Randomized Phase II Study of Axitinib versus Observation in Patients with Recurred or Metastatic Adenoid Cystic Carcinoma

PURPOSE

The role of chemotherapy in adenoid cystic carcinoma (ACC) is controversial because ACC is usually stable without chemotherapy and the lack of randomized trials. Here, we conducted the first randomized trial to evaluate the efficacy of axitinib as compared with observation in ACC.

PATIENTS AND METHODS

In this multicenter, prospective phase II trial, we enrolled patients with recurrent or metastatic ACC whose cancer had progressed within the past 9 months. Patients were randomly assigned to either axitinib (5 mg twice daily) or observation at a 1:1 ratio. Crossover from observation to axitinib was permitted after progression. The primary endpoint was a 6-month progression-free survival (PFS) rate. The secondary endpoints included objective response rate (ORR), overall survival (OS), PFS, duration of response, and adverse events.

RESULTS

Sixty patients were allocated to the axitinib or observation group, with response evaluation conducted in 54 patients. With a median follow-up of 25.4 months, the 6-month PFS rate was 73.0% with axitinib and 23.0% with observation. Median PFS was longer in the axitinib arm (10.8 months vs. 2.8 months, P < 0.001). The ORR of axitinib was 0.0%, but the disease control rate was 100.0% with axitinib and 51.9% with observation. Median OS was not reached with axitinib, but was 27.2 months with observation (P = 0.226). The most frequently reported adverse events for axitinib were oral mucositis and fatigue.

CONCLUSIONS

In this first randomized trial in patients with ACC, axitinib significantly increased the 6-month PFS rate as compared with observation. (ClinicalTrials.gov number, NCT02859012).

Totality outcome of afatinib sequential treatment in patients with EGFR mutation-positive NSCLC in Korea: KCSG LU-19-22

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Background: While osimertinib showed impressive efficacy and safety profile in 1st-line setting for EGFR mutation-positive (EGFR M+) NSCLC patients, there are no standard targeted therapy following progression. Thus, interest has been growing on sequential treatment of osimertinib as 2nd-line treatment for patients acquiring T790M resistance mutation after 2nd generation EGFR TKIs. We did a retrospective study to support the hypothesis that sequential approach of afatinib followed by osimertinib represents a practical treatment option in ‘real-world’ practice. Methods: In this non-interventional, multicenter study, EGFR M+ NSCLC patients had to start 1st-line afatinib treatment ≥ 13 months prior to data entry. They were categorized into 4 cohorts according to 2nd-line treatments with retesting results: T790M+ patients sequentially treated with osimertinib in cohort A, T790M patients treated with chemotherapy or other treatments in cohort B, and patients with unknown mutation status in cohort C. Cohort D included patients who were still ongoing with afatinib. Primary outcome was the time on treatment (TOT) of patients receiving 1st-line afatinib (TOT-1) followed by 2nd-line treatments (TOT-2). Secondary endpoints were acquisition rate of T790M after progression, objective response rates of afatinib (ORR-1) and 2nd-line treatments (ORR-2), and overall survival (OS). Results: Among a total of 761 enrolled patients, 737 patients excluding 24 screening failures were allocated into cohort A (n=116), B (n=143), C (n=111), and D (n=367). Median age was 62 years (22 - 90) with 53.05% of female proportion. Brain metastasis was discovered in 38.94% at initial diagnosis. Regarding genotypes of EGFR mutations, del19 was 57.53%, 31.48% for L858R, 7.33% for uncommon mutations, and 3.66% for compound mutation. Median TOTs in cohort A, B, C, and D were 35.09 months (95% CI, 30.09 to 43.53), 18.76 months (95% CI, 16.92 to 20.20), 12.02 months (95% CI, 10.22 to 14.98), and 42.61 months (95% CI, 30.95 to 59.23), respectively. Particularly, in cohort A, median TOT-1 and TOT-2 were 17.43 months (95% CI, 15.21 to 19.32) and 11.04 months (95% CI, 7.10 to 14.13), respectively. Retesting was attempted in 262 of 370 patients (70.81%) with 44.27% of T790M detection rate. ORR-1 and -2 in cohort A, B, and C were 84.48% and 56.03%, 82.52% and 29.08%, 54.95% and 21.70%, respectively and 68.94% of ORR for cohort D. Median OS has was not reached. Conclusions: These data suggest that, in real-world practice, sequential afatinib followed by osimertinib be a feasible and effective therapeutic strategy for EGFR M+ NSCLC patients acquiring T790M during the period of afatinib treatment. Of note, median TOT in cohort D is over 3.5 years, suggesting that 1st-line afatinib potentially allow certain patients to maintain long-term, chemotherapy-free state. Further analysis is currently being undertaken and will be presented.

