The UK Divide: Does Having a Pembrolizumab-Chemotherapy Option in Head and Neck Cancer Matter? Real-world Experience of First-line Palliative Pembrolizumab Monotherapy and Pembrolizumab-Chemotherapy Combination in Scotland

AIMS

The Scottish Medical Consortium recently approved first-line pembrolizumab monotherapy or in combination with chemotherapy for head and neck squamous cell carcinoma in the palliative setting, contrasting with the decision made by the National Institute for Health and Care Excellence, who approved monotherapy alone in England and Wales. The aim of this study was to provide real-world performance data for first-line pembrolizumab-containing treatments for head and neck squamous cell carcinoma in the palliative setting in Scotland.

MATERIALS AND METHODS

We analysed the electronic records of patients who started pembrolizumab-containing treatment between 1 March 2020 and 30 September 2021. Outcomes included overall survival, progression-free survival (PFS), the duration of response and the disease control rate. Data were compared with the KEYNOTE-048 study and clinical factors were evaluated for association with survival.

RESULTS

Our cohort included 91 patients (median follow-up 10.8 months). Patient characteristics were similar to those in the KEYNOTE-048 study, although our cohort had a higher proportion of patients with newly diagnosed, non-metastatic disease. For patients receiving monotherapy (n = 76), 12- and 24-month overall survival were 45% and 27%, respectively. For patients receiving pembrolizumab-chemotherapy (n = 15), 12-month overall survival was 60% (24-month overall survival had not yet been reached). Experiencing one or more immune-related adverse event (irAE; versus no irAEs), of any grade, was associated with favourable overall survival and PFS for patients receiving monotherapy in both univariable Log-rank analysis (median overall survival 17.4 months versus 8.6 months, respectively, P = 0.0033; median PFS 10.9 months versus 3.0 months, respectively, P < 0.0001) and multivariable analysis (Cox proportional hazards regression: overall survival hazard ratio 0.31, P = 0.0009; PFS hazard ratio 0.17, P < 0.0001).

CONCLUSION

Our real-world data support the KEYNOTE-048 study findings and the value of combination treatment options. Additionally, our data show that irAEs of any grade, as reported in routine clinical records, are associated with better outcomes in this patient group, adding to the growing body of evidence showing that irAEs are generally a positive marker of programmed death-ligand 1 (PD-L1) inhibitor response.

Diagnostic accuracy of diffusion-weighted imaging in variant Creutzfeldt-Jakob disease

PURPOSE

This study sought to investigate the diagnostic sensitivity of diffusion-weighted imaging (DWI) in variant Creutzfeldt-Jakob disease (vCJD), a prion disease with significant public health implications on account of its transmissibility. The importance of this research stemmed from the first neuropathologically confirmed vCJD case in a PRNP heterozygous individual in 2016, which displayed DWI features typical of sporadic CJD (sCJD). The case was classified as 'probable' sCJD in life, predominantly based on these imaging findings. While DWI has proven valuable in diagnosing sCJD, its utility in vCJD diagnosis remains unclear.

METHODS

DWI and Fluid-attenuated inversion recovery (FLAIR) images from probable and definite vCJD cases referred to the National CJD Research and Surveillance Unit (NCJDRSU) were independently analysed by an expert neuroradiologist. Scans were reviewed within a mixed cohort of CJD cases including definite sCJD and non-CJD controls.

RESULTS

FLAIR sequences demonstrated greater sensitivity in identifying the pulvinar sign in vCJD compared to DWI (73% vs 41%, p-value <0.001). Basal ganglia hyperintensities were more prevalent in DWI (84%) than FLAIR (64%), and cortical hyperintensities were exclusive to DWI (24%). The pulvinar sign showed a specificity of 98% for vCJD and was rare in sCJD.

CONCLUSION

DWI showed reduced sensitivity compared to FLAIR imaging in detecting the pulvinar sign in vCJD. Conversely, DWI can more distinctively identify basal ganglia and cortical hyperintensities, thus leading to imaging patterns more characteristic of sCJD. Therefore, DWI should be cautiously interpreted in vCJD diagnosis, with axial FLAIR potentially providing a more precise evaluation of the pulvinar sign.

"If people are hesitant at all, you just want a really big front door": a rapid qualitative interview study on the Luton COVID-19 vaccination outreach clinics

BACKGROUND

There is a lack of evidence on the usefulness, practicality, and acceptance of vaccination outreach clinics in the community especially during pandemics. In this qualitative study, we explored the experiences, motivations and perceptions of service users, health professionals, strategic staff, volunteers, and community workers involved in the COVID-19 vaccination outreach clinics in Luton.

