Real-world outcomes of nivolumab and cabozantinib in metastatic renal cell carcinoma: results from the International Metastatic Renal Cell Carcinoma Database Consortium

Objectives

In the present study, we explored the real-world efficacy of the immuno-oncology checkpoint inhibitor nivolumab and the tyrosine kinase inhibitor cabozantinib in the second-line setting.

Methods

Using the International Metastatic Renal Cell Carcinoma Database Consortium (imdc) dataset, a retrospective analysis of patients with metastatic renal cell carcinoma (mrcc) treated with nivolumab or cabozantinib in the second line after prior therapy targeted to the vascular endothelial growth factor receptor (vegfr) was performed. Baseline characteristics and imdc risk factors were collected. Overall survival (os) and time to treatment failure (ttf) were calculated using Kaplan-Meier curves. Overall response rates (orrs) were determined for each therapy. Multivariable Cox regression analysis was performed to determine survival differences between cabozantinib and nivolumab treatment.

Results

The analysis included 225 patients treated with nivolumab and 53 treated with cabozantinib. No significant difference in median os was observed: 22.10 months [95% confidence interval (ci): 17.18 months to not reached] with nivolumab and 23.70 months (95% ci: 15.52 months to not reached) with cabozantinib (p = 0.61). The ttf was also similar at 6.90 months (95% ci: 4.60 months to 9.20 months) with nivolumab and 7.39 months (95% ci: 5.52 months to 12.85 months) with cabozantinib (p = 0.20). The adjusted hazard ratio (hr) for nivolumab compared with cabozantinib was 1.30 (95% ci: 0.73 to 2.3), p = 0.38. When adjusted by imdc criteria and age, the hr was 1.32 (95% ci: 0.74 to 2.38), p = 0.35.

Conclusions

Real-world imdc data indicate comparable os and ttf for nivolumab and cabozantinib. Both agents are reasonable therapeutic options for patients progressing after initial first-line vegfr-targeted therapy.

Impact of contemporary patterns of chemotherapy utilization on survival in patients with advanced cancer of the urinary tract: a Retrospective International Study of Invasive/Advanced Cancer of the Urothelium (RISC)

Background

Cisplatin-based combination chemotherapy is the standard treatment of advanced urinary tract cancer (aUTC), but 50% of patients are ineligible for cisplatin according to recently published criteria. We used a multinational database to study patterns of chemotherapy utilization in patients with aUTC and determine their impact on survival.

Patients and methods

This was a retrospective study of patients with: UTC (bladder, renal pelvis, ureter or urethra); advanced disease (stages T4b and/or N+ and/or M+); urothelial, squamous or adenocarcinoma histology. Primary objective was overall survival (OS). Eligibility-for-cisplatin was defined by Eastern Cooperative Oncology Group performance status ≤ 1, creatinine clearance ≥ 60 ml/min, no hearing loss, no neuropathy and no heart failure. Cox regression multivariate analyses were used to establish independent associations of cisplatin versus noncisplatin-based chemotherapy on OS.

Results

1794 patients treated between 2000 and 2013 at 29 centers were analyzed. Median follow-up was 29.1 months. About 1333 patients (74%) received first-line chemotherapy: the use of first-line chemotherapy was associated with longer OS: [hazard ratio (HR): 1.91, 95% confidence interval (CI): 1.67-2.20]. Type of first-line chemotherapy received was: cisplatin-based 669 (50%), carboplatin-based 399 (30%) and other 265 (20%). Cisplatin use was an independent favorable prognostic factor (HR: 1.54, 95% CI: 1.35-1.77). This benefit was independent of baseline characteristics or comorbidities but was associated with eligibility-for-cisplatin: eligible patients treated with cisplatin lived longer than those who were not (HR: 1.74, 95% CI: 1.36-2.21), while such benefit was not observed among ineligible patients. About 26% of patients who did not receive cisplatin were eligible for this agent. Median OS of ineligible patients was poor irrespective of the chemotherapy used.

Conclusions

The importance of applying published criteria of eligibility-for-cisplatin was confirmed in a multinational, real-world setting in aUTC. The reasons for deviations from these criteria set targets to improve adherence. Effective therapies for cisplatin-ineligible patients are needed.