A phase II study of palbociclib for recurrent or refractory advanced thymic epithelial tumor (KCSG LU17-21)

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Background: Thymic epithelial tumors (TETs) are rare but the most common tumor of the anterior mediastinum. Platinum-based combination chemotherapy is standard of care which is associated with a 50%-90% overall response rate (ORR) in metastatic disease. However, there is no standard chemotherapeutic option after failure of platinum-based combination chemotherapy. Genetic alterations associated with cell cycle including pRB, p16INK4A, and cyclin D1 are commonly observed in TETs. Based on these results, we conducted a phase II trial to evaluate the efficacy and safety of palbociclib in patients with recurrent or refractory advanced TETs. Methods: This is a phase II multicenter, open-label, single arm study of palbociclib monotherapy in patients with recurrent or metastatic advanced TETs who failed one or more cytotoxic chemotherapy. Patients receive oral palbociclib 125mg daily for 21 days followed by a 7-day break. The primary endpoint was the progression-free survival (PFS) rate at 6 months (H0 = 30% vs H1 = 48%). Results: Between August 2017 and October 2019, 48 patients were enrolled. The median number of previous chemotherapy was 1 (range: 1-4) and 21 (43.7%) of 48 patients received thymectomy. By WHO classification, Type A (n = 1), Type B1 (n = 2), Type B2 (n = 8), Type B3 (n = 13), Type C (n = 23), and unknown (n = 1). With medial follow-up of 14.5 months (range 0.8-38.2), the median cycle of palbociclib was 10 (range 1-40). The PFS at 6 months was 60% and the median PFS was 11.0 months (95% CI: 4.6-17.4). Six of 48 patients (12.5%) achieved partial response. The median overall survival was 26.4 months (95% CI: 17.4-35.4). The most common adverse events of any grade included neutropenia (62.5%), anemia (37.5%) and thrombocytopenia (29.1%). Conclusions: Palbociblib monotherapy is well tolerable and encouraging efficacy in patients with TETs who failed platinum-based combination chemotherapy. Updated results will be presented. Clinical trial information: NCT03219554.

Real-world outcomes of anti-PD1 antibodies in platinum-refractory, PD-L1-positive recurrent and/or metastatic non-small cell lung cancer, and its potential practical predictors: first report from Korean Cancer Study Group LU19-05

PURPOSE

Although immune-checkpoint inhibitors have become a new therapeutic option for recurrent/metastatic non-small cell lung cancers (R/M-NSCLC), its clinical benefit in the real-world is still unclear.

METHODS

We investigated 1181 Korean patients with programmed death-1 ligand 1 (PD-L1)-positive [tumor proportion score (TPS) ≥ 10% by the SP263 assay or ≥ 50% by the 22C3 assay] R/M-NSCLC treated with pembrolizumab or nivolumab after failure of platinum-based chemotherapy.

RESULTS

The median age was 67 years, 13% of patients had ECOG-PS ≥ 2, and 27% were never-smokers. Adenocarcinoma was predominant (61%) and 18.1% harbored an EGFR activating mutation or ALK rearrangement. Pembrolizumab and nivolumab were administered to 51.3% and 48.7, respectively, and 42% received them beyond the third-line chemotherapy. Objective response rate (ORR) was 28.6%. Pembrolizumab group showed numerically higher ORR (30.7%) than the nivolumab group (26.4%), but it was comparable with that of the nivolumab group having PD-L1 TPS ≥ 50% (32.4%). Median progression-free survival (PFS) and overall survival (OS) were 2.9 (95% CI 0-27.9) and 10.7 months (95% CI 0-28.2), respectively. In multivariable analysis, concordance of TPS ≥ 50% in both PD-L1 assays and the development of immune-related adverse events (irAEs) were two significant predictors of better ORR, PFS, and OS. EGFR mutation could also predict significantly worse OS outcomes.

CONCLUSION

The real-world benefit of later-line anti-PD1 antibodies was comparable to clinical trials in patients with R/M-NSCLC, although patients generally were more heavily pretreated and had poorer ECOG-PS. Concordantly high PD-L1 TPS ≥ 50% and development of irAE could independently predict better treatment outcomes, while EGFR mutation negatively affected OS.

