Abstract 1122‐000146: A Survey of Current Status and Roles of Interventional Neurologists in Japan

Introduction : In Japan, there are more board‐certified neurosurgeons than board‐certified neurologists, and a significant part of stroke practice is provided by neurosurgeons. In neuroendovascular therapy practice, the trend of neurosurgeons to be in majority is more pronounced. The most of neuroendovascular therapy specialists (n = 1,586) certified by the Japanese Society for Neuroendovascular Therapy (JSNET) consists of neurosurgeons, and the proportion of neurologists/internists is only 8% (n = 128) as of April 2021. The aim of this study is to investigate the current status and roles of interventional neurologists, the minority providing neuroendovascular therapy, in Japanese clinical setting. Methods : Between 16th and 28th February 2021, the Japan Society of Vascular and Interventional Neurology (JSVIN) conducted a survey for society‐member neurologists and internists using questionnaires on Google Forms. The questionnaires consisted of 11 items regarding years after graduation, facility location, department, work style (full‐time or concurrent interventionalist), diseases for which respondents were engaged, disease/procedure preferences which respondents would treat by themselves, respondents’ roles in their own neuroendovascular therapy team, and others. Results : Replies were obtained from 112 (67.1%) out of all JSVIN‐member neurologists and internists (n = 167). The respondents included 71 JSNET‐certified specialists and they consisted of 56.3% of all the JSNET‐certified neurologists/internists. The departments to where the respondents belonged were Neurology in 66%, Cerebrovascular medicine in 25%, Neuroendovascular therapy in 4%, and Neurosurgery in 3%. The median years after graduation was 15 years (interquartile range, 10 – 21 years) and the proportion of respondents who have graduated 10 years or less was 30%. Respondents’ facilities were distributed around 27 prefectures of all 47 Japanese prefectures and a significant proportion of those was located in urban area; 20% in Osaka and 13% in Tokyo. The number of full‐time interventionalist was only 1. Sixty‐three (56%) were concurrently engaged in general neurology practice, and 33 (30%) in stroke neurology practice. The proportions of diseases for which the respondents were engaged were ischemic cerebrovascular diseases (acute large vessel occlusion strokes, carotid stenoses, and others) in 100%, hemorrhagic cerebrovascular diseases (cerebral aneurysms, arteriovenous shunts, and others) in 44%, and other diseases (tumors, spinal vascular disorders, and others) in 28%. The proportions of disease/procedure preferences which respondents would treat by themselves were acute stroke thrombectomy in 90%, carotid/intracranial stenoses in 87%, ruptured cerebral aneurysms in 38%, unruptured cerebral aneurysms in 31%, cerebral arteriovenous shunts in 33%, brain tumors in 29%, spinal vascular disorders in 13%, and pediatric diseases in 3%. Respondents’ roles in their own neuroendovascular therapy team were diagnostic performances based on neurologist’s skills in 89%, comorbidity assessment and management based on internist’s skills in 88%, precise neurological evaluation in 77%, neurosonological evaluation in 75%, and establishments of in‐hospital workflow/multi‐disciplinary collaboration in 71%. Conclusions : Most of interventional neurologists in Japan were engaged in neuroendovascular therapy mainly for ischemic cerebrovascular diseases in parallel with general neurology and/or stroke neurology practices. Interventional neurologists’ skill set developed in neurology/internist trainings and practices might contribute to the quality improvement of neuroendovascular therapy in Japan.

Increments in DNA-thioguanine level during thiopurine enhanced maintenance therapy of acute lymphoblastic leukemia

Maintenance therapy containing Methotrexate (MTX) and 6-Mercaptopurine (6MP) is essential to cure acute lymphoblastic leukemia (ALL). Cytotoxicity is elicited by incorporation of thioguanine nucleotides (TGN) into DNA (DNA-TG), and higher leucocyte DNA-TG is associated with increased relapse-free survival. As 6-Thioguanine (6TG) provides 6-fold higher cytosol TGN than 6MP, we added low-dose 6TG to MTX/6MP maintenance therapy to explore if this combination results in significantly higher DNA-TG. Target population of the “Thiopurine Enhanced ALL Maintenance therapy” (TEAM) study was n=30 patients, with non-high risk ALL, aged 1–45 years on MTX/6MP maintenance therapy receiving no other systemic chemotherapy. Incremental doses of 6TG were added to MTX/6MP maintenance therapy (start 6TG: 2.5 mg/m2/day, maximum: 12.5 mg/m2/day). Primary endpoint was DNA-TG increments. Thirty-four patients were included, and 30 patients completed maintenance therapy according to TEAM strategy. Of these 30 patients, 26 (87%) tolerated 10.0–12.5 mg/m2/day as maximum 6TG dose. TEAM resulted in significantly higher DNA-TG, when compared with both TEAM patients before TEAM inclusion (on average 251 fmol/μg DNA higher (95% CI 160–341; P<0.0001), and with historical patients receiving standard MTX/6MP maintenance therapy (on average 272 fmol/μg DNA higher (95% CI 147–398; P<0.0001). TEAM did not increase myelotoxicity or hepatotoxicity. Conclusively, TEAM is an innovative and feasible approach to improve maintenance therapy and results in higher DNA-TG without inducing additional toxicity. It may therefore be an effective strategy to reduce risk of ALL relapse through increased DNA-TG, and this will be tested in a randomized ALLTogether-1 substudy.