METHODS

Semi structured face to face, telephone, online interviews, and focus groups were conducted with 31 participants including health professionals, strategic staff, volunteers, community workers and service users. The Framework Method was used to analyse the data and generate themes.

RESULTS

Service users expressed positivity towards the convenience and familiarity of the location of the vaccination outreach clinics and the flexibility of receiving the vaccination in a local setting. Participants involved in the planning and delivery of the service commented on the worthwhile and rewarding experience but suggested more attention should be given to preparation time, service user recruitment, the working environment, and staff welfare.

CONCLUSIONS

The COVID-19 mobile vaccination outreach clinics in Luton tested and developed a different model of service delivery and demonstrated a collaborative way of working: "taking the health service to the patient, not the patient to the health service". Planning and local community engagement were seen as key to successful delivery of a mobile healthcare service.

Dual-Gendered Leadership: Gender-Inclusive Scientific-Political Public Health Communication Supporting Government COVID-19 Responses in Atlantic Canada

This research aims to identify the influence of woman leadership on improving the traditional man-dominated scientific-political communication towards positive COVID-19-driven public health interventions. Across Canada, dual-gendered leadership (women chief medical officers and men prime minister/premiers) at both federal and provincial levels illustrated a positive approach to "flatten the curve" during the first and second waves of COVID-19. With the four provinces of New Brunswick, Newfoundland and Labrador, Nova Scotia, and Prince Edward Island, Atlantic Canada formed the "Atlantic Bubble", which has become a great example domestically and internationally of successfully mitigating the pandemic while maintaining societal operation. Three provinces have benefitted from this complementary dual-gendered leadership. This case study utilized a scoping media coverage review approach, quantitatively examining how gender-inclusive scientific-political cooperation supported effective provincial responses in Atlantic Canada during the first two waves of COVID-19. This case study discovers that (1) at the provincial government level, woman leadership of mitigation, advocating, and coordination encouraged provincial authorities to adapt science-based interventions and deliver consistent and supportive public health information to the general public; and (2) at the community level, this dual-gendered leadership advanced community cohesion toward managing the community-based spread of COVID-19. Future studies may apply a longitudinal, retrospective approach with Canada-wide or cross-national comparison to further evaluate the strengths and weaknesses of dual-gendered leadership.

West Nile virus infection and interferon alpha treatment alter the spectrum and the levels of coding and noncoding host RNAs secreted in extracellular vesicles

BACKGROUND

Extracellular vesicles (EVs) are small membrane vesicles secreted by the cells that mediate intercellular transfer of molecules and contribute to transduction of various signals. Viral infection and action of pro-inflammatory cytokines has been shown to alter molecular composition of EV content. Transfer of antiviral proteins by EVs is thought to contribute to the development of inflammation and antiviral state. Altered incorporation of selected host RNAs into EVs in response to infection has also been demonstrated for several viruses, but not for WNV. Considering the medical significance of flaviviruses and the importance of deeper knowledge about the mechanisms of flavivirus-host interactions we assessed the ability of West Nile virus (WNV) and type I interferon (IFN), the main cytokine regulating antiviral response to WNV, to alter the composition of EV RNA cargo.

RESULTS

We employed next generation sequencing to perform transcriptome-wide profiling of RNA cargo in EVs produced by cells infected with WNV or exposed to IFN-alpha. RNA profile of EVs secreted by uninfected cells was also determined and used as a reference. We found that WNV infection significantly changed the levels of certain host microRNAs (miRNAs), small noncoding RNAs (sncRNAs) and mRNAs incorporated into EVs. Treatment with IFN-alpha also altered miRNA and mRNA profiles in EV but had less profound effect on sncRNAs. Functional classification of RNAs differentially incorporated into EVs upon infection and in response to IFN-alpha treatment demonstrated association of enriched in EVs mRNAs and miRNAs with viral processes and pro-inflammatory pathways. Further analysis revealed that WNV infection and IFN-alpha treatment changed the levels of common and unique mRNAs and miRNAs in EVs and that IFN-dependent and IFN-independent processes are involved in regulation of RNA sorting into EVs during infection.

CONCLUSIONS

WNV infection and IFN-alpha treatment alter the spectrum and the levels of mRNAs, miRNAs and sncRNAs in EVs. Differentially incorporated mRNAs and miRNAs in EVs produced in response to WNV infection and to IFN-alpha treatment are associated with viral processes and host response to infection. WNV infection affects composition of RNA cargo in EVs via IFN-dependent and IFN-independent mechanisms.

