The Bionic Bra: Using electromaterials to sense and modify breast support to enhance active living

BACKGROUND

Although the most supportive sports bras can control breast motion and associated breast pain, they are frequently deemed uncomfortable to wear and, as a result, many women report exercise bra discomfort. Given that exercise bra discomfort is associated with decreased levels of physical activity, there is a pertinent need to develop innovative solutions to address this problem.

OBJECTIVES

This research aimed to evaluate the use of electromaterial sensors and artificial muscle technology to create a bra that was capable of detecting increases in breast motion and then responding with increased breast support to enhance active living.

METHODS

The research involved two phases: (i) evaluating sensors suitable for monitoring and providing feedback on changes in the amplitude and frequency of breast motion, and (ii) evaluating an actuator capable of changing breast support provided by a bra during activity.

RESULTS

When assessed in isolation, the developed technologies were capable of sensing breast motion and actuating to provide some additional breast support.

CONCLUSIONS

The challenge now lies in integrating both technologies into a functional sports bra prototype, and assessing this prototype in a controlled biomechanical analysis to provide a breast support solution that will enable women to enjoy active living in comfort.

Best management practices for newly weaned calves for improved health and well-being

Morbidity and mortality in newly weaned calves resulting from bovine respiratory disease (BRD) continue to be the most significant problems facing the beef industry. Morbidity attributed to BRD accounts for approximately 75% of total feedlot morbidity. Several experiments have documented the economic impacts of BRD. Direct costs attributable to BRD include death loss, treatment and labor costs, and prevention costs, while indirect costs associated with BRD include decreased growth performance and feed efficiency, increased days on feed, and decreased carcass merit and market value. In recent years, cattle treated for BRD have returned $50 to $250 less per head at harvest than cattle never treated for BRD. Best management practices for newly weaned calves vary depending on a multitude of factors including: season of year calves are purchased, calf genetics, length of time in the marketing and transport channels, previous management and vaccination programs, and other factors. In general, calves purchased directly from a ranch have fewer health problems than calves purchased through auction markets. The longer a calf is in the marketing chain, the more likely health problems will be encountered. Calves that have spent several days in the marketing chain may develop clinical BRD before or very soon after arrival, whereas cattle with less time in the marketing chain may get sick later (2 to 4 wk), due to the length of time it takes for BRD to develop. On or before arrival, calves should be given a risk score (high, medium, or low) that relates to the quantity and magnitude of stress they have encountered and the probability they will develop BRD. High-risk calves typically will have been recently weaned, received no vaccinations, not been castrated or dehorned, been commingled, and moved through an auction market. Low-risk calves will often originate from a single source and will have gone through a preconditioning program that includes vaccination, castration, dehorning, weaning, and potentially feed bunk adaptation. Variation exists within risk category, so the preliminary assessment should be combined with visual observation on arrival as additional health assessments and feed intake information becomes available. Cattle managers should adjust management strategies based on risk category to meet the perceived needs of individual lots of cattle to improve the health and well-being of newly weaned calves.

Combined Elbow Release and Humeral Rotational Osteotomy in Arthrogryposis

PURPOSE

The purpose of this study was to determine if a simultaneous posterior elbow release and humeral osteotomy to correct both the elbow extension contracture and the humeral internal rotation contracture in children with arthrogryposis can produce similar results as a posterior elbow release alone.

METHODS

This study was a retrospective chart review of consecutive patients with arthrogryposis treated surgically for elbow extension contracture between 2007 and 2014. A total of 43 procedures in 36 patients had adequate available follow-up data and were included in the study. The postoperative range of motion reported was measured at the early follow-up (3-6 months), midterm follow-up (between 1 and 2 years), and the most recent long-term follow-up (after 2 years) from the date of surgery. Patients were grouped into 2 groups (simultaneous and release) based on the necessity of performing an ipsilateral humeral rotation osteotomy at the time of the release.

