Publications by authors named "Michael Poon"

135 Publications

Temozolomide sensitivity of malignant glioma cell lines - a systematic review assessing consistencies between in vitro studies.

BMC Cancer 2021 Nov 18;21(1):1240. Epub 2021 Nov 18.

Cancer Research UK Brain Tumour Centre of Excellence, Edinburgh Cancer Research Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK.

Background: Malignant glioma cell line models are integral to pre-clinical testing of novel potential therapies. Accurate prediction of likely efficacy in the clinic requires that these models are reliable and consistent. We assessed this by examining the reporting of experimental conditions and sensitivity to temozolomide in glioma cells lines.

Methods: We searched Medline and Embase (Jan 1994-Jan 2021) for studies evaluating the effect of temozolomide monotherapy on cell viability of at least one malignant glioma cell line. Key data items included type of cell lines, temozolomide exposure duration in hours (hr), and cell viability measure (IC).

Results: We included 212 studies from 2789 non-duplicate records that reported 248 distinct cell lines. The commonest cell line was U87 (60.4%). Only 10.4% studies used a patient-derived cell line. The proportion of studies not reporting each experimental condition ranged from 8.0-27.4%, including base medium (8.0%), serum supplementation (9.9%) and number of replicates (27.4%). In studies reporting IC, the median value for U87 at 24 h, 48 h and 72 h was 123.9 μM (IQR 75.3-277.7 μM), 223.1 μM (IQR 92.0-590.1 μM) and 230.0 μM (IQR 34.1-650.0 μM), respectively. The median IC at 72 h for patient-derived cell lines was 220 μM (IQR 81.1-800.0 μM).

Conclusion: Temozolomide sensitivity reported in comparable studies was not consistent between or within malignant glioma cell lines. Drug discovery science performed on these models cannot reliably inform clinical translation. A consensus model of reporting can maximise reproducibility and consistency among in vitro studies.
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http://dx.doi.org/10.1186/s12885-021-08972-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8600737PMC
November 2021

Raised cardiovascular disease mortality after central nervous system tumor diagnosis: analysis of 171,926 patients from UK and USA.

Neurooncol Adv 2021 Jan-Dec;3(1):vdab136. Epub 2021 Sep 21.

Usher Institute, University of Edinburgh, Edinburgh, UK.

Background: Patients with central nervous system (CNS) tumors may be at risk of dying from cardiovascular disease (CVD). We examined CVD mortality risk in patients with different histological subtypes of CNS tumors.

Methods: We analyzed UK(Wales)-based Secure Anonymized Information Linkage (SAIL) for 8743 CNS tumors patients diagnosed in 2000-2015, and US-based National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) for 163,183 patients in 2005-2015. We calculated age-, sex-, and calendar-year-adjusted standardized mortality ratios (SMRs) for CVD comparing CNS tumor patients to Wales and US residents. We used Cox regression models to examine factors associated with CVD mortality among CNS tumor patients.

Results: CVD was the second leading cause of death for CNS tumor patients in SAIL (UK) and SEER (US). Patients with CNS tumors had higher CVD mortality than the general population (SAIL SMR = 2.64, 95% CI = 2.39-2.90, SEER SMR = 1.38, 95% CI = 1.35-1.42). Malignant CNS tumor patients had over 2-fold higher mortality risk in US and UK cohorts. SMRs for nonmalignant tumors were almost 2-fold higher in SAIL than in SEER. CVD mortality risk particularly cerebrovascular disease was substantially greater in patients diagnosed at age younger than 50 years, and within the first year after their cancer diagnosis (SAIL SMR = 2.98, 95% CI = 2.39-3.66, SEER SMR = 2.14, 95% CI = 2.03-2.25). Age, sex, race/ethnicity in USA, deprivation in UK and no surgery were associated with CVD mortality.

Conclusions: Patients with CNS tumors had higher risk for CVD mortality, particularly from cerebrovascular disease compared to the general population, supporting further research to improve mortality outcomes.
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http://dx.doi.org/10.1093/noajnl/vdab136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8500688PMC
September 2021

The reporting quality of natural language processing studies: systematic review of studies of radiology reports.

BMC Med Imaging 2021 10 2;21(1):142. Epub 2021 Oct 2.

Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, Little France, Edinburgh, EH16 4TJ, Scotland, UK.

Background: Automated language analysis of radiology reports using natural language processing (NLP) can provide valuable information on patients' health and disease. With its rapid development, NLP studies should have transparent methodology to allow comparison of approaches and reproducibility. This systematic review aims to summarise the characteristics and reporting quality of studies applying NLP to radiology reports.

Methods: We searched Google Scholar for studies published in English that applied NLP to radiology reports of any imaging modality between January 2015 and October 2019. At least two reviewers independently performed screening and completed data extraction. We specified 15 criteria relating to data source, datasets, ground truth, outcomes, and reproducibility for quality assessment. The primary NLP performance measures were precision, recall and F1 score.

Results: Of the 4,836 records retrieved, we included 164 studies that used NLP on radiology reports. The commonest clinical applications of NLP were disease information or classification (28%) and diagnostic surveillance (27.4%). Most studies used English radiology reports (86%). Reports from mixed imaging modalities were used in 28% of the studies. Oncology (24%) was the most frequent disease area. Most studies had dataset size > 200 (85.4%) but the proportion of studies that described their annotated, training, validation, and test set were 67.1%, 63.4%, 45.7%, and 67.7% respectively. About half of the studies reported precision (48.8%) and recall (53.7%). Few studies reported external validation performed (10.8%), data availability (8.5%) and code availability (9.1%). There was no pattern of performance associated with the overall reporting quality.

Conclusions: There is a range of potential clinical applications for NLP of radiology reports in health services and research. However, we found suboptimal reporting quality that precludes comparison, reproducibility, and replication. Our results support the need for development of reporting standards specific to clinical NLP studies.
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http://dx.doi.org/10.1186/s12880-021-00671-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8487512PMC
October 2021

Trans-lesional fractional flow reserve gradient as derived from coronary CT improves patient management: ADVANCE registry.

J Cardiovasc Comput Tomogr 2021 Sep 2. Epub 2021 Sep 2.

Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada; Department of Cardiology, Fiona Stanley Hospital, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia.

Background: The role of change in fractional flow reserve derived from CT (FFR) across coronary stenoses (ΔFFR) in guiding downstream testing in patients with stable coronary artery disease (CAD) is unknown.

Objectives: To investigate the incremental value of ΔFFR in predicting early revascularization and improving efficiency of catheter laboratory utilization.

Materials: Patients with CAD on coronary CT angiography (CCTA) were enrolled in an international multicenter registry. Stenosis severity was assessed as per CAD-Reporting and Data System (CAD-RADS), and lesion-specific FFR was measured 2 ​cm distal to stenosis. ΔFFR was manually measured as the difference of FFR across visible stenosis.

Results: Of 4730 patients (66 ​± ​10 years; 34% female), 42.7% underwent ICA and 24.7% underwent early revascularization. ΔFFR remained an independent predictor for early revascularization (odds ratio per 0.05 increase [95% confidence interval], 1.31 [1.26-1.35]; p ​< ​0.001) after adjusting for risk factors, stenosis features, and lesion-specific FFR. Among the 3 models (model 1: risk factors ​+ ​stenosis type and location ​+ ​CAD-RADS; model 2: model 1 ​+ ​FFR; model 3: model 2 ​+ ​ΔFFR), model 3 improved discrimination compared to model 2 (area under the curve, 0.87 [0.86-0.88] vs 0.85 [0.84-0.86]; p ​< ​0.001), with the greatest incremental value for FFR 0.71-0.80. ΔFFR of 0.13 was the optimal cut-off as determined by the Youden index. In patients with CAD-RADS ≥3 and lesion-specific FFR ≤0.8, a diagnostic strategy incorporating ΔFFR >0.13, would potentially reduce ICA by 32.2% (1638-1110, p ​< ​0.001) and improve the revascularization to ICA ratio from 65.2% to 73.1%.

Conclusions: ΔFFR improves the discrimination of patients who underwent early revascularization compared to a standard diagnostic strategy of CCTA with FFR, particularly for those with FFR 0.71-0.80. ΔFFR has the potential to aid decision-making for ICA referral and improve efficiency of catheter laboratory utilization.
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http://dx.doi.org/10.1016/j.jcct.2021.08.003DOI Listing
September 2021

MYD88 L265P mutation in primary central nervous system lymphoma is associated with better survival: A single-center experience.

Neurooncol Adv 2021 Jan-Dec;3(1):vdab090. Epub 2021 Jul 7.

Department of Pathology, Western General Hospital, Edinburgh EH4 2XU, UK.

Background: The () mutation in primary central nervous system lymphomas (PCNSL) may be associated with unfavorable prognosis; however, current evidence remains limited. We aimed to characterize PCNSLs by integration of clinicopathological, molecular, treatment, and survival data.

Methods: We retrospectively identified and validated 57 consecutive patients with PCNSLs according to the 2017 WHO classification of lymphoid neoplasms over 13 years. Formalin-fixed paraffin-embedded tumor samples underwent polymerase chain reaction assay to detect mutation. We used Cox regression for survival analysis, including age, treatment, and as covariates. We searched the literature for studies reporting demographics, treatment, , and survival of PCNSL patients and incorporated individual patient data into our analyses.

Results: The median age was 66 years and 56% were women. All 57 patients had PCNSL of non-germinal center cell subtype and the majority (81%) received either single or combined therapies. There were 46 deaths observed over the median follow-up of 10 months. mutation status was available in 41 patients of which 36 (88%) were mutated. There was an association between mutation and better survival in the multivariable model (hazard ratio [HR] 0.277; 95% confidence interval [CI]: 0.09-0.83; = .023) but not in a univariable model. After incorporating additional 18 patients from the literature, this association was reproducible (HR 0.245; 95% CI: 0.09-0.64; = .004).

Conclusions: Adjusting for confounders, -mutant PCNSL appears to show improved survival. While further validation is warranted, detection of mutation will aid the identification of patients who may benefit from novel targeted therapies.
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http://dx.doi.org/10.1093/noajnl/vdab090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8349182PMC
July 2021

Secondary injury and inflammation after intracerebral haemorrhage: a systematic review and meta-analysis of molecular markers in patient brain tissue.

J Neurol Neurosurg Psychiatry 2021 Aug 6. Epub 2021 Aug 6.

Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK

Background: Inflammatory responses to intracerebral haemorrhage (ICH) are potential therapeutic targets. We aimed to quantify molecular markers of inflammation in human brain tissue after ICH compared with controls using meta-analysis.

Methods: We searched OVID MEDLINE (1946-) and Embase (1974-) in June 2020 for studies that reported any measure of a molecular marker of inflammation in brain tissue from five or more adults after ICH. We assessed risk of bias using a modified Newcastle-Ottawa Scale (mNOS; mNOS score 0-9; 9 indicates low bias), extracted aggregate data, and used random effects meta-analysis to pool associations of molecules where more than two independent case-control studies reported the same outcome and Gene Ontology enrichment analysis to identify over-represented biological processes in pooled sets of differentially expressed molecules (International Prospective Register of Systematic Reviews ID: CRD42018110204).

Results: Of 7501 studies identified, 44 were included: 6 were case series and 38 were case-control studies (median mNOS score 4, IQR 3-5). We extracted data from 21 491 analyses of 20 951 molecules reported by 38 case-control studies. Only one molecule (interleukin-1β protein) was quantified in three case-control studies (127 ICH cases vs 41 ICH-free controls), which found increased abundance of interleukin-1β protein after ICH (corrected standardised mean difference 1.74, 95% CI 0.28 to 3.21, p=0.036, I=46%). Processes associated with interleukin-1β signalling were enriched in sets of molecules that were more abundant after ICH.

Conclusion: Interleukin-1β abundance is increased after ICH, but analyses of other inflammatory molecules after ICH lack replication. Interleukin-1β pathway modulators may optimise inflammatory responses to ICH and merit testing in clinical trials.
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http://dx.doi.org/10.1136/jnnp-2021-327098DOI Listing
August 2021

A systematic review of natural language processing applied to radiology reports.