Effects of Inflammatory Disease on Clinical Progression and Treatment of Ischiogluteal Bursitis: A Retrospective Observational Study

Introduction:

The symptoms of Ischiogluteal Bursitis (IGB) are often nonspecific and atypical, and its diagnosis is more challenging. Moreover, it is difficult to predict cases of chronic progression or poor treatment response. Therefore, the aim of this study was to investigate the clinical course of IGB patients and identify factors that are predictive of failure of conservative treatment.

Materials and Methods:

Our study consisted of IGB patients diagnosed between 2010 March and 2016 December who had been followed-up for at least one year. Structured questionnaires and medical records were reviewed to analyse demographic characteristics, lifestyle patterns, blood tests, and imaging studies. We categorized the cases into two groups based on the response to conservative treatment and the need for surgical intervention.

Results:

The most common initial chief symptoms were buttock pains in 24 patients (37.5%). Physical examinations showed the tenderness of ischial tuberosity area in 59 (92.2%) patients, but no specific findings were confirmed in 5 patients (7.8%). 51 patients (79.7%) responded well to the conservative management, 11 patients (17.2%) needed injection, and 2 patients (3.1%) had surgical treatment performed due to continuous recurrence. There was no difference in demographic and blood lab data between the two groups. However, the incidence of inflammatory diseases (response group: 10.3% vs non-response group: 66.7%, p=0.004) was significantly different between the two groups.

Conclusion:

The diagnosis of IGB can be missed due to variations in clinical symptoms, and cautions should be exercised in patients with inflammatory diseases as conservative treatment is less effective in them, leading to chronic progression of IGB.

Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry

Objective

High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry.

Methods

We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months.

Results

Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours.

Conclusion

The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

The title: serum neutrophil Gelatinase-associated Lipocalin at 3 hours after return of spontaneous circulation in patients with cardiac arrest and therapeutic hypothermia: early predictor of acute kidney injury

Background

Serum neutrophil gelatinase-associated lipocalin (NGAL) could be used as a predictive marker of acute kidney injury (AKI) in patients with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) who are managed with targeted temperature management (TTM). However, the NGAL measurement timepoints vary from immediately after ROSC to several days later. The primary objective of this study was to determine an association between AKI and NGAL, both immediately (ROSC-NGAL) and 3 h after ROSC (3 h-NGAL), in OHCA patients with TTM. The secondary objective was to ascertain the association between NGAL levels in the early post-ROSC phase and the neurologic outcomes at discharge.

Methods

This prospective observational study was conducted between January 2016 and December 2018 and enrolled adult OHCA patients (≥18 years) with TTM after ROSC. The serum NGAL level was measured both immediately and 3 h after ROSC. Univariate and multivariate analyses were performed to identify the associations between AKI, poor neurologic outcome, and NGAL.

Results

Among 861 OHCA patients, 89 patients were enrolled. AKI occurred in 48 (55.1%) patients. On multivariate logistic regression analysis, 3 h-NGAL was significantly associated with AKI (odds ratio [OR] 1.022; 95% confidence interval [CI] 1.009–1.035; p = 0.001). The area under the receiver operating characteristic curve of 3 h-NGAL for AKI was 0.910 (95% CI 0.830–0.960), and a cut-off value of 178 ng/mL was identified. Both ROSC-NGAL and 3 h-NGAL were not significantly associated with poor neurologic outcome on multivariate logistic regression analysis (ROSC-NGAL; OR 1.017; 95% CI 0.998–1.036; p = 0.084, 3 h-NGAL; OR 0.997; 95% CI 0.992–1.001; p = 0.113).

Conclusions

The serum NGAL concentration measured 3 h after ROSC is an excellent early predictive marker for AKI in OHCA patients treated with TTM. Future research is needed to identify the optimal measurement timepoint to establish NGAL as a predictor of neurologic outcome and to validate the findings of this research.