RESULTS

At early follow-up, patients in both groups increased their total arc of motion. There was a significant difference in extension and arc of motion at midterm follow-up (between 1 and 2 years) between the simultaneous and the release groups with the simultaneous group significantly losing both terminal extension and total arc of motion. At more than 2 years follow-up, there remained a statistically significant difference in arc of motion, with the release group having a significantly larger arc of motion. Patients who underwent dual plating had a much larger arc of motion at early follow-up than the K-wire or single-plate fixation group, despite having similar preoperative extension, flexion, and arc of motion. This difference was also significant at late follow-up.

CONCLUSIONS

Patients with posterior release alone had significantly greater improvement in total arc of motion and significantly better elbow extension than patients who underwent a simultaneous humeral osteotomy. However, rigid fixation with early mobilization may yield results comparable with the release alone group.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Effect of Opioids, Alcohol, and Nonsteroidal Anti-inflammatory Drugs on Fracture Union

The estimated rate of fracture nonunion is between 5% and 10%, adding significant cost to the health care system. The cause of fracture nonunion is multifactorial, including the severity of the injury, patient factors resulting in aberrancies in the biology of fracture, and the side effects of pain control modalities. Minimizing surgeon-controlled factors causing nonunion is important to reduce the cost of health care and improve patient outcomes. Opioids, alcohol, and nonsteroidal anti-inflammatory drugs have been implicated as risk factors for fracture nonunion. Current literature was reviewed to examine the effects of opioids, alcohol, and nonsteroidal anti-inflammatory drugs on fracture union.

Effect of timing of challenge following short-term natural exposure to bovine viral diarrhea virus type 1b on animal performance and immune response in beef steers

Bovine respiratory disease (BRD) is the most common and economically detrimental disease of beef cattle during the postweaning period, causing the majority of morbidity and mortality in feedlots. The pathogenesis of this disease often includes an initial viral infection, which can predispose cattle to a secondary bacterial infection. The objective of this experiment was to determine the effects of timing of an intratracheal (MH) challenge relative to 72 h of natural exposure to bovine viral diarrhea virus (BVDV) type 1b persistently infected (PI) calves on performance, serum antibody production, total and differential white blood cell (WBC) count, rectal temperature, clinical severity score (CS), and haptoglobin (Hp). Steers ( = 24; 276 ± 31 kg initial BW) were randomly allocated to 1 of 3 treatments (8 steers/treatment) in a randomized complete block design. Treatments were steers not exposed to calves PI with BVDV 1b and not challenged with MH (CON), steers intratracheally challenged with MH 84 h after being exposed to calves PI with BVDV 1b for 72 h (LateCh), and steers intratracheally challenged with MH 12 h after being exposed to calves PI with BVDV 1b for 72 h (EarlyCh). Performance (ADG, DMI, and G:F) was decreased ( < 0.001) for both EarlyCh and LateCh from d 0 to 4. From d 5 to 17, LateCh appeared to compensate for this lost performance and demonstrated increased ADG ( = 0.01) and G:F ( = 0.01) compared with EarlyCh. Both EarlyCh and LateCh had decreased platelet counts ( < 0.001) compared with CON. Antibody concentrations of BVDV and MH were higher ( < 0.05) for both EarlyCh and LateCh compared with CON. Rectal temperature, CS, and Hp increased ( < 0.001) across time from h 4 to 48, h 4 to 36, and h 8 to 168, respectively. Within 24 h of MH challenge, WBC and neutrophil concentrations within the blood increased whereas lymphocyte concentrations decreased. The timing of BVDV exposure relative to a MH challenge appears to influence the CS and acute phase response associated with BRD. As typical beef cattle marketing channels allow for variation in the timing of respiratory pathogen exposure, understanding the physiological changes in morbid cattle will lead to improved management of BRD.

Fourth-Year Medical School Course Load and Success as a Medical Intern

BACKGROUND

The fourth year of medical school has come under recent scrutiny for its lack of structure, cost- and time-effectiveness, and quality of education it provides. Some have advocated for increasing clinical burden in the fourth year, while others have suggested it be abolished.

OBJECTIVE

To assess the relationship between fourth-year course load and success during internship.

