Dexmedetomidine infusion for sedation in a patient with myotonic dystrophy

Myotonic dystrophy type 1 is the most common muscular dystrophy in adults. Anaesthetic management should take into consideration the numerous body systems affected, including the musculoskeletal; respiratory; cardiovascular; gastro-intestinal; and central nervous systems. A 42-year-old man with myotonic dystrophy presented for septoplasty and bilateral inferior turbinate reductions. He had severe upper and lower extremity myotonia and weakness, pulmonary impairment with non-obstructive patterns and first-degree atrioventricular block with reduced ejection fraction. He used bilevel positive airway pressure, a cough assist device and was paced 3% of the time with a single-chamber pacemaker. To reduce potential complications associated with opioid use and general anaesthetics, an opioid-free technique was planned using local anaesthetic infiltration and sedation with a dexmedetomidine infusion. The patient maintained spontaneous ventilation and haemodynamic stability, and had an uneventful postoperative course. Dexmedetomidine is a highly selective α2-adrenergic receptor agonist that has the ability to provide sedation, analgesia and anxiolysis with a stable haemodynamic profile. Avoiding both opioids and general anaesthetics in these patients may decrease the risk of peri-operative complications.

Dynamics of Insect-Microbiome Interaction Influence Host and Microbial Symbiont

Insects share an intimate relationship with their gut microflora and this symbiotic association has developed into an essential evolutionary outcome intended for their survival through extreme environmental conditions. While it has been clearly established that insects, with very few exceptions, associate with several microbes during their life cycle, information regarding several aspects of these associations is yet to be fully unraveled. Acquisition of bacteria by insects marks the onset of microbial symbiosis, which is followed by the adaptation of these bacterial species to the gut environment for prolonged sustenance and successful transmission across generations. Although several insect-microbiome associations have been reported and each with their distinctive features, diversifications and specializations, it is still unclear as to what led to these diversifications. Recent studies have indicated the involvement of various evolutionary processes operating within an insect body that govern the transition of a free-living microbe to an obligate or facultative symbiont and eventually leading to the establishment and diversification of these symbiotic relationships. Data from various studies, summarized in this review, indicate that the symbiotic partners, i.e., the bacteria and the insect undergo several genetic, biochemical and physiological changes that have profound influence on their life cycle and biology. An interesting outcome of the insect-microbe interaction is the compliance of the microbial partner to its eventual genome reduction. Endosymbionts possess a smaller genome as compared to their free-living forms, and thus raising the question what is leading to reductive evolution in the microbial partner. This review attempts to highlight the fate of microbes within an insect body and its implications for both the bacteria and its insect host. While discussion on each specific association would be too voluminous and outside the scope of this review, we present an overview of some recent studies that contribute to a better understanding of the evolutionary trajectory and dynamics of the insect-microbe association and speculate that, in the future, a better understanding of the nature of this interaction could pave the path to a sustainable and environmentally safe way for controlling economically important pests of crop plants.

FRACTION-RCC: Innovative, high-throughput assessment of nivolumab + ipilimumab for treatment-refractory advanced renal cell carcinoma (aRCC)

5007

Background: The immuno-oncology (I-O) combination nivolumab + ipilimumab (NIVO+IPI) is approved for first-line (1L) and NIVO is approved for second-line treatment post TKI therapy in aRCC. The open-label, randomized, phase 2 Fast Real-Time Assessment of Combination Therapies in Immuno-Oncology (FRACTION-RCC; NCT02996110) platform study has an adaptive design allowing rapid evaluation of I-O therapies, including NIVO+IPI or other investigational combinations. This FRACTION analysis reports preliminary outcomes with NIVO+IPI in aRCC pts after progression on checkpoint inhibitor therapy. Methods: All pts, except 1, had previously received and progressed on checkpoint inhibitor treatment. Pts received NIVO+IPI (NIVO 3 mg/kg + IPI 1 mg/kg Q3W ×4, then after 6 weeks, NIVO 480 mg Q4W), up to 2 years or until progression, toxicity, or protocol-specified discontinuation. Primary endpoints were confirmed objective response rate (ORR; per investigator using RECIST v1.1), duration of response (DOR), and progression-free survival probability at week 24. Safety outcomes were reported. Results: 46 pts were randomized to NIVO+IPI. Pts had 0 (n = 1), 1 (n = 10), 2 (n = 12), 3 (n = 10), or ≥4 (n = 13) prior lines of therapy. All pretreated pts had prior anti-PD-(L)1-, none had prior anti-CTLA-4- therapy, and 37 had prior TKI-based therapy; 45 pts progressed on anti-PD-(L)1 as the most recent therapy. Most pts had clear cell aRCC (n = 44). After a median study follow-up of 8.9 months, ORR was 15.2%; no pts achieved complete response and 7 achieved partial response. DOR ranged from 2–19+ months (n = 7); 5 pts had ongoing response. Six of 7 responders had received ≥2 prior lines of therapy. Any-grade treatment-related adverse events (AEs) were reported in 36 pts (78.3%; fatigue, rash [both 19.6%], and diarrhea [17.4%] were most common). Grade 3–4 treatment-related AEs were reported in 13 pts (28.3%; diarrhea [8.7%], ↑amylase and ↑lipase [both 6.5%] were most common). Treatment-related immune-mediated AEs of any grade were reported in 22 pts (47.8%; rash [19.6%], diarrhea [17.4%], and ↑alanine aminotransferase [8.7%]). No treatment-related deaths were reported. Updated and expanded results with an additional 3 months of follow-up will be presented. Conclusions: These results suggest that NIVO+IPI may provide durable partial response in some pts with prior progression on checkpoint inhibitors, including some heavily pretreated pts. The safety profile of NIVO+IPI in FRACTION pts was similar to historic data in aRCC with this combination. Clinical trial information: NCT02996110 .