Randomized phase II study of axitinib versus observation in patients with recurred or metastatic adenoid cystic carcinoma

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Background: Adenoid cystic carcinoma (ACC) does not respond to cytotoxic chemotherapy. Several anti-angiogenic agents were evaluated in single arm phase II trials. However, the role of chemotherapy is still controversial, because of natural stable disease course without chemotherapy and lack of randomized trial. We firstly conducted a randomized trial to evaluate the efficacy of axitinib compared to observation. Methods: In this multicenter, prospective phase II trial, we enrolled recurred, metastatic ACC patients who progressed within 9 months. Patients were randomly assigned either axitinib (5mg twice daily) or observation arm with 1:1 ratio. Crossover to the axitinib arm was permitted for patients in the observation arm who had disease progression. The primary endpoint was 6-month progression-free survival (PFS) rate. The secondary endpoints included objective response rate (ORR), overall survival (OS), PFS, duration of response and adverse events. Results: A total of 60 patients randomly allocated to axitinib (N=30) and observation arm (N=30) and response evaluation was conducted in 57 patients. With a median follow-up of 25.4 months, the 6-month PFS rate was 73.2% (95% confidence interval [CI], 54.8 to 88.1%) in the axitinib arm and 23.2% (95% CI, 9.3 to 41.1%) in the observation arm (hazard ratio, 0.19; 95% CI, 0.08 to 0.45; P < 0.001). Median PFS was 10.8 months in axitinib arm and 2.8 months in observation arm ( P < 0.001). The ORR was 3.3% (95% CI, 0.1 to 17.2%) in the axitinib arm, and 0% (95% CI, 0 to 12.8%) in the observation arm. The disease control rate was 100% (95% CI, 88.4 to 100%) in the axitinib arm and 51.9% (95% CI, 32.0 to 71.3%) in the observation arm. After crossover, ORR of axitinib in the observation arm was 11.1% (95% CI, 2.4 to 29.2%). Median OS was not reached in axitinib arm, 28.5 months in observation arm ( P = 0.688). The most frequently reported adverse events of axitinib were grade 1 or 2 oral mucositis and fatigue. Detailed data of adverse events and mutational profile data will be presented. Conclusions: In this first randomized trial in patients with recurred or metastatic ACC, axitinib significantly increased 6-month PFS rate compared to observation. Clinical trial information: NCT02859012 .

Renal replacement therapy is independently associated with a lower risk of death in patients with severe acute kidney injury treated with targeted temperature management after out-of-hospital cardiac arrest

BACKGROUND

The effect of renal replacement therapy (RRT) on the outcomes of severe acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to evaluate the association of RRT with 6-month mortality in patients with severe AKI treated with targeted temperature management (TTM) after OHCA.

METHODS

This was a retrospective analysis of a prospectively collected multicentre observational cohort study that included adult OHCA patients treated with TTM across 22 hospitals in South Korea between October 2015 and December 2018. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was 6-month mortality and the secondary outcome was cerebral performance category (CPC) at 6 months. Multivariate Cox regression analysis was performed to define the role of RRT in stage 3 AKI.

RESULTS

Among 10,426 patients with OHCA, 1373 were treated with TTM. After excluding those who died within 48 h of return of spontaneous circulation (ROSC) and those with pre-arrest chronic kidney disease, our study cohort comprised 1063 patients. AKI developed in 590 (55.5%) patients and 223 (21.0%) had stage 3 AKI. Among them, 115 (51.6%) were treated with RRT. The most common treatment modality among RRT patients was continuous renal replacement therapy (111 [96.5%]), followed by intermittent haemodialysis (4 [3.5%]). The distributions of CPC (1-5) at 6 months for the non-RRT vs. the RRT group were 3/108 (2.8%) vs. 12/115 (10.4%) for CPC 1, 0/108 (0.0%) vs. 1/115 (0.9%) for CPC 2, 1/108 (0.9%) vs. 3/115 (2.6%) for CPC 3, 6/108 (5.6%) vs. 6/115 (5.2%) for CPC 4, and 98/108 (90.7%) vs. 93/115 (80.9%) for CPC 5, respectively (P = 0.01). The RRT group had significantly lower 6-month mortality than the non-RRT group (93/115 [81%] vs. 98/108 [91%], P = 0.04). Multivariate Cox regression analyses showed that RRT was independently associated with a lower risk of death in patients with stage 3 AKI (hazard ratio, 0.569 [95% confidence interval, 0.377-0.857, P = 0.01]).

CONCLUSION

Dialysis interventions were independently associated with a lower risk of death in patients with stage 3 AKI treated with TTM after OHCA.

Osimertinib for Patients With Non-Small-Cell Lung Cancer Harboring Uncommon EGFR Mutations: A Multicenter, Open-Label, Phase II Trial (KCSG-LU15-09)

PURPOSE

Approximately 10% of patients with epidermal growth factor receptor (EGFR) mutation-positive non-small-cell lung cancer (NSCLC) harbor uncommon mutations. Here, we report the efficacy and safety of osimertinib in patients with NSCLC harboring uncommon EGFR mutations.