METHODS

We reviewed transcripts of 78 internal medicine interns from 2011-2013 and compared the number of intensive courses (defined as subinternships, intensive care, surgical clerkships, and emergency medicine rotations) with multi-source performance evaluations from the internship. We assessed relative risk (RR) and 95% confidence interval (CI) of achieving excellent scores according to the number of intensive courses taken, using generalized estimating equations, adjusting for demographics, US Medical Licensing Examination (USMLE) Step 1 board scores, and other measures of medical school performance.

RESULTS

For each additional intensive course taken, the RR of obtaining an excellent score per intensive course was 1.05 (95% CI 1.03-1.07, P < .001), whereas the RR per nonintensive course taken was 0.99 (95% CI 0.98-1.00, P = .03). An association of intensive course work with increased risk of excellent performance was seen across multiple clinical competencies, including medical knowledge (RR 1.08, 95% CI 1.04-1.11); patient care (RR 1.07, 95% CI 1.04-1.10); and practice-based learning (RR 1.05, 95% CI 1.03-1.09).

CONCLUSIONS

For this single institution's cohort of medical interns, increased exposure to intensive course work during the fourth year of medical school was associated with better clinical evaluations during internship.

Deuterium as a Stereochemically Invisible Blocking Group for Chiral Ligand Synthesis

Highly diastereoselective lithiation (s-BuLi/TMEDA in Et₂O, -78 °C, 2 h) of (S)-2-ferrocenyl-4-(substituted)oxazolines followed by addition of MeOH-d₄ gave up to 95% D incorporation. Subsequent application of alternative lithiation conditions (n-BuLi in THF, -78 °C, 2 h), followed by addition of an electrophile, resulted in a reversal of diastereoselectivity controlled primarily by the high k_H/k_D value for lithiation (isomer ratio typically between 10:1 and 20:1).

The effects of technology use in feedlot production systems on feedlot performance and carcass characteristics

The objectives of this study were to examine the effects of feedlot production systems with and without the use of a β-adrenergic agonist compared to an all-natural production program on feedlot performance and carcass characteristics. Crossbred beef steers ( = 336; initial BW = 379 ± 8 kg) were randomized to 1 of 3 treatments in a randomized complete block design (RCBD; 14 steers/pen; 8 pens/treatment). Treatments consisted of an all-natural treatment (NAT), a conventional treatment (CONV), and a conventional treatment with a β-agonist (CONV-Z). All treatments were fed the same basal diet with NAT cattle receiving no growth promoting technologies. The CONV and CONV-Z cattle were implanted with 40 mg of estradiol and 200 mg of trenbolone acetate (TBA) on d 0 and were fed 33 and 9 mg/kg of monensin and tylosin daily, respectively. The CONV-Z cattle were fed zilpaterol hydrochloride (ZH) at 6.76 mg/kg (90% DM basis) for the last 20 days on feed (DOF) There was no effect of treatment on DMI ( = 0.83); however, CONV-Z steers gained 3.8% faster (1.64 vs. 1.58 kg/d; < 0.01) and were 5.3% more efficient (0.160 vs. 0.152; < 0.01) than CONV steers, and CONV steers gained 32.8% faster (1.58 vs. 1.19 kg/d; < 0.01) and were 26.7% more efficient (0.152 vs. 0.120; < 0.01) than NAT steers. There was a 35.7% improvement in estimated carcass gain (1.29 vs. 0.95 kg/d; < 0.01) and a 32.6% improvement in carcass efficiency (0.126 vs. 0.095; < 0.01) for CONV-Z steers compared to NAT steers. Hot carcass weight was increased by 8 kg for CONV-Z steers compared to CONV steers (394 vs. 386 kg; = 0.05) and 46 kg compared to NAT steers (394 vs. 348 kg; < 0.01). Longissimus muscle area was increased by 3.6 cm for CONV-Z steers compared to CONV steers (92.29 vs. 88.67 cm; = 0.02) and 12.1 cm for CONV-Z steers compared to NAT steers (92.29 vs. 80.16 cm; < 0.01), resulting in a 9.6% unit increase in USDA yield grade (YG) 1 (15.14 vs. 5.52%; < 0.05) and a 21.6% unit reduction in USDA YG 3 for CONV-Z steers compared to CONV steers (30.70 vs. 52.32%; < 0.05). The CONV-Z steers had a lower marbling score compared to the other treatments (432; 0.01), resulting in an 11.7% unit increase (20.70 vs. 9.03%; < 0.05) in USDA Select carcasses compared to CONV steers. The results of this experiment show that CONV-Z and CONV production results in a significant improvement in feedlot performance and USDA YG compared to NAT.

