. Over a 12-week period, we collected real-world and ePRO data via the application. We assessed qualitative feedback from mixed-methodology surveys and semi-structured interviews at onboarding and after two weeks of application use. Results: Six participants enrolled of whom four downloaded the application; four completed all interviews. One patient set up their device incorrectly and so couldn't receive the questionnaires; excluding this patient, the EQ-5D-5L and EORTC QLQ-BN20 completion rates were 100% and 83% respectively. Average scores (±SD) at onboarding and offboarding were EQ-5D-5L: 2.07±1.28 and 1.73±1.22, and QLQ-BN20: 13.33 and 22.5. In total: 212 symptoms, 174 activity, and 47 medication data points were captured, and 113 educational articles were read. Participants were generally optimistic about application use. All users stated they would recommend Vinehealth and expressed subjective improvements in care. Accessibility issues in the ePRO delivery system which impacted completion rate were identified and have subsequently been fully addressed. Conclusions: This feasibility study showed acceptable patient use, led to a subjective improvement in care, and demonstrated effective collection of real-world and validated ePRO data. This provides a strong basis to further explore the integration of the Vinehealth application into brain cancer care. This study will inform the design of a larger, more comprehensive trial continuing to evaluate improvements in care delivery through data collection, educational support and patient empowerment.

TP1-1 Endovascular versus surgical management of pericallosal artery aneurysms, single centre experience

Objectives

Comparing surgical versus endovascular management of pericallosal artery aneurysm.

Design

Retrospective case series.

Subjects

Patients managed in our unit for pericallosal artery aneurysms.

Methods

Patients medical and radiological records were reviewed collecting data about presentation, management, complications. Clinical outcome was assessed by mRS at 3,6 and 12 months. Imaging were reviewed to report aneurysm size and treatment outcome.

Results

Average follow up period 3.3 years SD ±3.5. 38 patients had SAH and 19 were incidentally discovered. Initial CT showed SAH in 21 patients, IVH in 3,ICH in 3 IVH and ICH in 9. 33 patients treated using endovascularly, 13 patients conservatively and 2 by surgical clipping. 33% of endovascular group had stroke caused by approach related complications. 41.3% of the patients had mRS (0–2) at 3 months period. Increased to 46.5% at 12 months. Average imaging follow up was 1.5 years (SD ±1.6). 36.3% of endovascular group showed aneurysm remnant filling or recurrence.

Conclusions

Pericallosal artery aneurysms are complex in nature and both management modalities are challenging. Complications were high in endovascular group. Surgical intervention should be considered in selected patients where complex intervention is required.

WM1-5 Predictors of retreatment of anterior communicating artery aneurysms after endovascular embolisation

Objectives

To establish recurrence and retreatment rates of anterior communicating artery aneurysms (ACom) after endovascular embolization and the complication rate of retreatment. To establish predicting morphological characteristics that would favour surgery or endovascular coiling.

Design

Retrospective review of all ACom aneurysms treated at a single neurological centre over a thirteen-year period.

Subjects

Patients undergoing endovascular treatment of ACom aneurysms.

Methods

Aneurysm and patient characteristics were recorded for retreated patients. Analysis of retreatment predictors on imaging was made.

Results

Between 2005 and 2018, 510 Acom aneurysms were treated, of which 456 presented with SAH and 54 were elective. Out of these, 36 underwent re-treatment. Out of the re-treated aneurysms 33 were identified from radiological follow up and three presented with a re-bleed. The complication rate from the second endovascular procedure was 5.6%. Four patients underwent surgical clipping after failed coiling. Retreatment was more likely in ruptured aneurysms. The dome shape, size (mm) and orientation, were recorded for both aneurysms requiring retreatment and aneurysms successfully excluded after the first procedure. Other parameters reported included time interval, coiling technique (balloon-assisted/stent-assisted).

Conclusions

Recurrence of Acom aneurysms after coiling carries significant morbidity. Recognising predictors of recurrence would help identify those aneurysms that are better treated with surgery.

Mechanical characterization of fourth generation composite humerus

Mechanical data on upper extremity surrogate bones, supporting use as biomechanical tools, is limited. The objective of this study was to characterize the structural behaviour of the fourth-generation composite humerus under simulated physiologic bending, specifically, stiffness, rigidity, and mid-diaphysial surface strains. Three humeri were tested in four-point bending, in anatomically defined anteroposterior (AP) and mediolateral (ML) planes. Stiffness and rigidity were derived using load–displacement data. Principal strains were determined at the anterior, posterior, medial, and lateral surfaces in the humeral mid-diaphysial transverse plane of one specimen using stacked rosettes. Linear structural behaviour was observed within the test range. Average stiffness and rigidity were greater in the ML (918 ± 18 N/mm; 98.4 ± 1.9 Nm2) than the AP plane (833 ± 16 N/mm; 89.3 ± 1.6 Nm2), with little inter-specimen variability. The ML/AP rigidity ratio was 1.1. Surface principal strains were similar at the anterior (5.41 µε/N) and posterior (5.43 µε/N) gauges for AP bending, and comparatively less for ML bending, i.e. 5.1 and 4.5 µε/N, at the medial and lateral gauges, respectively. This study provides novel strain and stiffness data for the fourth-generation composite humerus and also adds to published construct rigidity data. The presented results support the use of this composite bone as a tool for modelling and experimentation.

