There are now over a dozen disease modifying therapies (DMTs) available to treat multiple sclerosis (MS). They vary in efficacy and safety as well as in cost.The literature on the cost effectiveness of these is often confusing and contradictory. There is a lack of quality evidence enabling the comparison of different DMTs. There are scarce randomised controlled trials which look at one DMT compared with another that is not IFN or GA. There is also a lack of systematic reviews comparing the efficacy and safety of different DMTs. This makes it difficult to perform good quality cost-effectiveness analyses (CEAs). Furthermore, CEAs in and of themselves are difficult to interpret or compare due to the variation in methods and cost estimations as well as the use of outcome measures which cannot be proven over a reasonable timeframe.This review looks at the different DMTs available for MS and attempts to draw some conclusions on their cost-effectiveness. It also considers the costs and benefits of front loading the cost of treatment for MS by using more expensive and effective treatment earlier on.

Cerebral lipiodol embolisation is a rare but serious complication of lymphangiography. A man in his seventies had undergone lymphangiography for a refractory chyle leak following oesophagectomy. The day after lymphangiography, his conscious level dropped with bilaterally miotic pupils, increased muscle tone and double incontinence. CT scan of the head showed patchy high density throughout basal ganglia, cortex and cerebellum but no infarct, in keeping with lipiodol embolisation. He was managed initially in intensive care and subsequently underwent thoracoscopy with clipping and suturing of the left thoracic duct, and later a talc pleurodesis. At 3 months, he had some cognitive limitations and was walking with a stick.

IntroductionCerebral venous sinus thrombosis (CVST) can be a challenging condition to diagnose and treat. We previously performed an audit of CVST patients (2010–2014) and sought to re-audit for changes in practice.MethodsWe performed a retrospective audit of CVST patients admitted to Queen Elizabeth Hospital Birmingham, auditing against international guidelines. Comparisons with 2010–2014 data used Fisher’s exact test.ResultsBetween June 2015 and June 2019, 88 patients with CVST were included. Median age 44 years (range 16–87), 56% female. 56 (64%) patients underwent CT venography (CTV) and 16 (18%) MR venog- raphy (MRV); a greater proportion underwent venography than in 2010–2014 (31/51, 61%, p<0.001). Low molecular weight heparin was the commonest initial anticoagulant: 2010–2014 68% vs. 2015–2019 73% (p=0.70). There was a tendency towards less IV heparin over time: 18% vs. 7% (p=0.09). Although warfarin was the most common long-term anticoagulant in both audit periods (69% vs. 43%), direct oral antico- agulants (DOACs) were used in 12 (14%) patients in 2015–2019. 53% had thrombophilia screening despite this not being routinely recommended.ConclusionsIn 2015–2019, a greater proportion of patients with CVST were diagnosed using CTV/MRV and received less IV heparin. DOAC usage is increasing in CVST. Thrombophilia screening remains controversial.lisabatch1@gmail.com

PresentationA 73-year-old gentleman was admitted for 2 stage oesophagectomy (laparascopic abdominal and open thoracic) which was reported as uneventful. The tumour was subsequently confirmed T2N0M0 therefore cured by the operation. 3 days post operation increasing chest drain output was noted, this became milky with coarse creps on auscultation and this was confirmed later as a chyle leak.InterventionInterventional radiology performed lymphangiography under local anaesthesia on day 26 post op.ComplicationThe day after the procedure his GCS dropped with bilateral miotic pupils, increased tone and double incontinence. Initial bloods, arterial blood gas and glucose were normal. Naloxone was given with limited response. His surgical team requested CT head and neurology review.ResultsCT head showed patches of high density throughout basal ganglia, cortex and cerebellum but no infarct in keeping with embolization of lipiodol contrast medium. MRI head confirmed maturing ischaemic cortical and subcortical change.ManagementThe neurological picture showed an encephalopathy with more left sided upper motor neuron signs than on the right. He was managed initially in intensive care with supportive management however prognosis was unclear with no evidence-based treatment. There was also risk of late inflamma- tory reaction analogous to arachnoiditis seen post myelography.OutcomeHe subsequently had thoracotomy with clipping/suturing of the left thoracic duct. He was discharged home after three months in hospital.lisabatch1@gmail.com