Metallocene to metallocene conversion. Synthesis of an oxazoline-substituted pentamethyliridocenium cation from a ferrocenyloxazoline

A novel metallocene to metallocene conversion is reported in which an air-stable oxazoline-substituted ferrocene is converted into an air-stable oxazoline-substituted iridocenium ion.

Effects of beef production system on animal performance and carcass characteristics

The objective of this study was to evaluate conventional (CONV) and natural (NAT) beef production systems from annual pasture through finishing through grazing. Beef steers (n=180, initial BW=250±19 kg) were assigned randomly to 2 treatments in the pasture phase. Steers were implanted with 40 mg of trenbolone acetate (TBA), 8 mg estradiol, and 29 mg tylosin tartrate (CONV), or received no implant (NAT). Steers on the 2 treatments grazed wheat or cereal rye for 109 d. Conventional steers had an 18.5% improvement in ADG (1.22 vs. 1.03 kg/d, P<0.01) and a heavier final BW (385 vs. 366 kg, P<0.01) compared with NAT steers. Following the pasture phase, steers (n=160 steers, 5 steers/pen, 8 pens/treatment) were assigned to a 2×2 factorial in the feedlot phase. Production system (NAT vs. CONV) was maintained from the pasture phase, and the second factor was 7 vs. 12% low-quality roughage (DM basis, LOW vs. HIGH). During finishing, CONV steers were given 120 mg of TBA and 24 mg estradiol at processing, fed monensin and tylosin, and fed zilpaterol hydrochloride for the last 20 d of the experiment. There were no program×roughage level interactions (P>0.07). The CONV steers ate 6.9% more feed (11.8 vs. 11.0 kg/d, P<0.01), gained 28.4% faster (1.90 vs. 1.48 kg/d, P<0.01), and were 24.2% more efficient (0.164 vs. 0.132, P<0.01) compared with NAT steers. The LOW steers had greater G:F (0.153 vs. 0.144, P<0.01) compared with HIGH steers. There was a 28.3% improvement in estimated carcass weight gain (1.36 vs. 1.06 kg/d), 18.6% improvement in carcass efficiency (0.115 vs. 0.097, P<0.01), and 21.6% improvement (1.52 vs. 1.25 Mcal/kg, P<0.01) in calculated dietary NEg for CONV compared with NAT steers. Hot carcass weight was increased by 62 kg (424 vs. 362 kg, P<0.01) and LM area was increased by 16.9 cm2 (100.9 vs. 84.0 cm2, P<0.01), decreasing USDA yield grade (YG, 3.09 vs. 3.54, P<0.01) for CONV steers compared with NAT steers. Natural steers had a greater percentage of carcasses in the upper 2/3 of USDA Choice grade (48.7 vs. 18.7%, P<0.01), a greater percentage of YG 4 and 5 carcasses (25.4 vs. 9.3%, P<0.01), and a greater percentage of abscessed livers (39.6 vs. 10.5%, P<0.01) compared with CONV steers. The results show that CONV production results in more rapid and efficient production that resulted in heavier carcasses with superior YG and desirable quality grades with both roughage levels.

Clinical and oncological outcomes after surgical excision of pigmented villonodular synovitis at the foot and ankle

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare benign neoplastic disease of the synovium of joints and tendon sheaths, which may be locally aggressive. It can be broadly classified into localised disease or more diffuse forms, with the latter more prone to recurrence after surgical excision. We describe our experience in the management of foot and ankle PVNS, focusing on the diffuse type.