Impact of phytogenic feed additives on growth performance, nutrient digestion and methanogenesis in growing buffaloes

Twenty growing buffalo calves were fed on a basal diet consisting of wheat straw and concentrate mixture in a randomised block design, to study the effect of feeding phytogenic feed additives on growth performance, nutrient utilisation and methanogenesis. The four groups were viz. control (no additive), Mix-1 (ajwain oil and lemon grass oil in 1 : 1 ratio @ 0.05% of dry matter intake), Mix-2 (garlic and soapnut in 2 : 1 ratio @ 2% of DMI) and Mix-3 (garlic, soapnut, harad and ajwain in 2 : 1 : 1 : 1 ratio @ 1% of DMI). The experimental feeding was continued for a period of 8 months. A metabolism trial was conducted after 130 days of feeding. Methane emission from animals was measured by open-circuit indirect respiration calorimeter. The feed conversion efficiency was higher by 9.5% in Mix-1, 7% in Mix-2 and 10.2% in Mix-3 group than in control. The digestibility of nutrients was similar except crude protein, which was improved (P < 0.05) in treatment groups. All buffalo calves were in positive nitrogen balance. Comparative faecal nitrogen decreased and urinary nitrogen increased in all the supplemented groups compared with in the control group. Methane emission (in terms of L/kg dry matter intake and L/kg digestible dry matter intake) was reduced by 13.3% and 17.8% in Mix-1, 10.9% and 13.5% in Mix-2 and 5.1% and 9.8% in Mix-3 groups as compared with control. When expressed in L/kg organic matter intake and L/kg digestible organic matter intake, methane production was reduced by 13.3% and 16.7% in Mix-1, 10.9% and 12.9% in Mix-2 and 5.1% and 8.4% in Mix-3 groups compared with the control group. These feed additives inhibited methane emission without adversely affecting feed utilisation by the animals. The faecal energy, urinary energy and methane energy losses were not affected (P > 0.05) due to feeding of these additives. Further, long-term feeding experiments should be conducted on a large number of animals to validate these effects before they can be recommended for use at a field level.

Ventriculoperitoneal shunts in neonates: a retrospective study of outcomes with antibiotic-impregnated catheters and a modified peri-operative antibiotic protocol

BACKGROUND

CSF infection is a significant complication of ventriculoperitoneal (VP) shunts and results in prolonged hospital stay, developmental delay and decreased quality of life. To decrease the high rates of neonatal VP shunt infections, an updated clinical guideline that included the use of antibiotic-impregnated shunts and a revised peri-operative antibiotic protocol was introduced in our neonatal unit. In this study, we evaluated the efficacy of these new guidelines in reducing the CSF shunt infection rates.

METHODS

A retrospective cohort study of neonates (≤28 days) who had VP shunt insertions in our unit.

RESULTS

24 neonates in the first epoch received plain silastic shunt catheters (Feb 2002-April 2007), and 23 in the second epoch (August 2007-July 2015) received AIS catheters and a revised perioperative antibiotic protocol. Patient demographics were similar between both cohorts. Shunt related CSF infections were reduced in epoch 2 (2/23, 8.7%) compared to epoch 1 (5/24, 20.8%), but the results were not statistically significant (OR 0.36 (0.063-2.090); p = 0.256). Amongst neonates that needed VP shunt revision due to any cause, the median time interval between insertion to revision was significantly later in epoch 2 (epoch 1, 48 days (3-99); epoch 2, 148 days (20-396); p = 0.013).

CONCLUSIONS

AIS catheters and a 48-hour perioperative antibiotic regimen may be beneficial in neonatal hydrocephalus. Adequately powered RCTs in the neonatal population are needed to confirm these findings.

Enhancing the Radiologist-Patient Relationship through Improved Communication: A Quantitative Readability Analysis in Spine Radiology

BACKGROUND AND PURPOSE

More than 75 million Americans have less than adequate health literacy skills according to the National Center for Education Statistics. Readability scores are used as a measure of how well populations read and understand patient education materials. The purpose of this study was to assess the readability of Web sites dedicated to patient education for radiologic spine imaging and interventions.