A phase II study to evaluate the need for > two doses of nivolumab + ipilimumab combination (combo) immunotherapy

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Background: Standard of care nivolumab (nivo) + ipilimumab (ipi) combo immunotherapy is given for 4 doses in patients (pts) with unresectable stage III/IV melanoma. Whether 4 doses are needed is questionable as retrospective data suggest pts treated with <4 doses of combo due to toxicity can have durable benefit. No prospective trials have evaluated the efficacy of intentionally giving <4 doses of combo in unresectable stage III/IV melanoma. Methods: In this phase 2, multicenter clinical trial (n=60), pts with unresectable stage III/IV melanoma received 2 doses of nivo (1mg/kg) + ipi (3mg/kg) followed by a CT scan at week 6. Pts with complete (CR) or partial responses (PR) by RECIST 1.1 or stable disease without an increase in total measurable tumor burden had protocol defined early favorable anti-tumor effect (FATE) and ceased combo, transitioning to maintenance nivo. Pts without FATE at week 6 received the standard third and fourth doses of combo followed by maintenance nivo. The primary endpoint was response rate by RECIST 1.1 at week 12. Secondary endpoints included additional efficacy assessments and safety. Results: 41 pts (68%) had FATE at week 6. The best overall response rates (CR + PR) by RECIST at week 12 or any time afterwards were 48% (95% CI: 35.2-61.6%) and 53% (95% CI: 40.0-66.3%), respectively. 18%, 58%, 12%, 10% had 1, 2, 3, 4 doses of combo, respectively. With a median follow-up of 11 months, any grade treatment-related toxicity occurred in 100% (57% grade 3-4) of pts. Three pts died due to treatment-related toxicity (2 myocarditis, 1 possible adrenal insufficiency). Among the 19 pts without FATE at week 6 and not selected to de-escalate combo after dose 2, no pts ultimately responded with ongoing combo dosing. Conclusions: The first 2 doses of nivo + ipi appear to drive combo’s response efficacy and toxicity. Early radiographic imaging at week 6 may be able to identify pts who do not respond to combo dosing beyond dose 2. Randomized studies are planned to evaluate 1 dose of combo to see if efficacy is maintained with reduced toxicity. Clinical trial information: NCT03122522.

Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries

Globally, the discipline of neurosurgery has evolved remarkably fast. Despite being one of the latest medical specialties, which appeared only around hundred years ago, it has witnessed innovations in the aspects of diagnostics methods, macro and micro surgical techniques, and treatment modalities. Unfortunately, this development is not evenly distributed between developed and developing countries. The same is the case with neurosurgical education and training, which developed from only traditional apprentice programs in the past to more structured, competence-based programs with various teaching methods being utilized, in recent times. A similar gap can be observed between developed and developing counties when it comes to neurosurgical education. Fortunately, most of the scholars working in this field do understand the coherent relationship between neurosurgical education and neurosurgical practice. In context to this understanding, a symposium was organized during the World Federation of Neurological Surgeons (WFNS) Special World Congress Beijing 2019. This symposium was the brain child of Prof. Yoko Kato—one of the eminent leaders in neurosurgery and an inspiration for female neurosurgeons. Invited speakers from different continents presented the stages of development of neurosurgical education in their respective countries. This paper summarizes the outcome of these presentations, with particular emphasis on and the challenges faced by developing countries in terms of neurosurgical education and strategies to cope with these challenges.