Isolated language impairment as the primary presentation of sporadic Creutzfeldt Jakob Disease

OBJECTIVES

Sporadic Creutzfeldt Jakob Disease (sCJD) is a neurodegenerative disorder that typically presents as a rapidly progressive encephalopathy associated with various neurological features, culminating in akinetic mutism and death. Atypical cases, presenting with an isolated focal may cause diagnostic confusion. We described a series of patients with sCJD presenting with isolated language impairment.

MATERIALS & METHODS

We report a patient with sCJD referred to the NCJDRSU, who presented with isolated language impairment and subsequently identified all cases of sporadic CJD on the NCJDRSU database (covering the years 1990-2012) with an isolated language impairment presentation.

RESULTS

Nineteen patients (11 females) with sCJD (1.19% of all patients) had an isolated language disorder of at least 2 weeks duration as the first neurological symptom pattern. Mean age at onset was 68.28 years. No specific pattern of language affection was seen in these patients. Further progression usually affected more than one neurological domain, with all patients eventually developing cognitive decline and myoclonic jerks. The median duration of illness was 4 months. CSF 14.3.3 was positive and S100b level was elevated in all patients in whom it was performed. EEG and MRI showed typical features of sCJD in six patients each. Most patients showed MM genotype of PRNP codon 129.

CONCLUSION

This study highlights the fact that isolated aphasia can be the first neurological symptom approximately in 1% of patients with sCJD. The diagnosis is usually made with appearance of other clinical features and investigation results, but in a small minority, these may not be apparent for relatively long periods.

Recent advances in dengue pathogenesis and clinical management

This review describes and commentates on recent advances in the understanding of dengue pathogenesis and immunity, plus clinical research on vaccines and therapeutics. We expand specifically on the role of the dermis in dengue virus infection, the contribution of cellular and humoral immune responses to pathogenesis and immunity, NS1 and mechanisms of virus immune evasion. Additionally we review a series of therapeutic intervention trials for dengue, as well as recent clinical research aimed at improving clinical diagnosis, risk prediction and disease classification.

Evolution of an influenza pandemic in 13 countries from 5 continents monitored by protein microarray from neonatal screening bloodspots

BACKGROUND

Because of lack of worldwide standardization of influenza virus surveillance, comparison between countries of impact of a pandemic is challenging. For that, other approaches to allow internationally comparative serosurveys are welcome.

OBJECTIVES

Here we explore the use of neonatal screening dried blood spots to monitor the trends of the 2009 influenza A (H1N1) pdm virus by the use of a protein microarray.

STUDY DESIGN

We contacted colleagues from neonatal screening laboratories and asked for their willingness to participate in a study by testing anonymized neonatal screening bloodspots collected during the course of the pandemic. In total, 7749 dried blood spots from 13 countries in 5 continents where analyzed by using a protein microarray containing HA1 recombinant proteins derived from pandemic influenza A (H1N1) 2009 as well as seasonal influenza viruses.

RESULTS

Results confirm the early start of the pandemic with extensive circulation in the US and Canada, when circulation of the new virus was limited in other parts of the world. The data collected from sites in Mexico suggested limited circulation of the virus during the early pandemic phase in this country. In contrast and to our surprise, an increase in seroprevalence early in 2009 was noted in the dataset from Argentina, suggestive of much more widespread circulation of the novel virus in this country than in Mexico.

CONCLUSIONS

We conclude that this uniform serological testing of samples from a highly standardized screening system offers an interesting opportunity for monitoring population level attack rates of widespread diseases outbreaks and pandemics.

Predictors of large and small for gestational age birthweight in offspring of women with gestational diabetes mellitus

AIM

To identify predictors of large and small for gestational age in women with gestational diabetes mellitus.

METHODS

A retrospective audit of clinical data analysed for singleton births in women diagnosed with gestational diabetes by Australasian Diabetes in Pregnancy Society guidelines from 1994 to 2009. Exclusions were: incomplete data, delivered at < 36 weeks gestation and/or last recorded weight > 4 weeks pre-delivery. We assessed: pre-pregnancy BMI, ethnicity, total maternal weight gain, weight gain before and after treatment initiation for gestational diabetes, HbA(1c) at gestational diabetes presentation and treatment modality (diet or insulin) and smoking. Birthweight was assessed using customized percentile charts (large for gestational age > 90th; small for gestational age < 10th percentile). Multiple regression analyses were undertaken; statistical significance was p < 0.05.