MATERIALS AND METHODS

Eleven search terms relevant to radiologic spine imaging were searched on the public Internet, and the top 10 links for each term were collected and analyzed to determine readability scores by using 10 well-validated quantitative readability assessments from patient-centered education Web sites. The search terms included the following: x-ray spine, CT spine, MR imaging spine, lumbar puncture, kyphoplasty, vertebroplasty, discogram, myelogram, cervical spine, thoracic spine, and lumbar spine.

RESULTS

Collectively, the 110 articles were written at an 11.3 grade level (grade range, 7.1-16.9). None of the articles were written at the American Medical Association and National Institutes of Health recommended 3rd-to-7th grade reading levels. The vertebroplasty articles were written at a statistically significant (P < .05) more advanced level than the articles for x-ray spine, CT spine, and MR imaging spine.

CONCLUSIONS

Increasing use of the Internet to obtain health information has made it imperative that on-line patient education be written for easy comprehension by the average American. However, given the discordance between readability scores of the articles and the American Medical Association and National Institutes of Health recommended guidelines, it is likely that many patients do not fully benefit from these resources.

A rare case of bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture in an elderly male due to seizure activity

Musculoskeletal injuries such as dislocation of the shoulder and hip joints and fractures of the femoral neck are known complications of seizures. Bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture is a rare entity and is prone to delayed diagnosis, even more so in patients who experience post-seizure disorientation. The authors report the case of a 74-year-old male patient with bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture due to seizure activity. Bilateral open reconstruction and fixation of the quadrilateral plate with a 3.5-mm pre-bent reconstruction plate reinforced with 3.5-mm pelvic brim reconstruction plate was performed. In conclusion, this case is an example of rare bilateral quadrilateral plate fracture caused due to seizure activity, a fracture for which a high level of suspicion should be kept in mind while evaluating the patient post-seizure episode.

Effect of feeding of blend of essential oils on methane production, growth, and nutrient utilization in growing buffaloes

Objective

An experiment was conducted to study the effect of a blend of essential oils (BEO) on enteric methane emission and growth performance of buffaloes (Bubalus bubalis).

Methods

Twenty one growing male buffaloes (average body weight of 279±9.3 kg) were divided in to three groups. The animals of all the three groups were fed on a ration consisting of wheat straw and concentrate mixture targeting 500 g daily live weight gain. The three dietary groups were; Group 1, control without additive; Group 2 and 3, supplemented with BEO at 0.15 and 0.30 mL/kg of dry matter intake (DMI), respectively.

Results

During six months feeding trial, the intake and digestibility of dry matter and nutrients (organic matter, crude protein, ether extract, neutral detergent fibre, and acid detergent fibre) were similar in all the groups. The average body weight gain was tended to improve (p = 0.084) in Group 2 and Group 3 as compared to control animals. Feeding of BEO did not affect feed conversion efficiency of the animals. The calves of all the three groups were in positive nitrogen balance with no difference in nitrogen metabolism. During respiration chamber studies the methane production (L/kg DMI and L/kg digestible dry matter intake was significantly (p<0.001) lower in Group 2 and Group 3 as compared to control animals.

Conclusion

The results indicated that the BEO tested in the present study have shown potential to reduce enteric methane production without compromising the nutrient utilization and animal performance and could be further explored for its use as feed additive to mitigate enteric methane production in livestock.

Role of anti-tubercular treatment for positive endometrial aspirate DNA-PCR reproductive outcome in infertile patients in Indian setting - A randomized trial

AIMS

The aim of the study was to determine the effect of anti-tubercular therapy (ATT) versus no ATT on reproductive outcome in patients with positive endometrial aspirate DNA-PCR for tuberculosis.

SETTINGS AND DESIGN

Department of Obstetrics and Gynecology in collaboration with the Department of Microbiology at the All India Institute of Medical Sciences, New Delhi, India.