PATIENT AND METHODS

This was a multicenter, single-arm, open-label, phase II study in Korea. Patients with histologically confirmed metastatic or recurrent NSCLC harboring EGFR mutations other than the exon 19 deletion, L858R and T790M mutations, and exon 20 insertion were eligible for the study. The primary end point of objective response rate was assessed every 6 weeks by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. Secondary end points were progression-free survival, overall survival, duration of response, and safety.

RESULTS

Between March 2016 and October 2017, 37 patients were enrolled. All were evaluable except one patient who withdrew consent after starting treatment. Median age was 60 years, and 22 (61%) were male. Among patients, 61% received osimertinib as first-line therapy. The mutations identified were G719X (n = 19; 53%), followed by L861Q (n = 9; 25%), S768I (n = 8; 22%), and others (n = 4; 11%). Objective response rate was 50% (18 of 36 patients; 95% CI, 33% to 67%). Median progression-free survival was 8.2 months (95% CI, 5.9 to 10.5 months), and median overall survival was not reached. Median duration of response was 11.2 months (95% CI, 7.7 to 14.7 months). Adverse events of any grade were rash (n = 11; 31%), pruritus (n = 9; 25%), decreased appetite (n = 9; 25%), diarrhea (n = 8; 22%), and dyspnea (n = 8; 22%), but all adverse events were manageable.

CONCLUSION

Osimertinib demonstrated favorable activity with manageable toxicity in patients with NSCLC harboring uncommon EGFR mutations.

Encephalitis as a complication of a spinal-esophageal fistula due to discitis

In patients with back or scapular pain, if there is evidence of neurological symptoms, fever, chills, malaise, or other signs of infection, the work-up should consider the possibility of a spinal-esophageal fistula.

A Tabletop Persistent-Mode, Liquid Helium-Free 1.5-T MgB2 "Finger" MRI Magnet: Construction and Operation of a Prototype Magnet

This paper presents results of construction and operation of a persistent-mode, liquid-helium-free, small-scale prototype magnet for the development of a tabletop 1.5-T "finger" MRI system for osteoporosis screening. The prototype magnet, composed of 2 MgB2 coils, one superconducting joint, and a persistent-current switch (PCS) built from a portion of one coil, was wound with a one continuous ~80-m long unreacted and monofilament MgB2 wire and then reacted. The test magnet was charged successfully and generated the estimated target field of 1.75 T at 5 K with the proposed PCS operation. During initial persistent-mode, the field was slightly decayed due to the index dissipation of the joint; thereafter it sustained the persistent field of 1.7 T for 35 h. The test results validated the joint resistance of < 1.2 × 10-11 as well as the proposed approach involving the PCS coil circuit model.

Recovery from acute kidney injury as a potent predictor of survival and good neurological outcome at discharge after out-of-hospital cardiac arrest

Background

Acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is a well-known predictor for mortality. However, the natural course of AKI including recovery rate after OHCA is uncertain. This study investigated the clinical course of AKI after OHCA and determined whether recovery from AKI impacted the outcomes of OHCA.

Methods

This retrospective multicentre cohort study included adult OHCA patients treated with targeted temperature management (TTM) between January 2016 and December 2017. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was the recovery rate after AKI and its association with survival and good neurological outcome at discharge.

Results

A total of 3697 OHCA patients from six hospitals were screened and 275 were finally included. AKI developed in 175/275 (64%) patients and 69/175 (39%) patients recovered from AKI. In most cases, AKI developed within three days of return of spontaneous circulation [155/175 (89%), median time to AKI development 1 (1–2) day] and patients recovered within seven days of return of spontaneous circulation [59/69 (86%), median time to AKI recovery 3 (2–7) days]. Duration of AKI was significantly longer in the AKI non-recovery group than in the AKI recovery group [5 (2–9) vs. 1 (1–5) days; P < 0.001]. Most patients were diagnosed with AKI stage 1 initially [120/175 (69%)]. However, the number of stage 3 AKI patients increased from 30/175 (17%) to 77/175 (44%) after the initial diagnosis of AKI. The rate of survival discharge was significantly higher in the AKI recovery group than in the AKI non-recovery group [45/69 (65%) vs. 17/106 (16%); P < 0.001]. Recovery from AKI was a potent predictor of survival and good neurological outcome at discharge in the multivariate analysis (adjusted odds ratio, 8.308; 95% confidence interval, 3.120–22.123; P < 0.001 and adjusted odds ratio, 36.822; 95% confidence interval, 4.097–330.926; P = 0.001).