METHODS

Patients with PVNS were identified from a histology database from 2000 to 2010 at the University Hospitals of Leicester. The primary aim was to determine oncological outcomes and evaluate clinical outcomes with the Toronto Extremity Salvage Score (TESS) and the American Academy of Foot and Ankle Surgeons (AOFAS) scores.

RESULTS

30 patients, 16 males and 14 females with a mean age of 37±15 years, who underwent surgery, were identified. There were 22 nodular PVNS and 8 diffuse PVNS. The diffuse PVNS was more likely to be in the hindfoot (75%, 6/8), of which 50% (3/6) had osteoarthritis at presentation. The localised PVNS was mostly located in the forefoot (91%, 20/22). None of the localised PVNS had a recurrence. The surgical recurrence rate in this series was similar to the pooled recurrence rate from the literature [12.5% (1/8) compared to 12.2% (6/49)]. The mean TESS and AOFAS scores were 86 and 78, respectively.

CONCLUSIONS

Diffuse PVNS is more likely to occur in the hindfoot and nodular PVNS is more common in the forefoot. Aggressive synovectomy alone is an effective treatment for diffuse PVNS, with good oncological and clinical outcomes.

Extra-abdominal desmoid fibromatosis--a sarcoma unit review of practice, long term recurrence rates and survival

INTRODUCTION

Desmoid fibromatosis (DF) carries a significant morbidity and a recognised mortality. Despite this there are currently limited diagnostic or treatment algorithms specific to cases of extra-abdominal DF. Historically surgical excision has formed the cornerstone of treatment. Recently however a paradigm shift has meant many practitioners now adopt a more conservative approach, placing emphasis on active surveillance, function preserving resections, and non-surgical oncologic therapies.

METHODS

We performed an 8-year retrospective review of all cases of extra-abdominal DF managed within our region to assess the consistency of diagnostics, management and long-term outcome.

RESULTS

47 eligible cases were identified. Mean age at diagnosis was 41.3 years (1-81 years). Disease location and speciality of diagnosing practitioners were varied. Management was generally inconsistent. Variation was seen in imaging, biopsy techniques, MDT involvement and management. At a median follow up of 4.9 years our local recurrence rate was 19%.

DISCUSSION

The optimal management of DF is unknown. This has led to a lack of formalised guidance for practitioners managing this challenging condition, resulting in inconsistencies and areas for improvement in current management. We propose a diagnostic pathway which may improve consistency of care, reduce potentially unnecessary surgery and the associated morbidity, and significantly increase the rate of complete (R0) surgical resections when surgery is deemed appropriate whilst not significantly worsening oncological outcome. Specifically we propose all cases should be imaged appropriately (usually with MRI), undergo a planned biopsy (by radiologically guided core needle biopsy) and be managed centrally in conjunction with multidisciplinary sarcoma units.

Enantioselective synthesis and application to the allylic imidate rearrangement of amine-coordinated palladacycle catalysts of cobalt sandwich complexes

The reaction of (η(5)-(N,N-dimethylaminomethyl)cyclopentadien-yl)(η(4)-tetraphenylcyclobutadiene)cobalt with sodium tetrachloropalladate and (R)-N-acetylphenylalanine gave planar chiral palladacycle di-μ-chloridebis[(η(5)-(Sp)-2-(N,N-dimethylaminomethyl)cyclopentadienyl,1-C,3'-N)(η(4)-tetraphenylcyclobutadiene)cobalt]dipalladium [(Sp )-Me2 -CAP-Cl] in 92% ee and 64% yield. Enantiopurity (>98% ee) was achieved by purification of the monomeric (R)-proline adducts and conversion back to the chloride dimer. Treatment with AgOAc gave (Sp)-Me2-CAP-OAc which was applied to asymmetric transcyclopalladation (up to 78% ee). The (R)-N-acetylphenylalanine mediated palladation methodology was applicable also to the corresponding N,N-diethyl (82% ee, 39% yield) and pyrrolidinyl (>98% ee, 43% yield) cobalt sandwich complexes. A combination of 5 mol % of the latter [(Sp)-Pyrr-CAP-Cl] and AgNO3 (3.8 equiv) is a catalyst for the allylic imidate rearrangement of an (E)-N-aryltrifluoroacetimidate (up to 83% ee), and this catalyst system is also applicable to the rearrangement of a range of (E)-trichloroacetimidates (up to 99% ee). This asymmetric efficiency combined with the simplicity of catalyst synthesis provides accessible solutions to the generation of non-racemic allylic amine derivatives.