METHODS AND MATERIALS

This prospective randomized study was conducted on 100 women in the reproductive age group with primary or secondary infertility, attending the Gynecology OPD at AIIMS. Women with positive endometrial DNA-PCR, patent tubes on laparoscopy, and all other tests being negative for genital TB were randomized into two groups. In Group 1, patients received ATT for 6 months while in Group 2, patients were not given ATT. In patients who did not conceive a repeat endometrial sampling for DNA-PCR was performed at 6 months and 12 months post-laparoscopy.

STATISTICAL ANALYSIS

It was carried out using Stata 11.0 (College Station, TX, USA).

RESULTS

In Group 1 (ATT), 25 women achieved pregnancy with a pregnancy rate of 50% while in Group 2 (no ATT), 21 women achieved pregnancy with a pregnancy rate of 42% and the difference (95% CI) was 8.0% (-11.5%, 27.5%) which was not statistically significant (p=0.422). Difference (95% CI) in the rate of repeat EA DNA-PCR being positive between the two groups at 6 months was 3.1% (-2.9%, 9.1%), p=0.299, while at the end of 12 months, repeat DNA-PCR remained positive in 23 patients in Group 1 and in 26 patients in Group 2. Difference (95% CI) in the rate of repeat EA DNA-PCR being positive between the two groups at 12 months was 2.3% (-13.0%, 17.7%), p=0.767.

CONCLUSION

The present study does not validate ATT for positive DNA-PCR; however, it does provide an evidence to stop over-treating patients on the basis of positive EA DNA-PCR even after they have received a 6 months course of ATT. Repeating PCR at 6 months and at 12 months has no role and ATT should not be repeatedly given to the patient on the basis of repeat DNA-PCR alone.

CLINICAL TRIAL REGISTRATION NUMBER

CTRI/2015/10/006235, www.ctri.nic.in.

Localized insulin amyloidosis with use of concentrated insulin: a potential complication

BACKGROUND

Insulin-derived amyloidosis is a rare form of amyloidosis composed of insulin fibrils. The pH and concentration of insulin are known to influence the conformational state of the insulin hormone, with an increasing concentration favouring a more complex conformation. Concentrated insulin delivers a large amount of insulin to a localized area, raising the possibility of inducing conformational changes, forming insulin fibrils and leading to localized insulin amyloidosis.

CASE REPORT

A middle-aged woman with long history of Type 2 diabetes mellitus, treated with concentrated human insulin (U-500 insulin) presented with nodular lesions at the site of her daily insulin injections. A punch biopsy of the nodules showed skin with dermal amyloidosis staining favourably with Congo Red stain. The amyloid tumours were resected and areas positive for Congo Red stain were sent for liquid chromatography tandem mass spectrometry, which showed a peptide profile consistent with amyloid insulin.

CONCLUSION

Concentrated insulin was first introduced in 1952, however, it is only over the last two decades that it has been used increasingly, in congruence with the increasing incidence of obesity and diabetes mellitus seen in the USA. Only a few cases of insulin amyloidosis at the site of injection have been described in literature. With the increase in the use of insulin, this complication seems to be occurring more frequently. This is the first case report of a person with diabetes mellitus who developed localized insulin amyloidosis with the use of concentrated insulin, and points towards a potential complication of developing insulin amyloidosis with the use of concentrated insulin.

Bilateral simultaneous neck femur fracture following domestic fall in an elderly patient: a rare case report

Simultaneous bilateral neck femur fracture is a rare entity that has been associated with underlying bone disease, various metabolic diseases, high-energy trauma, and seizure disorders. Its occurrence following minimal trauma is very rare. This article presents the case of a 66-year-old female who sustained bilateral intracapsular fracture neck femur following a slip and fall at home. Single-stage bilateral cemented total hip replacement was done using a direct lateral approach with alternate right and left lateral positions. The authors report a satisfactory outcome, with Harris hip score of 98 at one year, which persisted until her last follow-up at 30 months.

Effectiveness of amitriptyline and lamotrigine in traumatic spinal cord injury-induced neuropathic pain: a randomized longitudinal comparative study

STUDY DESIGN

Randomized longitudinal comparative study.

OBJECTIVES

To compare the efficacy of lamotrigine and amitriptyline in the management of traumatic spinal cord injury (SCI)-induced neuropathic pain (NP).