BMC Med Inform Decis Mak 2021 06 3;21(1):179. Epub 2021 Jun 3.

School of Literatures, Languages and Cultures (LLC), University of Edinburgh, Edinburgh, Scotland.

Background: Natural language processing (NLP) has a significant role in advancing healthcare and has been found to be key in extracting structured information from radiology reports. Understanding recent developments in NLP application to radiology is of significance but recent reviews on this are limited. This study systematically assesses and quantifies recent literature in NLP applied to radiology reports.

Methods: We conduct an automated literature search yielding 4836 results using automated filtering, metadata enriching steps and citation search combined with manual review. Our analysis is based on 21 variables including radiology characteristics, NLP methodology, performance, study, and clinical application characteristics.

Results: We present a comprehensive analysis of the 164 publications retrieved with publications in 2019 almost triple those in 2015. Each publication is categorised into one of 6 clinical application categories. Deep learning use increases in the period but conventional machine learning approaches are still prevalent. Deep learning remains challenged when data is scarce and there is little evidence of adoption into clinical practice. Despite 17% of studies reporting greater than 0.85 F1 scores, it is hard to comparatively evaluate these approaches given that most of them use different datasets. Only 14 studies made their data and 15 their code available with 10 externally validating results.

Conclusions: Automated understanding of clinical narratives of the radiology reports has the potential to enhance the healthcare process and we show that research in this field continues to grow. Reproducibility and explainability of models are important if the domain is to move applications into clinical use. More could be done to share code enabling validation of methods on different institutional data and to reduce heterogeneity in reporting of study properties allowing inter-study comparisons. Our results have significance for researchers in the field providing a systematic synthesis of existing work to build on, identify gaps, opportunities for collaboration and avoid duplication.
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http://dx.doi.org/10.1186/s12911-021-01533-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176715PMC
June 2021

CovidNeuroOnc: A UK multicenter, prospective cohort study of the impact of the COVID-19 pandemic on the neuro-oncology service.

Neurooncol Adv 2021 Jan-Dec;3(1):vdab014. Epub 2021 Jan 28.

Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.

Background: The COVID-19 pandemic has profoundly affected cancer services. Our objective was to determine the effect of the COVID-19 pandemic on decision making and the resulting outcomes for patients with newly diagnosed or recurrent intracranial tumors.

Methods: We performed a multicenter prospective study of all adult patients discussed in weekly neuro-oncology and skull base multidisciplinary team meetings who had a newly diagnosed or recurrent intracranial (excluding pituitary) tumor between 01 April and 31 May 2020. All patients had at least 30-day follow-up data. Descriptive statistical reporting was used.

Results: There were 1357 referrals for newly diagnosed or recurrent intracranial tumors across 15 neuro-oncology centers. Of centers with all intracranial tumors, a change in initial management was reported in 8.6% of cases ( = 104/1210). Decisions to change the management plan reduced over time from a peak of 19% referrals at the start of the study to 0% by the end of the study period. Changes in management were reported in 16% ( = 75/466) of cases previously recommended for surgery and 28% of cases previously recommended for chemotherapy ( = 20/72). The reported SARS-CoV-2 infection rate was similar in surgical and non-surgical patients (2.6% vs. 2.4%, > .9).

Conclusions: Disruption to neuro-oncology services in the UK caused by the COVID-19 pandemic was most marked in the first month, affecting all diagnoses. Patients considered for chemotherapy were most affected. In those recommended surgical treatment this was successfully completed. Longer-term outcome data will evaluate oncological treatments received by these patients and overall survival.
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http://dx.doi.org/10.1093/noajnl/vdab014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928638PMC
January 2021

Risks of recurrent stroke and all serious vascular events after spontaneous intracerebral haemorrhage: pooled analyses of two population-based studies.

Lancet Neurol 2021 06;20(6):437-447

Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.

Background: Patients with stroke due to spontaneous (non-traumatic) intracerebral haemorrhage (ICH) are at risk of recurrent ICH, ischaemic stroke, and other serious vascular events. We aimed to analyse these risks in population-based studies and compare them with the risks in RESTART, which assessed antiplatelet therapy after ICH.

Methods: We pooled individual patient data from two prospective, population-based inception cohort studies of all patients with an incident firs-in-a-lifetime ICH in Oxfordshire, England (Oxford Vascular Study; April 1, 2002, to Sept 28, 2018) and Lothian, Scotland, UK (Lothian Audit of the Treatment of Cerebral Haemorrhage; June 1, 2010, to May 31, 2013). We quantified the absolute and relative risks of recurrent ICH, ischaemic stroke, or any serious vascular event (non-fatal stroke, non-fatal myocardial infarction, or vascular death), stratified by ICH location (lobar vs non-lobar) and comorbid atrial fibrillation (AF). We compared pooled event rates with those after allocation to avoid antiplatelet therapy in RESTART.

Findings: Among 674 patients (mean age 74·7 years [SD 12·6], 320 [47%] men) with 1553 person-years of follow-up, 46 recurrent ICHs (event rate 3·2 per 100 patient-years, 95% CI 2·0-5·1) and 25 ischaemic strokes (1·7 per 100 patient-years, 0·8-3·3) were reported. Patients with lobar ICH (n=317) had higher risk of recurrent ICH (5·1 per 100 patient-years, 95% CI 3·6-7·2) than patients with non-lobar ICH (n=355; 1·8 per 100 patient-years, 1·0-3·3; hazard ratio [HR] 3·2, 95% CI 1·6-6·3; p=0·0010), but there was no evidence of a difference in the risk of ischaemic stroke (1·8 per 100 patient-years, 1·0-3·2, vs 1·6 per 100 patient-years, 0·6-4·4; HR 1·1, 95% CI 0·5-2·8). Conversely, there was no evidence of a difference in recurrent ICH rate in patients with AF (n=147; 3·3 per 100 patient-years, 95% CI 1·0-10·7) compared with those without (n=526; 3·2 per 100 patient-years, 2·2-4·7; HR 0·9, 95% CI 0·4-2·1), but the risk of ischaemic stroke was higher with AF (6·3 per 100 patient-years, 3·7-10·9, vs 0·7 per 100 patient-years, 0·1-5·6; HR 8·2, 3·3-20·3; p<0·0001), resulting in patients with AF having a higher risk of all serious vascular events than patients without AF (15·5 per 100 patient-years, 10·0-24·1, vs 6·8 per 100 patient-years, 3·6-12·5; HR 1·78, 95% CI 1·16-2·74; p=0·0090). Only for patients with lobar ICH without comorbid AF was the risk of recurrent ICH greater than the risk of ischaemic stroke (5·2 per 100 patient-years, 95% CI 3·6-7·5, vs 0·9 per 100 patient-years, 0·2-4·8; p=0·00034). Comparing data from the pooled population-based studies with that from patients allocated to not receive antiplatelet therapy in RESTART, there was no evidence of a difference in the rate of recurrent ICH (3·5 per 100 patient-years, 95% CI 1·9-6·0, vs 4·4 per 100 patient-years, 2·6-6·1) or ischaemic stroke (3·4 per 100 patient-years, 1·9-5·9, vs 5·3 per 100 patient-years, 3·3-7·2).