Impact of health management, health treatments, and zilpaterol hydrochloride supplementation on carcass quality, color, and palatability traits in heifers

Two hundred sixty-eight strip loins were collected from heifers fed at Oklahoma State University in Stillwater, OK. In Exp. 1, heifers (n = 127) were assigned to 1 of 3 health management treatment groups: antimicrobial administrations were given based on standard feedlot protocol (SFP) or ruminal temperature (RT) or given a metaphylactic treatment of tulathromycin (MT) followed by visual assessment (VA). In Exp. 2, heifers (n = 155) were assigned to the same treatment groups as above and were supplemented zilpaterol hydrochloride (ZH) or control (CON). Three steaks were collected from each strip loin, 1 each for retail display, sensory evaluation, and Warner-Bratzler shear force (WBSF). Color was evaluated from the retail display steak using a trained color panel and objectively using a HunterLab Miniscan XE. An Instron Universal Testing Machine with a Warner-Bratzler head was used for evaluation of instrumental tenderness, and a trained sensory panel was used to assess palatability traits. Heifers treated by VA had the least number of antimicrobial administrations and lowest yield grade and also had the lightest HCW (P < 0.05) compared with the heifers treated by the other health management protocols. There were no subjective color attribute differences or sensory panel differences (P > 0.05) across all health management systems or antimicrobial administrations. There were no differences in carcass and performance traits for any antimicrobial administrations treatment groups (P > 0.05). Heifers who had 0 or 1 antimicrobial administrations had lower (P < 0.05) a* (redness/greenness: positive values = red and negative values = green), and b* (yellowness/blueness: positive values = yellow and negative values = blue) values compared with those who had 2 antimicrobial administrations. In Exp. 2, heifers treated by VA had the least number (P < 0.05) of antimicrobial administrations when compared with MT and RT. Health management group did not have any other effects on carcass, sensory, or color attributes. Zilpaterol hydrochloride supplementation caused a decrease (P < 0.05) in internal fat and yield grade, but no interactions were observed between the number of antimicrobial administrations and ZH supplementation. With the supplementation of ZH, WBSF significantly increased (P < 0.05). At the end of retail display, the control group had a greater (P < 0.05) surface discoloration when compared with the ZH group. Treatment and detection of bovine respiratory diseases (BRD) is critical to the industry economically and results from this study show that different methods can be used to detect BRD without dramatically impacting carcass, sensory, and retail case life characteristics.

Incidence and risk of treatment-related mortality in cancer patients treated with the mammalian target of rapamycin inhibitors

BACKGROUND

Inhibition of the mammalian target of rapamycin (mTOR) is an established treatment for multiple malignancies. We carried out an up-to-date meta-analysis to determine the risk of fatal adverse events (FAEs) in cancer patients treated with mTOR inhibitors.

PATIENTS AND METHODS

PubMed, conferences and clinicaltrials.gov databases were searched for articles reported from January 1966 to June 2012. Eligible studies were limited to approved mTOR inhibitors (everolimus and temsirolimus) and reported on patients with cancer, randomized design and adequate safety profiles. Data extraction was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

In all, 3193 patients from eight randomized, controlled trials (RCTs) were included, 2236 from everolimus trials and 957 from temsirolimus trials. The relative risk (RR) of FAEs related to mTOR inhibitors use was 2.20 (95% CI, 1.25-3.90; P = 0.006) compared with control patients. On subgroup analysis, no difference in the rate of FAEs was found between everolimus and temsirolimus or between tumor types [renal cell carcinoma (RCC) versus non-RCC]. No evidence of publication bias was observed.