Conclusions

In our cohort of adult OHCA patients treated with TTM (n = 275), the recovery rate from AKI after OHCA was 39%, and recovery from AKI was a potent predictor of survival and good neurological outcome at discharge.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2535-1) contains supplementary material, which is available to authorized users.

Acarbose Add-on Therapy in Patients with Type 2 Diabetes Mellitus with Metformin and Sitagliptin Failure: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Study

BACKGROUND

We evaluated the efficacy and safety of acarbose add-on therapy in Korean patients with type 2 diabetes mellitus (T2DM) who are inadequately controlled with metformin and sitagliptin.

METHODS

A total of 165 subjects were randomized to metformin and sitagliptin (Met+Sita, n=65), metformin, sitagliptin, and acarbose (Met+Sita+Acarb, n=66) and sitagliptin and acarbose (Sita+Acarb, exploratory assessment, n=34) therapy in five institutions in Korea. After 16 weeks of acarbose add-on or metformin-switch therapy, a triple combination therapy was maintained from week 16 to 24.

RESULTS

The add-on of acarbose (Met+Sita+Acarb group) demonstrated a 0.44%±0.08% (P<0.001 vs. baseline) decrease in glycosylated hemoglobin (HbA1c) at week 16, while changes in HbA1c were insignificant in the Met+Sita group (-0.09%±0.10%, P=0.113). After 8 weeks of triple combination therapy, HbA1c levels were comparable between Met+Sita and Met+Sita+Acarb group (7.66%±0.13% vs. 7.47%±0.12%, P=0.321). Acarbose add-on therapy demonstrated suppressed glucagon secretion (area under the curve of glucagon, 4,726.17±415.80 ng·min/L vs. 3,314.38±191.63 ng·min/L, P=0.004) in the absence of excess insulin secretion during the meal tolerance tests at week 16 versus baseline. The incidence of adverse or serious adverse events was similar between two groups.

CONCLUSION

In conclusion, a 16-week acarbose add-on therapy to metformin and sitagliptin, effectively lowered HbA1c without significant adverse events. Acarbose might be a good choice as a third-line therapy in addition to metformin and sitagliptin in Korean subjects with T2DM who have predominant postprandial hyperglycemia and a high carbohydrate intake.

Grey-white matter ratio measured using early unenhanced brain computed tomography shows no correlation with neurological outcomes in patients undergoing targeted temperature management after cardiac arrest

AIM

This study evaluated whether the grey-white matter ratio (GWR) assessed via early brain computed tomography (CT) within 2 h after the return of spontaneous circulation (ROSC) following cardiac arrest is associated with poor neurological outcomes after 6 months in post-cardiac arrest patients treated with targeted temperature management (TTM).

METHODS

This study used data from the Korean Hypothermia Network prospective registry obtained from November 2015 to October 2017 to assess patients with out-of-hospital cardiac arrest (OHCA) who underwent brain CT within 2 h following the ROSC. The primary endpoint was the neurological outcome 6 months post-cardiac arrest (cerebral performance category; CPC). The GWR was measured using early brain CT images. The subgroup analysis examined the difference in GWRs obtained from early and repeated brain CT.

RESULTS

Five-hundred-twelve patients were enrolled. Good (CPC 1-2) and poor (CPC 3-5) neurological outcomes were observed in 162 (31.6%) and 350 (68.4%) patients, respectively. The multivariate logistic regression analysis revealed that the GWR measured using early brain CT was a statistically nonsignificant predictor of poor neurologic outcomes (p = 0.727). In patients with poor outcomes, the mean GWR obtained from early and repeated CT images were 1.171 ± 0.058 and 1.091 ± 0.133, respectively (p < 0.001); there was no statistically significant difference between the GWRs in patients with good outcomes.

CONCLUSION

The GWR assessed via early brain CT alone is not an independent factor predictive of poor neurologic outcomes but could be useful when used with repeated CT data.

A Randomized, Open-Label, Phase II Study Comparing Pemetrexed Plus Cisplatin Followed by Maintenance Pemetrexed versus Pemetrexed Alone in Patients with Epidermal Growth Factor Receptor (EGFR)-Mutant Non-small Cell Lung Cancer after Failure of First-Line EGFR Tyrosine Kinase Inhibitor: KCSG-LU12-13

PURPOSE

The optimal cytotoxic regimens have not been established for patients with non-small cell lung cancer (NSCLC) who develop disease progression on first-line epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI).