RESULTS

There were 1695 women first seen at (mean ± sd) 28.1 ± 5.3 weeks gestation (range 6-39). Ethnic mix was South-East Asian 36.7%, Middle Eastern 27.6%, European 22.4%, Indian/Pakistani 8.6%, Samoan 1.9%, African 1.5% and Maori 1.1%. Therapy was diet 69.1% and insulin 30.9%. Mean total weight gain was 12.3 ± 6.1 kg, the majority (10.6 ± 6.0 kg), gained before dietary intervention. There were 7.9% small for gestational age and 15.2% large for gestational age births. Significant independent large for gestational age predictors were: weight gain before intervention, pre-pregnancy BMI, weight gain after intervention and treatment type, but not HbA1c or smoking. Significant small for gestational age predictors were: weight gain before intervention, weight gain after intervention, but not pre-pregnancy BMI, HbA(1c) or smoking.

CONCLUSION

Conventional treatment for gestational diabetes mellitus concentrates on management of blood glucose levels. The trends identified here emphasize the need to also address pregnancy weight gain stratified by pre-pregnancy BMI.

Economic costs of achieving current conservation goals in the future as climate changes

Conservation of biologically diverse regions has thus far been accomplished largely through the establishment and maintenance of protected areas. Climate change is expected to shift climate space of many species outside existing reserve boundaries. We used climate-envelope models to examine shifts in climate space of 11 species that are representative of the Mount Hamilton Project area (MHPA) (California, U.S.A.), which includes areas within Alameda, Santa Clara, San Joaquin, Stanislaus, Merced, and San Benito counties and is in the state's Central Coast ecoregion. We used Marxan site-selection software to determine the minimum area required as climate changes to achieve a baseline conservation goal equal to 80% of existing climate space for all species in the MHPA through 2050 and 2100. Additionally, we assessed the costs associated with use of existing conservation strategies (land acquisition and management actions such as species translocation, monitoring, and captive breeding) necessary to meet current species-conservation goals as climate changes. Meeting conservation goals as climate changes through 2050 required an additional 256,000 ha (332%) of protected area, primarily to the south and west of the MHPA. Through 2050 the total cost of land acquisition and management was estimated at US$1.67-1.79 billion, or 139-149% of the cost of achieving the same conservation goals with no climate change. To maintain 80% of climate space through 2100 required nearly 380,000 additional hectares that would cost $2.46-2.62 billion, or 209-219% of the cost of achieving the same conservation goals with no climate change. Furthermore, maintaining 80% of existing climate space within California for 27% of the focal species was not possible by 2100 because climate space for these species did not exist in the state. The high costs of conserving species as the climate changes-that we found in an assessment of one conservation project-highlights the need for tools that will aid in iterative goal setting given the uncertainty of the effects of climate change and adaptive management that includes new conservation strategies and consideration of the long-term economic costs of conservation.

Noninvasive investigation of asymmetrically conjoined tripus twins with features of rachipagus, parapagus dicephalus, and cephalopagus

A hypothetical mechanism for conjoined twinning postulated by Spencer ([2003] Developmental Malformations and Clinical Implications, Baltimore: Johns Hopkins University Press, p 1-476) suggests that, after separation, monovular twins fuse in one of eight predictable homologous sites. The tripus fetal specimen under study embodies characteristics of three types therefore preventing it from classification into a simple variant of any one of the eight twin types described by Spencer. The aim of this study was to reveal internal structural anomalies of the fetal specimen by using magnetic resonance imaging and computerized tomography. Dorsally appended to the primary twin is a secondary head mass (brain tissue and ocular globe) and two spinal columns converging at T4/T5, suggesting rachipagus twinning. The ventral orientation of the secondary twin's (right lateral) lower limb suggests parapagus twinning. The caudal divergence of the spinal columns and the presence of a secondary hemipelvis, separate from the primary pelvis, suggest cephalopagus twinning. Measurements of the long bones indicate a gestational age of ∼20-23 weeks. Secondary malformations of the primary fetal body include anencephaly, cleft palate, renal agenesis, decreased left ventricular outflow, and a prematurely terminating descending aorta. This study demonstrates the possibility of using current imaging techniques to study very old, formalin-preserved human material for documentation and scientific discussion without destroying the specimen, thus keeping it intact for posterity.

[Molecular imaging: future uses in arthritides]

Molecular imaging is an upcoming field in radiology as a result of great advances in imaging technology, genetics, and biochemistry in the recent past. Early-stage imaging of molecular pathological changes in cells opens the gates to new methods in medical treatment of diseases that otherwise would only be detected in advanced stages. Methods of imaging biochemical pathways with molecular agents are currently an issue of intensive research. This article reviews current modalities of molecular imaging in arthritis that should offer future perspective on early disease detection, diagnosis, and monitoring of treatment efficiency and how they can pave the way to optimized therapy.