CONCLUSION

The use of mTOR inhibitors is associated with a small but higher risk of FAEs compared to control patients. In the appropriate clinical scenario, the use of these drugs remains justified in their approved indications.

Incidence and risk of treatment-related mortality in patients with renal cell cancer (RCC) and non-RCC treated with mammalian target of rapamycin (mTOR) inhibitors

347

Background: Inhibition of the mammalian target of rapamycin (mTOR) is an established therapeutic modality for multiple malignancies including renal cell carcinoma (RCC). Agents that target mTOR have been sporadically associated with an increased risk of potentially life-threatening adverse events. We performed an up-to-date meta-analysis to determine the risk of fatal adverse events (FAEs) in cancer patients treated with mTOR inhibitors, including RCC. Methods: MEDLINE/PubMed, conferences and clinicaltrials.gov databases were searched for articles reported from January 1966 to June 2012. Eligible studies were limited to trials of US Food and Drug Administration—approved mTOR inhibitors (everolimus and temsirolimus) that reported on patients with cancer, randomized design, and adequate safety profiles. Data extraction was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Statistical analyses were conducted to calculate the summary incidence, relative risk (RR), and 95% Confidence Intervals (CIs) by using random-effects or fixed-effects models on the basis of the heterogeneity of included studies. Results: In all 2,990 patients from 8 randomized controlled trials (RCTs) were included, 2033 from everolimus trials and 957 from temsirolimus trials. The incidence of FAEs related to mTOR inhibitors use was 3.4% (95% CI, 1.9-6.0) with a RR of 2.33 (95% CI, 1.32 to 4.10; P = .003) compared to control patients. On subgroup analysis, no difference in the rate of FAEs was found between everolimus and temsirolimus or between tumor types (RCC vs. non-RCC). No evidence of publication bias was observed. Conclusions: The use of mTOR inhibitors is associated with an increased risk of FAEs in RCC and non-RCC patients, compared with control patients.

Incidence and risk of infections in renal cell cancer (RCC) and non-RCC patients treated with everolimus and temsirolimus: A meta-analysis of randomized control trials

353

Background: Everolimus and temsirolimus are mammalian target of rapamycin (mTOR) inhibitors used in a variety of malignancies including renal cell carcinoma (RCC). These targeted agents have been associated with a unique set of adverse events including infections. We performed an up-to-date meta-analysis of published clinical trials to further characterize the risk of infections in cancer patients treated with mTOR inhibitors. Methods: Pubmed and oncology conference proceedings were searched for studies from January 1966 to June 2012. Eligible studies were limited to phase II and III randomized controlled trials (RCTs) of everolimus or temsirolimus that reported on patients with cancer of any tumor type including RCC and with adequate safety profiles. Summary incidence, RR, and 95% CIs were calculated using random- or fixed-effects models based on the heterogeneity of the included studies. Results: A total of 2,990 patients from 8 RCTs were included. The incidence of all-grade infections due to mTOR inhibitor treatment was 35.7% (95% CI, 28.8-43.3) and that of high-grade infections was 4.2% (95% CI, 2.1-8.4). The relative risk of all-grade infection due to mTOR inhibitors was 1.95 (95% CI, 1.67-2.29, p<.001) and that of high-grade infection was 1.91 (95% CI, 1.09-3.35, p=.024). Subgroup analysis found no difference in the incidence or risks of infections between everolimus and temsirolimus or between different tumor types (RCC vs. non RCC). Infections included respiratory tract (38.0%), urinary tract (17.1%), skin/soft tissue (3.6%), others (2.6%), and infection/not specified (38.7%). No evidence of publication bias was observed. Conclusions: Treatment with mTOR inhibitors, everolimus and temsirolimus, is associated with a significant increase in risk of infection in RCC and non-RCC patients.