‘I AM NOT A MONSTER': THE LINGUISTIC STIGMA OF BORDERLINE PERSONALITY DISORDER.

"Borderline Personality Disorder is arguably the most distressing disorder amongst the DSM diagnoses for all involved. Although psychiatric labelling can be validating it is often stigmatising. Due to the nature of BPD, people living with the disorder (PBPD) tend to be marginalized and discriminated against. A quick and random review of the World Wide Web (including a selection of popular social media platforms) reveals a common linguistic theme in describing BPD. PBPD are ‘toxic’, ‘difficult’ and ‘manipulative. Other labels, more diagnostically - oriented see PBPD as the ‘PDs’ or ‘the borderlines’. These also carry negative connotations of the inner and outer groups - ‘us’ vs ‘them’. Given the nature of the labels, recovery for PBPD is often dubious. One might think - ‘I am a monster anyway’, a classic example of cognitive dissonance. The language used in clinical practice as well as out of it is a powerful weapon. Some might poetically describe BPD as a lethal cocktail of blended psychopathologies with the ingredients including chronic suicidality, abandonment and intermittent lucidity to name a few. Of note, externalising such pathologies in an adaptive way is almost a fantasy for the therapy team. A more user friendly descriptive diagnosis is ‘difficulty in emotion regulation’. However, probably the most accurate ‘label’ of BPD for PBPD is ‘living in acute pain’. The current climate and the uncertainty surrounded the ongoing COVID-19 pandemic has meant a significantly increased risk not only in symptoms remission but also in the increase in cyber-bullying and suicidality rate. The pandemic has also put a halt to the Participant and Public Involvement in the evidence based practice. Linguistic shift in reducing stigma is essential and of immediate need."

Transition to Telehealth Physical Therapy After Hip Arthroscopy for Femoroacetabular Impingement: A Pilot Study With Retrospective Matched-Cohort Analysis

Background: Telehealth use has increased significantly of late. However, outside of total hip and knee arthroplasty, there is minimal evidence regarding its efficacy in orthopaedics and postoperative rehabilitation. Purpose: To determine the efficacy and cost-effectiveness of a transition to postoperative telehealth physical therapy in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI). Study Design: Cohort study; Level of evidence, 3. Methods: Included were 51 patients undergoing postoperative physical therapy after hip arthroscopy for FAI. The intervention group consisted of patients undergoing initial in-person visits followed by a transition to telehealth physical therapy for 3 months postoperatively (group 1; n = 17). Comparison groups included patients undergoing in-person physical therapy with the same physical therapy team as the telehealth group (group 2; n = 17) and patients undergoing in-person therapy with a different therapy team at the same facility (group 3; n = 17). All groups were matched 1-to-1 by patient age and sex. All patients completed the short version of the International Hip Outcome Tool (iHOT-12) both preoperatively and at 3 months postoperatively. At 3 months postoperatively, it was determined whether patients met the minimally clinically important difference (MCID; ≥13 points) or substantial clinical benefit (SCB; ≥28 points) or whether they reached a Patient Acceptable Symptomatic State (PASS; ≥64 points). Billed charges were recorded as a measure of cost. Results: The overall mean age of the study patients ranged from 33 to 34 years. Among the 3 groups, there was no significant difference in the preoperative, postoperative, or pre- to postoperative change in iHOT-12 scores or in the percentage of patients meeting MCID, SCB, or PASS at 3 months. Group 1 had significantly lower mean costs ($1015.67) compared with group 2 ($1555.62; P = .011) or group 3 ($1896.38; P < .001). Conclusion: In this pilot study, telehealth physical therapy after hip arthroscopy was found to lead to similar short-term outcomes and was cost-effective compared with in-person physical therapy.