MATERIALS AND METHODS

We conducted a multi-center randomized phase II trial to compare the clinical outcomes between pemetrexed plus cisplatin combination therapy followed by maintenance pemetrexed (PC) and pemetrexed monotherapy (P) after failure of first-line EGFR-TKI. The primary objective was progression-free survival (PFS), and secondary objectives included overall response rate (ORR), overall survival (OS), health-related quality of life (HRQOL), and safety and toxicity profiles.

RESULTS

A total of 96 patientswere randomized, and 91 patientswere treated at 14 centers in Korea. The ORR was 34.8% (16/46) for the PC arm and 17.8% (8/45) for the P arm (p=0.066). With 23.4 months of follow-up, the median PFS was 5.4 months in the PC arm and 6.4 months in the P arm (p=0.114). The median OS was 17.9 months and 15.7 months in PC and P arms, respectively (p=0.787). Adverse events ≥ grade 3 were reported in 12 patients (26.1%) in the PC arm and nine patients (20.0%) in the P arm (p=0.491). The overall time trends of HRQOL were not significantly different between the two arms.

CONCLUSION

The outcomes of pemetrexed therapy in NSCLC patients with disease progression after firstline EGFR-TKI might not be improved by adding cisplatin.

Toothpick injury mimicking acute cholecystitis

Introduction: Accidental foreign bodies ingestion is common in emergency department. However, if the objects are sharp, the complication rate is higher. Toothpick can cause severe complications of gastrointestinal tract due to being long, sharp ends on both sides, slender, and resistant to digestion. Case presentation: A 64-year-old man presented to the emergency department with fever and right upper abdominal pain for 3 days. The physical examination revealed severe pain with rebound tenderness in the right upper abdominal quadrant and positive Murphy’s sign. The provisional diagnosis of acute cholecystitis was made. The contrast abdominal-pelvic computed tomography scan revealed linear-shaped lesion penetrating hepatic flexure of colon and proximal transverse colon. The patient showed deterioration of vital sign, and therefore, emergency laparotomy was performed. Colon perforation by wooden toothpick was diagnosed. Discussion and conclusion: Toothpick ingestion without awareness is rare but fatal, especially when physicians failed to suspect foreign body ingestion. We think of this as one of the differential diagnoses, so we use contrast computed tomography scan.

Incidence and Risk Factors of Immediate Hypersensitivity Reactions Associated With Low-Osmolar Iodinated Contrast Media: A Longitudinal Study Based on a Real-Time Monitoring System

OBJECTIVES

We investigated the incidence of immediate hypersensitivity reaction (HSR) caused by different types of low-osmolar contrast media (LOCM) and cumulative exposure to LOCM.

METHODS

This cohort study included all consecutive patients who underwent LOCM-enhanced computed tomography from 2012 through 2014. We assessed 5 LOCM (iobitridol, iohexol, iomeprol, iopamidol, and iopromide). All patients were monitored for adverse events, and new symptoms and signs were recorded in real time using the Contrast Safety Monitoring and Management System (CoSM2oS).

RESULTS

The overall incidence of immediate HSR to LOCM was 0.97% (2004 events resulting from 205 726 exposures). Incidence differed significantly depending on whether the patient had a previous history of HSR to LOCM (0.80% in patients with no history and 16.99% in patients with a positive history of HSR to LOCM, P=.001). The incidence of HSR to individual LOCM ranged from 0.72% (iohexol) to 1.34% (iomeprol), although there were no significant differences across the 5 LOCM. A longitudinal analysis demonstrated that the incidence of HSR increased gradually with more frequent previous exposure to LOCM (HR=2.006 [95%CI, 1.517-2.653], P<.001). However, this cumulative increase in risk was observed in patients who had experienced HSR to LOCM, but not in those who had not.

CONCLUSION

The incidence of HSR did not differ significantly across the 5 LOCM assessed in the study. Repeated exposure to LOCM did not increase the risk of HSR among patients who had never experienced HSR to LOCM.

Clinical outcomes and prognostic factors in patients directly transferred to the intensive care unit from long-term care beds in institutions and hospitals: a retrospective clinical study

Background

There has been a steady increase in the aging population and an increase in the need for long-term care beds in institutions and hospitals (LTCHs) in Korea. The aim of this study was to investigate prognosis and to identify factors contributing to mortality of critically ill patients with respiratory problems who were directly transferred to intensive care units (ICU) from LTCHs.