Interpretation: The risks of recurrent ICH, ischaemic stroke, and all serious vascular events after ICH differ by ICH location and comorbid AF. These data enable risk stratification of patients in clinical practice and ongoing randomised trials.

Funding: UK Medical Research Council, Stroke Association, British Heart Foundation, Wellcome Trust, and the National Institute for Health Research Oxford Biomedical Research Centre.
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http://dx.doi.org/10.1016/S1474-4422(21)00075-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8134058PMC
June 2021

Impact of Cardiovascular Care of COVID-19: Lessons Learned, Current Challenges, and Future Opportunities.

Radiol Cardiothorac Imaging 2020 Aug 23;2(4):e200251. Epub 2020 Jul 23.

Division of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY 10075-1850 (M.P., M.K.); Center for Heart Lung Innovation, University of British Columbia & St Paul's Hospital, Vancouver, Canada (J.L.); Cardiovascular Division, University of Utah Health, Salt Lake City, Utah (F.W.); and Sanger Heart & Vascular Institute, Atrium Health, Charlotte NC (G.R.).

COVID-19 has disrupted traditional cardiovascular care pathways leading to significant challenges; with these challenges have also come opportunities to iterate our testing strategies to ensure they are patient centered and also that they are most appropriate and best align with infection protection protocols. © RSNA, 2020.
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http://dx.doi.org/10.1148/ryct.2020200251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380120PMC
August 2020

Letter to the Editor. Misconceptions in the field guide to big data for neurosurgeons.

J Neurosurg 2021 Jan 29:1-2. Epub 2021 Jan 29.

4Artificial Intelligence and its Applications Institute, School of Informatics, University of Edinburgh, United Kingdom.

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http://dx.doi.org/10.3171/2020.10.JNS203834DOI Listing
January 2021

Utility of image-guided external ventriculostomy: analysis of contemporary practice in the United Kingdom and Ireland.

J Neurosurg 2021 01 29:1-9. Epub 2021 Jan 29.

9Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, United Kingdom.

Objective: Freehand external ventricular drain (EVD) insertion is associated with a high rate of catheter misplacement. Image-guided EVD placement with neuronavigation or ultrasound has been proposed as a safer, more accurate alternative with potential to facilitate proper placement and reduce catheter malfunction risk. This study aimed to determine the impact of image-guided EVD placement on catheter tip position and drain functionality.

Methods: This study is a secondary analysis of a data set from a prospective, multicenter study. Data were collated for EVD placements undertaken in the United Kingdom and Ireland from November 2014 to April 2015. In total, 21 large tertiary care academic medical centers were included.

Results: Over the study period, 632 EVDs were inserted and 65.9% had tips lying free-floating in the CSF. Only 19.6% of insertions took place under image guidance. The use of image guidance did not significantly improve the position of the catheter tip on postoperative imaging, even when stratified by ventricular size. There was also no association between navigation use and drain blockage.

Conclusions: Image-guided EVD placement was not associated with an increased likelihood of achieving optimal catheter position or with a lower rate of catheter blockage. Educational efforts should aim to enhance surgeons' ability to apply the technique correctly in cases of disturbed cerebral anatomy or small ventricles to reduce procedural risks and facilitate effective catheter positioning.
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http://dx.doi.org/10.3171/2020.8.JNS20321DOI Listing
January 2021

Discovery of PIPE-359, a Brain-Penetrant, Selective M Receptor Antagonist with Robust Efficacy in Murine MOG-EAE.

ACS Med Chem Lett 2021 Jan 24;12(1):155-161. Epub 2020 Dec 24.

Pipeline Therapeutics, 10578 Science Center Drive, Suite 200, San Diego, California 92121, United States.

The discovery of PIPE-359, a brain-penetrant and selective antagonist of the muscarinic acetylcholine receptor subtype 1 is described. Starting from a literature-reported M antagonist, linker replacement and structure-activity relationship investigations of the eastern 1-(pyridinyl)piperazine led to the identification of a novel, potent, and selective antagonist with good MDCKII-MDR1 permeability. Continued semi-iterative positional scanning facilitated improvements in the metabolic and hERG profiles, which ultimately delivered PIPE-359. This advanced drug candidate exhibited robust efficacy in mouse myelin oligodendrocyte glycoprotein (MOG)-induced experimental autoimmune encephalitis (EAE), a preclinical model for multiple sclerosis.
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http://dx.doi.org/10.1021/acsmedchemlett.0c00626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812680PMC
January 2021

Investigation and management of serum sodium after subarachnoid haemorrhage (SaSH): a survey of practice in the United Kingdom and Republic of Ireland.

Br J Neurosurg 2021 Jan 20:1-4. Epub 2021 Jan 20.

Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.

Background: Hyponatraemia is a common complication of aneurysmal subarachnoid haemorrhage (SAH). We aimed to determine current neurosurgical practice for the identification, investigation and management of hyponatraemia after SAH.

Methods: An online questionnaire was completed by UK and Irish neurosurgical trainees and consultant collaborators in the Sodium after Subarachnoid Haemorrhage (SaSH) audit.