60 Front Door Specialist Frailty MDT Working at MFT NHS Trust—The Therapy Team Poster Presentation

Introduction The therapy team consists of physiotherapists, Occupational therapists and therapy technicians working generically to deliver a comprehensive therapy assessment to patients presenting in our Emergency Department, Clinical Decisions Unit and Medical Admissions Unit between the hours of 08:00–18:00 7 days a week. The therapists provide the hospitals frailty service in ED and MAU with early therapy assessment and intervention, supporting the provision of a Comprehensive Geriatric Assessment. The aims of our service are to provide early therapy assessment of our most vulnerable patients to avoid unnecessary hospital admissions and reduce readmission rates, and for those requiring hospital care to provide early mobilisation and discharge planning to reduce length of stay and complications associated with hospital admission. We provide the therapy component of the CGA as part of the specialist frailty MDT service and act as an interface with local community health and social services. Method A full review of our frailty MDT service was undertaken and a re-allocation of our resources and staff was piloted in July 2019. During this pilot our therapy staff presence was re-distributed allowing greater patient numbers to be assessed promptly on their arrival to ED. This adjustment supported the Frailty MDT actions of: Results Data collection showed total referrals to therapy increased from 67 (June 2019) to 160 (July 2019). In July same day discharges were at 43%; discharges ≥72 hours 24%; 7 day readmission at 9%; 28 day readmissions at 11% and 38% were referred to community services. Conclusion These changes enabled us to provide a full MDT frailty service to frail older people presenting at our ED in a timely manner and to a larger number of suitable patients.

A medical speech therapist in a multidisciplinary rehabilitation team. Practical experience of the Clinic of the Brain Institute

Background. In domestic and foreign publications, there are no descriptions of the principles of interaction between a medical speech therapist (MST) and other members of a multidisciplinary rehabilitation team (MDRT). Aim. To analyze our own experience in organizing the work of the speech therapy service of the regional neurorehabilitation Center. Materials and methods. We conducted a retrospective analysis of the activities of the division of MST of the interterritorial Center for Neurorehabilitation “Clinic of the Brain Institute“ (CBI) for the period 2015–2019. In the structure of the CBI, there is a 24-hour hospital with 45 beds, including a 9-bed intensive care unit, an 8-bed day hospital, a polyclinic with 50 visits per shift, and a telemedicine center. The speech therapy team of the MDRT consists of 8 specialists with higher education in the specialty “speech pathologist-defectologist“. Speech therapy examination consists of key blocks of clinical diagnosis of speech therapy syndromes: dysphagia, dysarthria, aphasia and prosoparesis. Each block represents a complex of a basic score scale and additional instrumental, including neurophysiological methods. The basis of speech therapy is voice training, articulation and probe massage and other standard procedures, combined in the concept of “basic techniques” for speech therapy syndromes. Drug and non-drug modulations are used to enhance the basic techniques. Results. In the period from 2015 to 2019, 5243 patients were treated in CBI after acute cerebral circulatory disorders and traumatic brain injuries, of which 4273 (81%) needed the help of clinical speech therapists. The most common problem was dysarthria – 55%. Speech breakdown in the framework of aphasia syndrome was noted in 26% of all hospitalized patients. Dysphagia was diagnosed in 30% of all hospitalized patients. During the hospitalization period of 14 days, each patient receives at least 45 minutes of daily individual training with a specialist and group articulation exercises, including weekends. The lesson is preceded by a modulating drug or non-drug procedure. For 5 years, 4273 patients were treated with speech therapy team. In 154 (11.6%) patients, speech therapy syndromes completely regressed, in 28% the severity of their manifestations decreased by 1–2 levels. Conclusion. At the early stage of rehabilitation, the speech therapist is called upon to solve priority tasks: achieving the maximum possible level of independence of the patient, at least staying at home with a minimum level of dependence on the help of a guardian. This is a prerequisite for the implementation of an individual comprehensive rehabilitation program. Despite many methodological and organizational problems, the MST is a key member of the MDRT, without which an effective rehabilitation process is impossible.

COVD-03. IMPACT OF COVID-19 ON THERAPY PROVISION FOR CHILDREN WITH CNS TUMOURS

INTRODUCTION The COVID-19 pandemic has led to widespread change in the delivery of rehabilitation. The Teenage Cancer Trust reported that 69% of young people with cancer saw their physiotherapist less than usual during the pandemic raising concerns about physiotherapy input. METHODS Retrospective analysis of all children’s therapy input managed under the Neuro Oncology Rehabilitation Team (NORT) between 1st April and 30th July 2020. Descriptive analysis of change to physiotherapy provision during this time period by Tertiary and local community services. RESULTS 49 children were managed under the NORT Therapy Team during this timeframe. 9 children were newly diagnosed with CNS tumours. There was no impact on inpatient therapy provision, 3 had delayed local therapy provision on discharge requiring increased virtual input by the Tertiary centre. 40 children were outpatients managed under the NORT therapy team. 16 children were also receiving regular local physiotherapy input prior to the COVID-19 pandemic. 13 of these children subsequently had their local physiotherapy input suspended during this time period, 8 children were offered virtual input as an alternative by the Tertiary centre, 2 children received increased face to face appointments at the Tertiary centre. 14 of the 24 children managed solely under the Tertiary NORT Therapy Team changed to virtual therapy reviews. DISCUSSION There is a clear change in therapy provision as a result of the COVID-19 pandemic. Future research should consider the effectiveness of neurorehabilitation conducted virtually and the impact on physical function of reduced local therapy provision in children with CNS tumours.