SETTING

Sawai Man Singh Medical College and Hospital, Jaipur, India.

METHODS

A total of 147 individuals with NP were randomized for a 3-week trial of either amitriptyline or lamotrigine. Amitriptyline was administered orally at doses of 25, 50 and 100 mg once daily at night time, and lamotrigine was administered orally at doses of 25, 50 and 100 mg twice daily, both for 1 week by means of optional titration. Assessment of NP was done at baseline and thereafter at 1, 2 and 3 weeks using Short-form MC Gill Pain Questionnaire-2 (SFMPQ2) scores.

RESULTS

There was a significant difference between the mean values of the SFMPQ2 score at baseline and those at each follow-up for amitriptyline. Similar results were seen in the lamotrigine group. When the differences in mean SFMPQ2 scores at different time frames from baseline were compared with those of the other group, values were found to be nonsignificant as seen on the Mann-Whitney U-test.

CONCLUSIONS

These findings support the use of both amitriptyline and lamotrigine in the management of NP after traumatic SCI.

Epidemiology of Dog Bites: A Community-Based Study in India

Rabies is a deadly disease with no cure which is mainly caused by dog bites. Data on dog bites and knowledge, attitude and practices (KAP) related to dog bites are not generally available to rural communities.

We made a cross-sectional study of a rural community of ten villages served by a primary health centre selected by random sampling. Ten per cent of households selected by systematic random sampling were interviewed for KAP regarding dog bites.

The dog bite rate was 25.7/1000 population per year. The rate for males was higher than for females; half of the bites were in summer; 40% did not go for any prophylaxis; half of the victims treated their wounds with chilli powder. Eighty per cent of the bites were class II or III and leg bites were most common. The majority of the community knew dog bites can cause death but they did not know the correct incubation period. Most knew that injections were available to prevent rabies. Only half said they would visit a hospital for treatment. Around 50% received tetanus toxoid.

Evaluation of the pylorus with concurrent intraluminal pressure and EndoFLIP in patients with nausea and vomiting

BACKGROUND

Nausea and vomiting occurs in gastroparesis due to diabetes mellitus or unknown causes. The aim of this study was to compare (i) pyloric distensibility to pyloric manometric pressure in patients with nausea and vomiting and (ii) to correlate distensibility with delays in gastric emptying.

METHODS

Sleeve manometry and EndoFLIP were performed sequentially during the same endoscopy on 114 patients with nausea and vomiting (47 with diabetes mellitus and 67 with idiopathic cause) after a standardized gastric emptying study. The sleeve manometer was positioned fluoroscopically, and the EndoFLIP was placed endoscopically. Manometric pressure using a water-perfused catheter and distensibility using an EndoFLIP filled with 40 cc of saline were measured from the pylorus.

KEY RESULTS

The basal pyloric pressure was elevated (>10 mmHg) in 34 patients and was normal in 80 patients. The basal and peak pressures were similar in patient with normal and delayed gastric emptying (p > 0.05). There was a significant decrease in distensibility (8.0 ± 1.0 mm(2) /mmHg) in patients with gastric retention (>20% at 4 h) compared with patients (12.4 ± 1.4 mm(2) /mmHg) (p < 0.01) with normal gastric retention (<10%). Pressure measurements from the sleeve manometer and the EndoFLIP correlated (r = 0.29) (p < 0.002), and increased EndoFLIP balloon pressure (19.4 ± 1.4 mmHg) (p < 0.01) was associated with a severe delay in gastric emptying.

CONCLUSIONS & INFERENCES

Elevated basal pyloric pressure occurs in 42% of patients with nausea and vomiting and delayed emptying. Decreased pyloric distensibility occurs with nausea, vomiting, and delayed gastric emptying. The EndoFLIP is a useful tool in the evaluation of pyloric function in symptomatic patients.