Results: Between August 2019 and June 2020, 43 responses were received from 31 of 32 UK and Ireland adult neurosurgical units (NSUs). All units reported routine measurement of serum sodium either daily or every other day. Most NSUs reported routine investigation of hyponatraemia after SAH with paired serum and urinary osmolalities (94%), urinary sodium (84%), daily fluid balance (84%), but few measured glucose (19%), morning cortisol (13%), or performed a short Synacthen test (3%). Management of hyponatraemia was variable, with units reporting use of oral sodium supplementation (77%), fluid restriction (58%), hypertonic saline (55%), and fludrocortisone (19%).

Conclusions: Reported assessment of serum sodium after SAH was consistent between units, whereas management of hyponatraemia varied. This may reflect the lack of a specific evidence-base to inform practice.
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http://dx.doi.org/10.1080/02688697.2020.1859460DOI Listing
January 2021

Might changes in diagnostic practice explain increasing incidence of brain and central nervous system tumors? A population-based study in Wales (United Kingdom) and the United States.

Neuro Oncol 2021 06;23(6):979-989

Usher Institute, University of Edinburgh, Edinburgh, UK.

Background: Increasing incidence of central nervous system (CNS) tumors has been noted in some populations. However, the influence of changing surgical and imaging practices has not been consistently accounted for.

Methods: We evaluated average annual percentage change (AAPC) in age- and gender-stratified incidence of CNS tumors by tumor subtypes and histological confirmation in Wales, United Kingdom (1997-2015) and the United States (2004-2015) using joinpoint regression.

Findings: In Wales, the incidence of histologically confirmed CNS tumors increased more than all CNS tumors (AAPC 3.62% vs 1.63%), indicating an increasing proportion undergoing surgery. Grade II and III glioma incidence declined significantly (AAPC -3.09% and -1.85%, respectively) but remained stable for those with histological confirmation. Grade IV glioma incidence increased overall (AAPC 3.99%), more markedly for those with histological confirmation (AAPC 5.36%), suggesting reduced glioma subtype misclassification due to increased surgery. In the United States, the incidence of CNS tumors increased overall but was stable for histologically confirmed tumors (AAPC 1.86% vs 0.09%) indicating an increase in patients diagnosed without surgery. An increase in grade IV gliomas (AAPC 0.28%) and a decline in grade II gliomas (AAPC -3.41%) were accompanied by similar changes in those with histological confirmation, indicating the overall trends in glioma subtypes were unlikely to be caused by changing diagnostic and clinical management.

Conclusions: Changes in clinical practice have influenced the incidence of CNS tumors in the United Kingdom and the United States. These should be considered when evaluating trends and in epidemiological studies of putative risk factors for CNS tumors.
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http://dx.doi.org/10.1093/neuonc/noaa282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168824PMC
June 2021

Letter to the Editor. Validating the 5-factor modified frailty index.

Authors:
Michael T C Poon

J Neurosurg 2020 Nov 13:1-2. Epub 2020 Nov 13.

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http://dx.doi.org/10.3171/2020.8.JNS203241DOI Listing
November 2020

The clinical utility of FFR stratified by age.

J Cardiovasc Comput Tomogr 2021 Mar-Apr;15(2):121-128. Epub 2020 Sep 23.

Department of Radiology, Providence Health Care, St. Paul's Hospital, University of British Columbia, Vancouver, Canada. Electronic address:

Background: CT coronary angiography (CTA) with Fractional Flow Reserve as determined by CT (FFR) is a safe alternative to invasive coronary angiography. A negative FFR has been shown to have low cardiac event rates compared to those with a positive FFR. However, the clinical utility of FFR according to age is not known.

Methods: Patients' in the ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) registry, were stratified into those ≥65 or <65 years of age. The impact of FFR on clinical decision-making, as assessed by patient age, was determined by evaluating patient management using CTA results alone, followed by site investigators submitting a report on the treatment plan based upon the newly provided FFR data. Outcomes at 1-year post CTA were assessed, including major adverse cardiovascular events (myocardial infarction, all-cause mortality or unplanned hospitalization for ACS leading to revascularisation) and total revascularisation. Positive FFR was deemed to be ​≤ ​0.8.

Results: FFR was calculated in 1849 (40.6%) subjects aged <65 and 2704 (59.4%) ​≥ ​65 years of age. Subjects ≥65 years were more likely to have anatomic obstructive disease on CTA (≥50% stenosis), compared to those aged <65 (69.7% and 73.2% respectively, p ​= ​0.008). There was a similar graded increase in recommended and actual revascularisation with either CABG or PCI, with declining FFR strata for subjects above and below the age of 65. MACE and revascularisation rates were not significantly different for those ​≥ ​or <65, regardless of FFR positivity or stenosis severity <50% or ≥50%. With a negative FFR result, and anatomical stenosis ≥50%, those ​≥ ​and <65 years of age, had similar rates of MACE (0.2% for both, p ​= ​0.1) and revascularisation (8.7% and 10.4% respectively p ​= ​0.4). Logistic regression analysis, with age as a continuous variable, and adjustment for Diamond Forrester Risk, baseline FFR and treatment (CABG, PCI, medical therapy), indicated a statistically significant, but small increase in the odds of a MACE event with increasing age (OR 1.04, 95% CI 1.006-1.08, p ​= ​0.02). Amongst patients with a FFR > 0.80, there was no effect of age on the odds of revascularisation.

Conclusion: The findings of this study point to a low risk of MACE events or need for revascularisation in those aged ​≥ ​or <65 with a FFR>0.80, despite the higher incidence of anatomic obstructive CAD in those ≥65 years. The findings show the clinical usefulness and outcomes of FFR are largely constant regardless of age.
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http://dx.doi.org/10.1016/j.jcct.2020.08.006DOI Listing
July 2021

Monitoring indirect impact of COVID-19 pandemic on services for cardiovascular diseases in the UK.

Heart 2020 12 5;106(24):1890-1897. Epub 2020 Oct 5.

The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK

Objective: To monitor hospital activity for presentation, diagnosis and treatment of cardiovascular diseases during the COVID-19) pandemic to inform on indirect effects.