Propensity score matching/reweighting analysis comparing intravenous golimumab to infliximab for ankylosing spondylitis using data from the GO-ALIVE and ASSERT trials

Objective

To compare the relative efficacy of intravenous golimumab (GOL IV) and infliximab (IFX) for active ankylosing spondylitis (AS).

Methods

Propensity score (PS) methods were used to compare the efficacy of GOL IV 2 mg/kg and IFX 5 mg/kg using individual patient data (IPD) from the active arms of the phase 3 GO-ALIVE and ASSERT studies. Outcomes included the proportion of patients with a ≥ 20% improvement in the Assessment of Spondyloarthritis International Society Criteria (ASAS20), change from baseline in Bath Ankylosing Spondylitis Functional Index (BASFI) score, and change from baseline in C-reactive protein (CRP) levels from weeks 4–52.

Results

Before matching, 105 patients were treated with GOL IV and 201 patients were treated with IFX. After matching on all covariates, 118 patients were included in the ASAS20 analysis, 96 in the BASFI analysis, and 160 in the CRP analysis. After matching, GOL IV showed significantly greater improvement in ASAS20 response than IFX for weeks 28–44 (e.g., OR = 9.05 [95% CI 1.62–50.4] at week 44) and was comparable in change from baseline in BASFI scores and CRP levels to IFX at all time points. Results were robust for inclusion of different sets of covariates in scenario analyses.

Conclusions

This is the first analysis of its kind to leverage clinical trial data to compare two biologics using PS methods in the treatment of active AS. Overall, GOL IV was associated with greater improvement in ASAS20 response than IFX in patients with AS at 28, 36, and 44 weeks of follow-up.

Key Points • Although intravenous golimumab (GOL IV) and infliximab (IFX) are the only two IV-based tumor necrosis factor (TNF) inhibitors with demonstrated phase 3 clinical efficacy in patients with ankylosing spondylitis (AS), no study has evaluated their comparative efficacy in a head-to-head trial. • Propensity score matching was used to derive indirect treatment comparisons of GOL IV and IFX for ≥ 20% in the Assessment of Spondyloarthritis International Society Criteria (ASAS20), change in Bath Ankylosing Spondylitis Functional Index (BASFI), and change in C-reactive protein (CRP) using individual patient data from the GO-ALIVE and ASSERT phase 3 trials. • Propensity score matched indirect comparisons showed improved relative efficacy of GOL IV compared to IFX; after matching for up to 16 baseline covariates, GOL IV was associated with significantly greater odds of ASAS20 response at weeks 28, 36, and 44 than IFX as well as equivalent changes from baseline in BASFI and CRP. • This novel application of propensity score matching using data from phase 3 trials, the first analysis of its kind in AS, allowed adjustment for important imbalances in prognostic factors between trials to generate estimates of comparative efficacy between GOL IV and IFX in the absence of a head-to-head trial between these treatments.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-05051-1) contains supplementary material, which is available to authorized users.

A185 ABDOMINAL WALL VARICES: A CASE REPORT

Background

Portal hypertension in cirrhosis results in variable and numerous portosystemic collateral circulations. Computed tomography (CT) and Doppler ultrasound (US) can identify these collateral vessels, especially abdominal wall varices, which can be encountered during a bedside paracentesis.

Aims

Describe a case of traumatic abdominal wall variceal bleed.

Methods

Case report.

Results

A 53 year-old Caucasian male presented to the emergency department (ED) with 4-days of abdominal pain and 2-months of increased abdominal girth. His medical history included Child Pugh Class B alcoholic liver cirrhosis diagnosed 1 year ago. No prior history of ascites, esophageal variceal bleed or hepatic encephalopathy. In the ED, his US showed moderate ascites with right portal vein flow reversal. A diagnostic RLQ paracentesis showed yellow ascitic fluid, no spontaneous bacterial peritonitis (SBP), and he was discharged home with diuretics.