Serum lipid peroxidation and antioxidant enzyme levels in male and female diabetic patients

INTRODUCTION

The depletion of defensive body chemicals called antioxidants may increase the risk of complications from the most common form of diabetes mellitus. This study aims to evaluate blood serum lipid peroxidation product (malondialdehyde), an antioxidant, in non-insulin dependent male and female type 2 diabetic patients.

METHODS

Blood serum samples were collected from the diabetic patients and non-diabetic healthy controls. Malondialdehyde (MDA) level, which is an index of endogenous lipid peroxidation, reduced glutathione and protein content of the serum were estimated.

RESULTS

A significant elevation in MDA level and decrease in glutathione and protein content was observed in both male and female diabetic patients in comparison to non-diabetic controls.

CONCLUSION

Our findings indicate that the increase in the lipid peroxidation product MDA and decline in glutathione-dependent antioxidant defences may appear early in non-insulin dependent type 2 diabetes mellitus patients before the development of secondary complications.

In vivo genotoxic effect of nickel chloride in mice leukocytes using comet assay

DNA damage induced by nickel chloride (NiCl2) in leucocytes of Swiss albino mice has been studied in vivo. The comet assay or the alkaline single cell gel electrophoresis (SCGE) assay was used to measure the DNA damage. The mice were administered orally with acute doses of 3.4, 6.8, 13.6, 27.2, 54.4 and 108.8 mg/kg body weight (b.wt.) NiCl2. Samples of whole blood were collected at 24, 48 and 72 h, first week and second week post-treatment for alkaline SCGE assay to study single/double strand breaks in DNA. A significant increase in mean comet tail length indicating DNA damage was observed with NiCl2 at 24, 48 and 72 h post-treatment (P<0.05). A gradual decrease in the mean tail length was observed at 72 h post-treatment indicating repair of the damaged DNA. The mean tail length showed a dose-related increase and time dependent decrease after treatment with NiCl2 when compared to controls. The study also confirms that the comet assay is a sensitive and rapid method to detect DNA damage caused by heavy metals like nickel (Ni).

In vivo genotoxic effect of cadmium chloride in mice leukocytes using comet assay

The alkaline single cell gel electrophoresis (SCGE) or "comet" assay under alkaline conditions was used to measure DNA damage in the leukocytes of Swiss Albino male mice exposed to cadmium chloride (CdCl(2)). The effect of CdCl(2) was studied after a single acute oral administration of a range of doses starting from 0.5 to 128.0 mg/kg b.wt of CdCl(2). The samples of whole blood were collected from each mouse at 24, 48, 72, and 96 h post-treatment to study single/double strand breaks in DNA. A significant increase in mean comet tail length indicating DNA damage was observed with CdCl(2) at 24 h post-treatment (P<0.05) with CdCl(2) when compared to controls. A gradual decrease in the mean tail length was observed at 48 h post-treatment indicating repair of the damaged DNA. The mean tail length showed a dose-related increase and time-dependent decrease after treatment with CdCl(2) when compared to controls. The study also confirms that the comet assay is a sensitive and rapid method to detect DNA damage caused by heavy metal like Cadmium (Cd).

In vivo genotoxic effects of mercuric chloride in rat peripheral blood leucocytes using comet assay

DNA damage induced by Mercuric chloride (HgCl2) in leucocytes of Wistar albino male rats has been studied in vivo. The comet assay or the alkaline single cell gel electrophoresis (SCGE) assay was used to measure the DNA damage. The rats were administered orally with doses ranging from 0.0054, 0.0108, 0.0216, 0.0432 to 0.0864 mg/kg body weight (b.wt.) of HgCl2. The assay was performed on whole blood at 24, 48, 72 h, 1st and 2nd week. The reason leucocytes were used was to reflect biomarker studies in humans. A significant increase in mean comet tail length indicating DNA damage was observed at all time intervals with HgCl2 except in 2nd week post treatment when compared to controls. The mean comet tail length revealed a clear dose dependent increase from 0.0054 to 0.0432 mg/kg b.wt. A maximum increase in mean comet tail length was observed at 0.0432 mg/kg b.wt. 24 h after treatment. From 48 h post treatment, the mean comet tail lengths of all the doses gradually decreased and by week 2 of post treatment, they had approached control levels, pointing to repair of the damaged DNA. These findings suggest that the comet assay is a highly sensitive technique to study DNA damage caused by metals.