Methods: Retrospective serial cross-sectional study in nine UK hospitals using hospital activity data from 28 October 2019 (pre-COVID-19) to 10 May 2020 (pre-easing of lockdown) and for the same weeks during 2018-2019. We analysed aggregate data for selected cardiovascular diseases before and during the epidemic. We produced an online visualisation tool to enable near real-time monitoring of trends.

Results: Across nine hospitals, total admissions and emergency department (ED) attendances decreased after lockdown (23 March 2020) by 57.9% (57.1%-58.6%) and 52.9% (52.2%-53.5%), respectively, compared with the previous year. Activity for cardiac, cerebrovascular and other vascular conditions started to decline 1-2 weeks before lockdown and fell by 31%-88% after lockdown, with the greatest reductions observed for coronary artery bypass grafts, carotid endarterectomy, aortic aneurysm repair and peripheral arterial disease procedures. Compared with before the first UK COVID-19 (31 January 2020), activity declined across diseases and specialties between the first case and lockdown (total ED attendances relative reduction (RR) 0.94, 0.93-0.95; total hospital admissions RR 0.96, 0.95-0.97) and after lockdown (attendances RR 0.63, 0.62-0.64; admissions RR 0.59, 0.57-0.60). There was limited recovery towards usual levels of some activities from mid-April 2020.

Conclusions: Substantial reductions in total and cardiovascular activities are likely to contribute to a major burden of indirect effects of the pandemic, suggesting they should be monitored and mitigated urgently.
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http://dx.doi.org/10.1136/heartjnl-2020-317870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7536637PMC
December 2020

Impact of COVID-19 pandemic on surgical neuro-oncology multi-disciplinary team decision making: a national survey (COVID-CNSMDT Study).

BMJ Open 2020 08 16;10(8):e040898. Epub 2020 Aug 16.

Department of Neurosurgery, The Walton Centre National Health Service Foundation Trust, Liverpool, UK.

Objectives: Pressures on healthcare systems due to COVID-19 has impacted patients without COVID-19 with surgery disproportionally affected. This study aims to understand the impact on the initial management of patients with brain tumours by measuring changes to normal multidisciplinary team (MDT) decision making.

Design: A prospective survey performed in UK neurosurgical units performed from 23 March 2020 until 24 April 2020.

Setting: Regional neurosurgical units outside London (as the pandemic was more advanced at time of study).

Participants: Representatives from all units were invited to collect data on new patients discussed at their MDT meetings during the study period. Each unit decided if management decision for each patient had changed due to COVID-19.

Primary And Secondary Outcome Measures: Primary outcome measures included number of patients where the decision to undergo surgery changed compared with standard management usually offered by that MDT. Secondary outcome measures included changes in surgical extent, numbers referred to MDT, number of patients denied surgery not receiving any treatment and reasons for any variation across the UK.

Results: 18 units (75%) provided information from 80 MDT meetings that discussed 1221 patients. 10.7% of patients had their management changed-the majority (68%) did not undergo surgery and more than half of this group not undergoing surgery had no active treatment. There was marked variation across the UK (0%-28% change in management). Units that did not change management could maintain capacity with dedicated oncology lists. Low volume units were less affected.

Conclusion: COVID-19 has had an impact on patients requiring surgery for malignant brain tumours, with patients receiving different treatments-most commonly not receiving surgery or any treatment at all. The variations show dedicated cancer operating lists may mitigate these pressures.

Study Registration: This study was registered with the Royal College of Surgeons of England's COVID-19 Research Group (https://www.rcseng.ac.uk/coronavirus/rcs-covid-research-group/).
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http://dx.doi.org/10.1136/bmjopen-2020-040898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430412PMC
August 2020

Longer-term (≥ 2 years) survival in patients with glioblastoma in population-based studies pre- and post-2005: a systematic review and meta-analysis.

Sci Rep 2020 07 15;10(1):11622. Epub 2020 Jul 15.

Brain Tumour Centre of Excellence, Cancer Research UK Edinburgh Centre, University of Edinburgh, Edinburgh, UK.

Translation of survival benefits observed in glioblastoma clinical trials to populations and to longer-term survival remains uncertain. We aimed to assess if ≥ 2-year survival has changed in relation to the trial of radiotherapy plus concomitant and adjuvant temozolomide published in 2005. We searched MEDLINE and Embase for population-based studies with ≥ 50 patients published after 2002 reporting survival at ≥ 2 years following glioblastoma diagnosis. Primary endpoints were survival at 2-, 3- and 5-years stratified by recruitment period. We meta-analysed survival estimates using a random effects model stratified according to whether recruitment ended before 2005 (earlier) or started during or after 2005 (later). PROSPERO registration number CRD42019130035. Twenty-three populations from 63 potentially eligible studies contributed to the meta-analyses. Pooled 2-year overall survival estimates for the earlier and later study periods were 9% (95% confidence interval [CI] 6-12%; n/N = 1,488/17,507) and 18% (95% CI 14-22%; n/N = 5,670/32,390), respectively. Similarly, pooled 3-year survival estimates increased from 4% (95% CI 2-6%; n/N = 325/10,556) to 11% (95% CI 9-14%; n/N = 1900/16,397). One study with a within-population comparison showed similar improvement in survival among the older population. Pooled 5-year survival estimates were 3% (95% CI 1-5%; n/N = 401/14,919) and 4% (95% CI 2-5%; n/N = 1,291/28,748) for the earlier and later periods, respectively. Meta-analyses of real-world data suggested a doubling of 2- and 3-year survival in glioblastoma patients since 2005. However, 5-year survival remains poor with no apparent improvement. Detailed clinically annotated population-based data and further molecular characterization of longer-term survivors may explain the unchanged survival beyond 5 years.
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http://dx.doi.org/10.1038/s41598-020-68011-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7363854PMC
July 2020

Temporal changes in FFR-Guided Management of Coronary Artery Disease - Lessons from the ADVANCE Registry.

J Cardiovasc Comput Tomogr 2021 Jan-Feb;15(1):48-55. Epub 2020 May 1.

Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiovascular Medicine, Stanford University, Stanford, CA, USA; Department of Radiology, Stanford University, Stanford, CA, USA. Electronic address:

Background: The ADVANCE registry is a large prospective study of outcomes and resource utilization in patients undergoing coronary computed tomography angiography (CCTA) and CT-based fractional flow reserve (FFR). As experience with new technologies and practices develops over time, we investigated temporal changes in the use of FFR within the ADVANCE registry.

Methods: 5083 patients with coronary artery disease (CAD) on CCTA were prospectively enrolled in the ADVANCE registry and were divided into 3 equally sized cohorts based on the temporal order of enrollment per site. Demographics, CCTA and FFR findings, and clinical outcomes through 1-year follow-up, were recorded and compared between tertiles.

Results: The number of patients with a ≥70% stenosis on CCTA was similar over time (33.6%, 30.9%, and 33.8% for cohort 1-3). The rate of positive FFR ≤0.80 was higher for cohorts 2 (67.3%) and 3 (74.6%) than for cohort 1 (57.1%, p < 0.001). Invasive FFR rates decreased from 25.8% to 22.4% between cohort 1 and 3 (p = 0.023). Moreover, patients with a FFR ≤0.80 were less frequently referred for invasive coronary angiography (ICA) (from 62.9% to 52.9%, p < 0.001), and underwent fewer revascularizations between cohort 1 and 3 (from 41.9% to 32.0%, p < 0.001). The prevalence of major events was low (1.2%) and similar between cohorts.

Conclusions: Growing experience with FFR improved the likelihood of identifying hemodynamically significant CAD and safely reduced the need for ICA and revascularization in patients with anatomically significant disease even in the instance of an abnormal FFR
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http://dx.doi.org/10.1016/j.jcct.2020.04.011DOI Listing
April 2021

Drains result in greater reduction of subdural width and midline shift in burr hole evacuation of chronic subdural haematoma.

Acta Neurochir (Wien) 2020 06 27;162(6):1455-1466. Epub 2020 Apr 27.

Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.

Background: Drain insertion following chronic subdural haematoma (CSDH) evacuation reduces recurrence and improves outcomes. The mechanism of this improvement is uncertain. We assessed whether drains result in improved postoperative imaging, and which radiological factors are associated with recurrence and functional outcome.

Methods: A multi-centre, prospective cohort study of CSDH patients was performed between May 2013 and January 2014. Patients aged > 16 years undergoing burr hole evacuation of primary CSDH with pre- and postoperative imaging were included in this subgroup analysis. Baseline and clinical details were collected. Pre- and postoperative maximal subdural width and midline shift (MLS) along with clot density were recorded. Primary outcomes comprised mRS at discharge and symptomatic recurrence requiring re-drainage. Comparisons were made using multiple logistic regression.

Results: Three hundred nineteen patients were identified for inclusion. Two hundred seventy-two of 319 (85%) patients underwent drain insertion at the time of surgery versus 45/319 (14%) who did not. Twenty-nine of 272 patients who underwent drain insertion experienced recurrence (10.9%) versus 9 of 45 patients without drain insertion (20.5%; p = 0.07). Overall change in median subdural width was significantly greater in the drain versus 'no drain' groups (11 mm versus 6 mm, p < 0.01). Overall change in median midline shift (MLS) was also significantly greater in the drain group (4 mm versus 3 mm, p < 0.01). On multivariate analysis, change in maximal width and MLS were significant predictors of recurrence, although only the former remained a significant predictor for functional outcome.

Conclusions: The use of subdural drains results in significantly improved postoperative imaging in burr hole evacuation of CSDH, thus providing radiological corroboration for their recommended use.
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http://dx.doi.org/10.1007/s00701-020-04356-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235065PMC
June 2020

Does pre-operative multifidus morphology on MRI predict clinical outcomes in adults following surgical treatment for degenerative lumbar spine disease? A systematic review.

Eur Spine J 2020 06 23;29(6):1318-1327. Epub 2020 Apr 23.

Edinburgh Spinal Surgery Outcomes Study Group, Department of Neurosurgery, Western General Hospital, Edinburgh, United Kingdom.

Aim: Low back pain (LBP) resulting from degenerative lumbar spine disease is a leading contributor to global disability. Changes in the morphology of the lumbar multifidus muscle on magnetic-resonance imaging (MRI) are associated with worse LBP and disability, but the association between multifidus morphology and post-operative outcomes is not known. The purpose of this systematic review is to examine the relationship between pre-operative multifidus morphology and post-operative changes in pain and disability.

Methods: We performed a systematic search using the Cochrane Library, EMBASE, MEDLINE, CINAHL and Scopus databases covering the period from January 1946 to January 2018. The literature was searched and assessed by independent reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. All relevant papers were assessed for risk of bias according to the Quality in Prognosis Studies tool.

Results: The initial search yielded 436 studies, of which 6 studies were included in the analysis. Four studies were at a low risk of bias. These studies included a total of 873 patients undergoing spinal surgery. An association between low fat infiltration and greater improvement in LBP and disability following surgery was identified. There was insufficient evidence to identify a relationship between cross-sectional area (CSA) and LBP or disability.

Conclusions: This systematic review found evidence for an association between low multifidus fat infiltration on MRI at baseline and greater reductions in measures of LBP and disability following surgical treatment. There is also limited evidence for an association between larger pre-operative multifidus CSA and improvements in disability, but not pain. The findings of this review should be interpreted with caution due to the small quantity of the available literature.
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http://dx.doi.org/10.1007/s00586-020-06423-6DOI Listing
June 2020

Validation of Appropriate Use Criteria for Coronary Computed Tomographic Angiography for Chest Pain Evaluation in a Tertiary Care Emergency Room.

J Thorac Imaging 2020 May;35(3):193-197

Radiology.

Purpose: Appropriate use criteria (AUC) defines the appropriateness of imaging procedures for specific clinical scenarios to promote evidence-based utilization and improve cost-effective care. The goal of this study was to assess the diagnostic yield and downstream health care resource utilization according to the AUC categorization for coronary computed tomography angiography (CCTA) in emergency department (ED) patients presenting with chest pain.