He returned to the ED the next day for increased abdominal girth with a Hb of 103 g/L. A diagnostic RLQ paracentesis showed orange-red ascitic fluid and no SBP. The following day, a therapeutic US-guided paracentesis was attempted in the RLQ and left-lower quadrant LLQ; however, ascitic fluid aspirate was grossly bloody. The procedure was aborted. Hb was 82 g/L and progressively decreased. CT angiogram was performed and showed a 10.7 x 4.7 x 8.0 cm hyperdense fluid in the right paracolic gutter near the paracentesis site, consistent with intraperitoneal hemorrhage (Figure A). The insertion site was seen as abdominal wall musculature focal thickening around abdominal wall varices and no contrast extravasation was seen. Gastroesophageal, splenic hilar and omental varices were seen. Doppler US showed no sonographic signs of active extravasation. Interventional Radiology performed a US-guided paracentesis and aspirated 3650 mL of hemorrhagic fluid. Color Doppler US showed small varices within the subcutaneous soft tissues (Figure A).

The patient later developed hematemesis with an EGD showing a large high-risk esophageal varix actively bleeding that was banded. Given the refractory variceal bleeding, a Minnesota tube was inserted 4 days later and a transjugular intrahepatic portosystemic shunt was inserted the following day. Unfortunately, the patient developed progressive worsening hepatic encephalopy, multi-organ failure and expired 7-days later.

Conclusions

Adjunct imaging modalities such as color flow Doppler US or CT can be used as a screening tool to identify abdominal wall varices and reduce paracentesis bleeding complications.

Funding Agencies

None

Current Clinical Trials in the Treatment of Advanced Melanomas

The treatment of metastatic melanomas revolutionized during the past decade because of a better understanding of various pathways and mutations that play different roles in the pathogenesis of this disease. The incorporation of immunotherapy was the first in these efforts, followed by targeted therapies as monotherapeutic options, and then in combinations. In this article, we review the historical and landmark clinical trials that changed our treatment paradigm for advanced melanomas, also we review ongoing clinical trials that would be applicable in the near future and would expectedly improve outcomes for these patients.

Engaging Community-Based Cancer Physicians: Experience of the Memorial Sloan Kettering Cancer Center Cancer Alliance

BACKGROUND

The proliferation of relationships between community health systems and academic medical centers has created a need to identify effective components of these models. This article reports on frontline physician experiences, with one such relationship established through the Memorial Sloan Kettering Cancer Center (MSK) Cancer Alliance. MSK created the Alliance with the goals of rapidly bringing the newest standards of care into community settings and increasing patient access to clinical trials in their local communities.

METHODS

Alliance leadership administered a 10-question anonymous survey to physicians treating patients with cancer across the 3 Alliance member health systems: Hartford HealthCare Cancer Institute, Lehigh Valley Cancer Institute, and Miami Cancer Institute at Baptist Health South Florida. The purpose of the survey was to identify opportunities to improve physician engagement.

RESULTS

There were 103 clinician respondents across Alliance members, of which 87 reported participation in a disease management team and were included in the final analysis. Most respondents reported high value from Alliance activities, such as attending MSK tumor boards (94%) and lecture series (96%), among those who reported them applicable. Across all respondents, most reported satisfaction with engagement opportunities, such as MSK physician participation in their institution's meetings (76%). When asked where they would like to see increased engagement, the most commonly reported response was for more lecture series (45%). Most respondents (88%) reported that the Alliance led to practice change, either for themselves or for other clinicians at their institution. Many attributed this practice change to MSK disease-specific process measures.

CONCLUSIONS

The activities most valued by community physicians were heavily physician relationship-based. The encouraging experience of the MSK Cancer Alliance suggests that activities involving physician investment may be effective for promoting practice change in the context of cross-institution relationships. Future research is needed in this area.

Single centre experience of flow diverter treatment of complex intracranial aneurysms from South India: Intermediate and long-term outcomes

Background and Purpose

To report the intermediate and long-term clinical and angiographic outcomes of the treatment of complex intracranial aneurysms with flow diverter (FD) stents.

Setting

A tertiary care centre from south India.

Materials and Methods

Patients treated with FD stents were retrospectively analyzed. The clinical demographics, technical success, angiographic, and long-term outcomes were recorded.

Results

A total of 13 patients underwent FD treatment, in whom 11 procedures were successful. The cohort included large or giant intracranial aneurysms and recurrent aneurysms following conventional endovascular treatment. Major morbidity was observed in 1 patient, who developed basal ganglia bleed that needed evacuation. Minor complications were seen in 36% of patients without clinical sequelae. Significant obliteration of aneurysm was noted on 1 month computed tomography angiogram in >80% of the patients. Angiographic complete obliteration was noted in 89% of the patients at 6 months. Cranial nerve deficits were noted in 2 patients that improved on subsequent follow up. There was no mortality observed in this cohort.