In vivo genotoxic effect of potassium dichromate in mice leukocytes using comet assay

Hexavalent chromium is a well-known mutagen and carcinogen. In the present investigation, single-/double-stranded DNA breaks by potassium dichromate (K2Cr2O7) in mice, a sensitive model for genotoxic effects, have been studied in vivo using alkaline single-cell gel electrophoresis (SCGE)/comet assay. Mice were administered orally with a range of doses starting from 0.59 to 76.0 mg/kg body weight of K2Cr2O7 and samples of whole blood were collected at 24, 48, 72, 96 h, week 1 and week 2 post-treatment for alkaline SCGE assay to study DNA damage. The rationale for using leukocytes was to reflect biomarker analysis in humans. Significant increase in mean comet tail length (5.7-24.25 microM) indicating DNA damage was observed at all the doses with K2Cr2O7 when compared with controls (3.26 microM). Maximum increase in mean comet tail length was observed at 9.5 mg/kg body weight at 48 h post-treatment (24.25 microM). The mean comet tail length showed a clear dose-dependent increase from 0.59 to 9.5 mg/kg body weight and a dose-dependent decrease in higher doses (19.0-76.0 mg/kg body weight). A gradual decrease in the tail lengths from 72 h post-treatment was observed by the second week, and values had returned to control levels at all doses, indicating repair of the damaged DNA and/or loss of heavily damaged cells. The study also reveals that comet assay is a sensitive and rapid method for detecting DNA damage caused by heavy metals such as chromium (Cr).

Genotoxic effect of lead nitrate on mice using SCGE (comet assay)

Single stranded DNA breakage induced by lead nitrate in mice has been studied in vivo using alkaline single cell gel electrophoresis (comet assay). Mice were administered orally 0.7, 1.4, 2.8, 5.6, 11. 2, 22.4, 44.8 and 89.6 mg/kg body weight of lead nitrate and the assay was performed on whole blood at 24, 48, 72 h, 1st and 2nd week. Significant increase in mean tail-length of DNA was observed at all time intervals after treatment with lead nitrate when compared to controls. The mean tail-length did not show a dose-related increase and the elevation in the mean tail-length was of a fluctuating type. Increase in mean tail-lengths clearly gives evidence that lead nitrate causes DNA damage effectively. The study indicates that the alkaline comet assay is a sensitive and rapid method to detect DNA damage caused by heavy metals.

Effects of inter-alpha-inhibitor and several of its derivatives on calcium oxalate crystallization in vitro

The bikunin peptide chain of the protease inhibitor inter-alpha-inhibitor (IalphaI) has been reported to be an inhibitor of calcium oxalate (CaOx) crystallization, and hence has been proposed as having a role in CaOx kidney stone formation. However, further experimental evidence is required to assess if fragments of IalphaI other than bikunin may play a role in the regulation of crystallization events in stone formation. The aim of the present study was to assess the effects of IalphaI and several of its derivatives on CaOx crystallization in a seeded inorganic system and to compare these effects with those of a known inhibitor of crystallization, prothrombin. IalphaI was purified from a preparation of human plasma and fragmented by alkaline hydrolysis, and two of its peptide chains, bikunin and heavy chain 1 (H1), were purified further by HPLC. Their purity was confirmed by SDS/PAGE. Using Coulter counter and [(14)C]oxalate analysis and scanning electron microscopy, IalphaI, its H1 chain and bikunin from urine and from plasma were shown to be relatively weak inhibitors of CaOx crystallization in vitro at expected physiological concentrations. It was concluded that members of the IalphaI family may not be as important in kidney stone formation as has been generally proposed, although further studies are required before a possible role for IalphaI and its fragments in stone formation can be unambiguously discounted.

Role of yoga in the treatment of neurotic disorders: current status and future directions

A large number of studies have consistently demonstrated the potential of yoga, not only in the treatment of psychiatric and psychosomatic disorder but also in promoting positive physical and mental health. This paper reviews various studies on the treatment of neurosis with techniques derived from yoga. A few lacunae have been identified and possible directions for future research are outlined. It is hoped that research along these lines will develop a standardized method of yoga therapy which can be utilized and integrated within the existing methods of treatment of neurotic disorders.