Materials And Methods: A total of 789 consecutive patients in the ED with chest pain and no known coronary artery disease (CAD) who underwent CCTA were classified as appropriate, uncertain, or inappropriate use according to the 2010 AUC. We abstracted index and 30-day data from the electronic medical record to determine diagnostic yield (rate of obstructive CAD and revascularization) and health care resource utilization (downstream stress test and 30-d hospital return rate).

Results: Rates of appropriate, uncertain, and inappropriate utilization were 48.4%, 48.8%, and 2.8%. Among appropriate, uncertain, and inappropriate classifications, rates of obstructive CAD were 9%, 8%, and 32% (P=0.002); rates of revascularization were 3%, 1%, and 36% (P<0.001); downstream stress test utilization rates were 5% versus 5% versus 14% (P=0.17), and 30-day hospital return rates were 6% versus 6% versus 5% (P>0.99), respectively.

Conclusions: Appropriate and uncertain uses were associated with low diagnostic yield compared with inappropriate use; however, our findings do not demonstrate differences between appropriate use categories with respect to downstream health care resource utilization. Further studies are needed to define the role of AUC for CCTA in the ED setting.
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http://dx.doi.org/10.1097/RTI.0000000000000473DOI Listing
May 2020

Toxicity outcome of endorectal brachytherapy boost in medically inoperable patients.

Strahlenther Onkol 2020 Nov 20;196(11):993-997. Epub 2020 Apr 20.

Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong, China.

Aim: This communication reviews results and toxicity of image-guided high-dose-rate endorectal brachytherapy (HDREBT) boost after external beam radiotherapy (ERT) in medically inoperable patients with rectal cancer.

Materials And Methods: A total of 18 patients with rectal cancer and clinical stage T2-4N0‑2 treated with HDREBT boost after ERT were retrospectively reviewed.

Results: Following treatment with a median total dose (EQD2, α/β = 10) of 66 Gy (range 48-92 Gy), the incidence of early and late rectal grade 3 toxicity was 11% and 19%, respectively. There was no correlation between the occurrence of acute and late toxicity.

Conclusion: With proper technique, a combined approach using EBRT and HDREBT was associated with acceptable toxicity in medically inoperable rectal cancer patients.
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http://dx.doi.org/10.1007/s00066-020-01612-0DOI Listing
November 2020

Ventriculoperitoneal shunt insertion in human immunodeficiency virus infected adults: a systematic review and meta-analysis.

BMC Neurol 2020 Apr 17;20(1):141. Epub 2020 Apr 17.

Division of Neurosurgery, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925, South Africa.

Background: Hydrocephalus is a common, life threatening complication of human immunodeficiency virus (HIV)-related central nervous system opportunistic infection which can be treated by insertion of a ventriculoperitoneal shunt (VPS). In HIV-infected patients there is concern that VPS might be associated with unacceptably high mortality. To identify prognostic indicators, we aimed to compare survival and clinical outcome following VPS placement between all studied causes of hydrocephalus in HIV infected patients.

Methods: The following electronic databases were searched: The Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), EMBASE, CINAHL Plus, LILACS, Research Registry, the metaRegister of Controlled Trials, ClinicalTrials.gov, African Journals Online, and the OpenGrey database. We included observational studies of HIV-infected patients treated with VPS which reported of survival or clinical outcome. Data was extracted using standardised proformas. Risk of bias was assessed using validated domain-based tools.

Results: Seven Hunderd twenty-three unique study records were screened. Nine observational studies were included. Three included a total of 75 patients with tuberculous meningitis (TBM) and six included a total of 49 patients with cryptococcal meningitis (CM). All of the CM and two of the TBM studies were of weak quality. One of the TBM studies was of moderate quality. One-month mortality ranged from 62.5-100% for CM and 33.3-61.9% for TBM. These pooled data were of low to very-low quality and was inadequate to support meta-analysis between aetiologies. Pooling of results from two studies with a total of 77 participants indicated that HIV-infected patients with TBM had higher risk of one-month mortality compared with HIV non-infected controls (odds ratio 3.03; 95% confidence-interval 1.13-8.12; p = 0.03).

Conclusions: The evidence base is currently inadequate to inform prognostication in VPS insertion in HIV-infected patients. A population-based prospective cohort study is required to address this, in the first instance.
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http://dx.doi.org/10.1186/s12883-020-01713-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164262PMC
April 2020

Evaluation of acute chest pain: Evolving paradigm of coronary risk scores and imaging.

Rev Cardiovasc Med 2019 Dec;20(4):231-244

Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, 10075, USA.

There is a broad differential diagnosis for patients presenting with acute chest pain. History, physical examination, electrocardiogram, and serial troponin assays are pivotal in assessing patients with suspected acute coronary syndrome. However, if the initial workup is equivocal, physicians are faced with a challenge to find the optimal strategy for further triage. Risk stratification scores have been validated for patients with known acute coronary syndrome, such as the TIMI and GRACE scores, but there may be limitations in undifferentiated chest pain patients. Advancements in imaging modalities such as coronary computed tomography angiography and the addition CT derived fractional flow reserve, have demonstrated utility in evaluating patients presenting with acute chest pain. With this article, we aim to provide a comprehensive review of the non-invasive modalities that are available to evaluate acute chest pain patients suspected of cardiac etiology in the emergency room. We also added a focus on new imaging modalities that have shown to have prognostic implications in stable ischemic heart disease.
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http://dx.doi.org/10.31083/j.rcm.2019.04.589DOI Listing
December 2019

Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis.

Acta Neurochir (Wien) 2019 10 13;161(10):2013-2026. Epub 2019 Aug 13.

Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK.

Background: In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as "non-aneurysmal" SAH (naSAH).

Methods: A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model.

Results: Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9-6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0-2) at 3-6 months following diagnosis was 92.0% [95% CI 86.0-96.5]. Complications included re-bleeding (3.1% [95% CI 1.5-5.2]), hydrocephalus (16.0% [95% CI 11.2-21.4]), vasospasm (9.6% [95% CI 6.5-13.3]) and seizure (3.5% [95% CI 1.7-5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4-21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1-92.9]) and higher risk of complications for non-PnaSAH patients.

Conclusion: This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients.
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http://dx.doi.org/10.1007/s00701-019-04025-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739283PMC
October 2019
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