Effects of plants containing secondary metabolites as feed additives on rumen metabolites and methanogen diversity of buffaloes

Four fistulated adult Murrah buffaloes were fed on a basal diet consisting of wheat straw and concentrate mixture in a 4 × 4 Latin square design to study the effects of feeding plants containing secondary metabolites on rumen metabolites and methanogen diversity. The four groups were Control (no additive), Mix-1 (ajwain oil and lemon grass oil in a 1 : 1 ratio @ 0.05% of dry matter intake), Mix-2 (garlic and soapnut in a 2 : 1 ratio @ 2% of dry matter intake) and Mix-3 (garlic, soapnut, harad and ajwain in a 2 : 1 : 1 : 1 ratio @ 1% of dry matter intake). In each phase of 30 days’ duration, after 19 days of feeding, rumen liquor was sampled for two consecutive days at 0, 2, 4, 6 and 8 h post-feeding, whereas rumen content was sampled at 0 h feeding. The pH of the rumen liquor was recorded at every collection and then the rumen liquor of every collection was pooled day-wise and animal-wise. These pooled samples were used for estimation of rumen metabolites like ammonia, lactic acid and volatile fatty acids. Microscopic counting of protozoa was done in both 0 h and pooled samples of rumen liquor. Rumen contents collected from different locations of rumen were processed for enzyme estimation. The rumen contents were squeezed and the liquid portion was used for DNA isolation, which was further processed to determine methanogen diversity. Daily intake of feed was similar (P > 0.05) in all the four groups. The ammonia-N concentration and ciliate protozoa population were reduced significantly in the treatment groups supplemented with additives. Rumen pH, lactic acid, volatile fatty acids and enzyme activities were not affected (P > 0.05) by feeding of any of these additives. Methanogenic diversity comparison was made between the Control and Mix-1 group. The basic local alignment search tool (BLAST) analysis of the 133 (44 from the Control group and 89 from the Mix-1 group) sequences showed similarity of the sequences of rumen archaea by up to 97% to the known sequences of rumen methanogens. The sequences with minimum length of 750 bp were selected for phylogenetic analysis. Per cent identity of these sequences with that of the available nearest neighbour as calculated by MEGA 5.03 software showed identity of the clones in the range of 88–97%. The clones were similar with Methanobrevibacter smithii ATCC 35061, uncultured Methanobrevibacter sp. clone MEME95 and M. ruminantium M1. Overall, feeding of any of these feed additives to fistulated buffaloes did not affect feed intake, rumen pH, or rumen metabolites except ammonia and enzyme profile. Methanogen diversity showed the possibility of Methanobrevibacter as the major methanogen in buffalo rumen liquor.

Use of patient ethnography to support quality improvement in benign prostatic hyperplasia

BACKGROUND

Patient-centeredness is a primary aim of quality improvement (QI) but optimal strategies to achieve that goal remain elusive. Benign prostatic hyperplasia (BPH) is one of the commonest urologic diagnoses and significantly affects quality of life. Patient ethnography is an emerging qualitative method of observation and dynamic interviews to understand the context through which the patient experiences care. We implemented patient ethnography to support our QI infrastructure and improve patient-centeredness in BPH.

PROBLEM

Little is known about how to measure whether processes of care are patient-centered. We did not know whether the care processes our patients experienced provided value from their perspective.

GOALS

We sought to discover previously unrecognized components of care that patients perceived to be of low value. Our primary goal was to develop QI initiatives that targeted low-value themes identified in the ethnography. Our secondary goal was a rapid rollout of three targeted initiatives.

STRATEGY

We used a 4-step patient ethnography: (1) created detailed process maps to define phases of care, (2) interviewed patients, (3) synthesized transcript data in focus groups using the Crawford Slip method, and (4) targeted undesirable components of care for QI. Semi-structured interviews with seven representative patients identified low-value themes. Focus groups, comprised of primary care physicians, case coordinators, nurses, and urologists, evaluated the interview transcripts and generated improvement opportunities prioritized based on feasibility, patient value, scalability, and innovation. We used affinity mapping and priority matrix techniques to prioritize QI opportunities.

RESULTS

We identified five low-value themes from the patient interviews and developed corresponding QI opportunities. These included issues surrounding the referral and consultation process as well as postoperative care, especially home urinary catheter maintenance. Six months after completing the ethnography three of five targeted improvement opportunities had been implemented.