Growth of the teaching nursing home. The Veterans Administration experience

Nursing homes are becoming increasingly involved with medical education, and the Veterans Administration (VA) has been particularly active in this movement. We conducted a system-wide survey of VA nursing home facilities to determine the degree to which they participate in medical and other professional training and the features associated with such training. Of the 116 VA nursing homes in 1987, 113 (97.4%) returned completed questionnaires. Compared to "standard" VA facilities (n = 85), "teaching" nursing homes (n = 28)--those in which physicians received at least 20 hours of training per capita annually--were significantly larger, admitted and discharged significantly more patients per occupied bed, and placed a significantly larger proportion of discharged patients in noninstitutional community settings. Care costs in the teaching nursing homes were slightly but not significantly higher, despite significant increases in levels of professional staffing and amounts of training activities in all disciplines. During the survey year, teaching nursing homes provided training experiences for 440 students, residents, and fellows in internal and rehabilitation medicine, as well as for 2,700 other health professionals. The growth of teaching nursing homes in the VA system appears to be associated with positive changes in the pattern of health-care delivery, and it is increasing the number of health-care professionals trained in long-term care.

Health status of nurses and yoga. I. Baseline data

In this ongoing ICMR project on "Effect of Yoga on the Health of Nurses", some baseline data on the health of nurses of Nehru Hospital, P.G.I., Chandigarh are reported. This was obtained before the start of yoga therapy in selected cases and collected with the help of six psychological tools. Out of a total of 501 nurses, 452 (90.2%) could be contacted and studied. Mean age was 30.43 years and mean years of service 9.93 years. Mean scores on the psychological tests indicated poor health status of nurses, average neuroticism, depressive tendencies and role stress. Sense of Well-Being was high in them. The data is discussed in the light of researches in this area. This is the first of a series of three articles to be published in the Journal.

Factors influencing treatment acceptance in neurotic patients referred for yoga therapy-;an exploratory study

A total of 186 neurotic patients seeking treatment in the psychiatry outpatient clinic of the Nehru Hospital, P.G.I.M.E.R. were assigned consequently to three treatments i.e. Yoga therapy (Y), Yogic Relaxation (YR) and Chemotherapy (C). A record was kept of the number of visits made by each patient during the 5 months study period. In order to find out the factors associated with treatment acceptance, a comparison was made of those subjects who completed 4-6 weeks of treatment with those who dropped out before completing the treatment in the yoga group. The dropouts and non-dropouts were found to be comparable on sociodemographic and clinical variables. They were also similar with regard to the attitude to yoga. The only factor which distinguished the two groups was the severity of illness at intake. Those who continued treatment had significantly higher scores on the P. G. I. Health Questionnaire N-2 and the clinical ratings of the severity of illness. Further, analysis of stage at which dropout occurred, and the responses to the reply paid questionnaire indicated that treatment failure as not the main reason for dropout.

Relationship between the patient's attitude towards yoga and the treatment outcome

Correlations were obtained between scores on the P.G.I. Yoga Attitude Scale and improvement in a group of 20 psychoneurotic patients undertaking yoga therapy of 4-6 weeks duration. A significant positive correlation was found between the improvement in social and vocational disability and scores on the P.G.I Yoga Attitude Scale at intake. However, during treatment and followup, there was a significant change in the attitude towards yoga - it became more positive. Correlations were also performed between improvement and change in attitude over the 5-month study period. Significant positive correlation was seen only on personal distress. Improvement in the other symptoms of neurosis i.e. anxiety, depression, musculo-cutaneous features, vegetative symptoms of neurosis i.e. anxiety, depression, musculo-cutaneous features, vegetative symptoms and the other neurotic features i.e. hysteria, hypochondriasis, obsessions-compulsions and phobia did not show any relationship with the patient's attitude towards yoga.

Some properties of vicinal diol-epoxides derived from benzo(a)anthracene and benzo(a)pyrene

The alkylating properties of pairs of syn- and anti-isomers of 2 diol-epoxides derived from benzo(a)pyrene (BP) and of 1 derived from benz(a)anthracene (BA) have been investigated. Of the anti-diol-epoxides, anti-BP 7,8-diol-9,10-oxide was the most reactive compound towards DNA, towards sodium p-nitrothiophenolate in a non-aqueous solvent system, and towards 4-(p-nitrobenzyl)pyridine in aqueous solution; anti-BP 9,10,-diol-7,8-oxide was of intermediate reactivity and anti-BA 8,9-diol-10,11-oxide was least reactive. The syn-diol-epoxides gave unsatisfactory results with DNA and 4-(p-nitrobenzyl)pyridine because of their rapid solvolysis in aqueous solution, but with sodium p-nitrothiophenolate showed the order of reactivity syn-BP 7,8-diol-9,10-oxide greater than syn-BA 8,9-diol-10,11-oxide greater than syn-BP 9,10-diol-7,8-oxide. The products of the reaction between diol-epoxides and nucleic acids were examined by Sephadex LH-20 chromatography followed by high-pressure liquid chromatography (HPLC) and the diol-epoxides were shown to react principally with the guanosine and adenosine moieties of RNA.