Conclusion

FD treatment of complex cerebral aneurysms was associated with favorable clinical and angiographic outcomes in the intermediate and long-term follow up. Minor complications were common, which needed to be effectively managed to prevent major catastrophic events. The steep learning curve influenced the technical success of the procedure.

Therapeutic implications of a novel driver classification system for cutaneous and unknown primary melanomas

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Background: Cutaneous and “unknown primary” melanomas frequently harbor alterations that activate the Mitogen Activated Protein Kinase (MAPK) pathway, and are often classified as BRAF, NRAS, NF1 mutant, or “triple wild type.” Multigene sequencing may identify additional oncogenic drivers, but the clinical impact of this information is unknown. Methods: Patients with BRAF inhibitor naïve melanoma underwent prospective tumor molecular profiling using a targeted capture-based assay (MSK-IMPACT), and demographic and treatment data were collected. Time to treatment failure was assessed for patients who received frontline PD-1 monotherapy or nivolumab plus ipilimumab. Results: 576 patients were successfully sequenced. 533 samples (96%) harbored a known or presumed oncogenic mutation in 1 of 28 genes in the RTK-RAS-MAPK pathway. 187 tumors (32%) had two or more drivers in this pathway, and the rates of driver co-alterations varied widely by specific driver. A hierarchical classification of 9 driver groups (BRAF V600E; V600K/R/M; BRAF non-V600; NRAS Q61; Other RAS; NF1; KIT; Other driver; Unknown driver) was significantly associated with tumor mutational burden, primary melanoma site, and patient age. Time to treatment failure varied by driver class and site of primary melanoma for PD-1 monotherapy but not nivolumab plus ipilimumab. 150 patients with BRAF V600 wild-type melanoma required systemic therapy after progression on checkpoint blockade. 21 were given genomically matched therapy, and 5/21 had clinical benefit for ≥6 months. Complete and durable responses were observed with TRK and ROS1 inhibitors in patients with NTRK1/2/3 and ROS1 fusion positive tumors. Conclusions: Oncogenic alterations in the RTK-RAS-MAPK pathway can be detected using targeted capture NGS in the vast majority of cutaneous and unknown primary melanomas. A hierarchical classification of 9 driver groups revealed clinically relevant melanoma subsets with varying clinical outcomes to PD-1 monotherapy. Select patients with oncogenic kinase fusions can achieve durable therapeutic benefit with targeted inhibitors of these rare drivers.

Durable clinical benefit from combination ipilimumab (IPI) and nivolumab (NIVO) in anti-PD-1 therapy resistant, platinum resistant metastatic urothelial carcinoma (mUC)

481

Background: Overcoming resistance to anti-PD-1 therapy in UC patients (pts) is of major interest given the modest single agent response rates for pts with mUC. Herein we report the outcome of combined NIVO and IPI in pts who progressed on single agent NIVO. Methods: This prospective, open label, adaptive study treated platinum resistant mUC pts with NIVO monotherapy with the designated intent to add IPI at disease progression. RECIST 1.1 assessments were performed every 6 wks for 24 wks then every 12 wks. Primary endpoint was objective response rate (ORR). Secondary endpoints included overall survival (OS) and possible associations between clinical endpoints and tumor genomic characteristics. Next generation sequencing (NGS) was performed to assess DNA Damage Response (DDR) gene mutations and Tumor Mutation Burden (TMB). Results: To date, 21 pts who progressed after NIVO monotherapy have received IPI plus NIVO. ORRs to prior NIVO monotherapy were variable; partial response (PR = 4/21, 19%), stable disease (SD = 6/21, 29%) and progressive disease (PD = 11/21,52%). 57% (12/21) had visceral metastases. For IPI + NIVO the ORR was 19% (PR: n=4, CR: n=0) and duration of response >12 mo in a subset; 2 pts with PR remain on treatment (3+, 5+ mo), 1 pt has an ongoing PR (13+ months) after stopping treatment due to toxicity. Responding disease sites include node, liver and lung. Immune-related toxicity ≥ G3 seen in 9 pts (43%), of whom 4 (44%) had disease control (PR+SD≥3mo). No correlation detected between clinical outcome and TMB or DDR mutations. Conclusions: IPI plus NIVO responses can be seen in pts with NIVO resistance and the benefit from combined checkpoint blockade can be prolonged. Immune related toxicity frequently accompanied disease control. TMB and DDR were not associated with benefit in this small cohort; immune correlative analyses are ongoing. Clinical trial information: NCT02553642. [Table: see text]