Methods

Following a retrospective review of clinical data and radiographic findings between July 2009 and September 2016, we included 111 patients with respiratory problems who had visited the emergency room (ER) transferred from LTCHs due to respiratory symptoms and who were then admitted to the ICU.

Results

The mean age of the 111 patients was 79 years, and 71 patients (64%) were male. Pneumonia developed in 98 patients (88.3%), pulmonary thromboembolism in 4 (3.6%) and pulmonary tuberculosis in 3 (2.7%). Overall mortality was 19.8% (22/111). Multiple-drug-resistant (MDR) pathogens (odds ratio [OR], 17.43; 95% confidence interval [CI], 1.96–155.40) and serum albumin levels < 2.15 g/dL, which were derived through ROC (sensitivity, 72.7%; specificity, 85.4%) (OR, 28.05; 95% CI, 5.47–143.75), were independent predictors for mortality. The need for invasive ventilation (OR, 2.74; 95% CI, 1.02–7.32) and history of antibiotic use within the 3 months (OR, 3.23; 95% CI, 1.32–7.90) were risk factors for harboring MDR pathogens.

Conclusions

The presence of MDR pathogens and having low serum albumin levels may be poor prognostic factors in patients with respiratory problems who are admitted to the ICU from LTCHs. A history of antibiotic use within the 3 months and the need for invasive ventilation can be helpful in choosing the appropriate antibiotics to combat MDR pathogens at the time of admission.

Supraclavicular area swelling in neurofibromatosis patient

Neurofibromatosis 1 is an autosomal dominant disorder characterized by cafe-au-lait spots, cutaneous neurofibroma, and bony deformities. Vascular abnormality such as stenosis, aneurysm, or rupture associated with neurofibromatosis 1 is rare. Rupture of vertebral artery aneurysm into the thoracic cavity is extremely rare. The outcomes of patients with aneurysmal ruptures are very poor when spontaneous hemothorax occur. A 31-year-old woman presented to the emergency department with left shoulder pain and with both lower chest wall pain and left supraclavicular area swelling. The chest computed tomography scan revealed about 4-cm pseudo-aneurysm probable arising from the left vertebral artery with large hematoma at left supraclavicular area. Neurofibromatosis 1 is generally being regarded as a benign disease but has the potential for serious vascular complications. When aneurysms were ruptured, cervical hematoma, hemothorax, or hypotension was developed. It is potentially a life-threatening condition, so it must require emergent management. Emergency physicians must remember the relation of neurofibromatosis 1 and serious vascular complications and ensure rapid access to rule out vascular lesions, so as to prevent the life-threatening condition.

Validation and proposal for cut-off values of an abbreviated version of the Alcohol Use Disorder Identification Test using the Korean National Health and Nutrition Examination Survey

Objective

Several abbreviated versions of the Alcohol Use Disorder Identification Test (AUDIT) have been developed and are widely used in clinical settings. In this study, we provide evidence supporting the use of abbreviated versions of AUDIT by comparing the utility of various abbreviated versions and determining cut-off values for the population of South Korea.

Methods

Data were obtained from the 4th to 6th Korean National Health and Nutrition Examination Surveys. After calculating the whole AUDIT score, we applied the cut-off value of at-risk drinking proposed by the World Health Organization and divided the study sample into normal and at-risk drinking groups. Receiver operating characteristic curves were drawn for AUDIT-3rd question (Q3) alone, AUDIT-quantity and frequency (QF), AUDIT-consumption (C), AUDIT-4, and AUDIT-primary clinic (PC), and optimal cut-off values were obtained for each group.

Results

A total of 46,450 subjects were analyzed. The at-risk drinking group comprised 29.2% of all subjects. The area under receiver operating characteristic curve (AUROC) of the abbreviated versions of AUDIT increased from 0.954 to 0.991 as the number of questions increased from one to four. The differences in AUROC between the abbreviated versions of AUDIT were statistically significant. The most appropriate cut-off values for AUDIT-Q3 alone, AUDIT-QF, AUDIT-C, AUDIT-4, and AUDIT-PC for adults over age 19 were 2, 4, 5, 6, and 4 points, respectively.

Conclusion

As the number of items analyzed increased from one to four items, the AUROC increased to a statistically significant level. Cut-off values for abbreviated versions of AUDIT are similar in South Korea to other countries.