Incidence of Infections and Predictors of Mortality During Checkpoint Inhibitor Immunotherapy in Patients With Advanced Lung Cancer: A Retrospective Cohort Study

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionized nonsmall cell lung cancer (NSCLC) treatment and significantly increased overall survival of patients. However, the incidence of concurrent infections and their management is still debated.

METHODS

From August 2015 to October 2019, all consecutive patients with NSCLC who received nivolumab or pembrolizumab as first- or second-line therapy were retrospectively evaluated. At the time of analysis all patients had died. Clinical characteristics of patients, type of infections, and predictors of mortality were analyzed.

RESULTS

A total of 118 patients were identified: 74 in the nivolumab group and 44 in the pembrolizumab group. At least 1 infection was recorded in 22% of the nivolumab-group versus 27% of the pembrolizumab-group (P = .178). In both groups, the main infection was pneumonia, followed by skin and soft tissue infections, urinary tract infections, and gastroenteritis. Crude mortality for first infection was 10.7%, followed by 25% and 40% for the second and third recurrence, respectively (p for trend = .146). No opportunistic infections were recorded. It is notable that, by Cox-regression model, the independent predictor of mortality was a higher Eastern Cooperative Oncology Group performance status at baseline (P < .001), whereas the multidisciplinary diagnosis and treatment of concurrent infections was associated with a reduced probability of mortality (adjusted hazard ratio = 0.50; 95% confidence interval = 0.30-0.83; P < .001).

CONCLUSIONS

In patients with NSCLC treated with ICIs, multidisciplinary management of concurrent infections may reduce the risk of mortality. Further studies to investigate risk factors for infections, as well as appropriate management strategies and preventive measures in this setting, are warranted.

Smoking Prevalence, Knowledge and Perceptions on Tobacco Control Among Healthcare Professionals: A Survey in an Italian Cancer Center

Smoking is recognized as the major cause of lung cancer. Healthcare professionals play an important role in lung cancer prevention policies, as they act as a source of guidance for patients and advocates. The following survey evaluated prevalence, knowledge, and attitudes toward tobacco smoking among a sample of workers in "IRCCS Istituto Tumori "Giovanni Paolo II" of Bari, an Italian cancer hospital. An anonymous questionnaire was completed by 104 healthcare professionals to collect personal and occupational data about smoking status, knowledge about the harms of smoking, current legislation in place, Second-Hand Smoke (SHS) awareness, and, for ex-smokers, the reasons for quitting. Among participants, 17.8% were current smokers, 26.2% former smokers, and 56% never smoked. Only 40% acknowledged that the smoking ban is generally respected, and 63.2% reported that they smoke during working hours. Most of the participants perceived tobacco control policy as an efficient way to protect public health. Currently, the implementation of Italian anti-smoking legislation has so far improved neither smoking cessation rates nor the will to quit smoking completely. Our experience highlights that to date the anti-smoking strategies have limited efficacy even in a cancer center; in fact, there is still a large prevalence of smokers among hospital personnel. Therefore, it is strongly suggested that interventions be shared with all healthcare workers, specifically aimed at developing a culture of health promotion.

Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review

This article investigates the effects of tobacco control policies on smoking initiation, cessation and prevalence by examining the papers published in the last 5 years. Twenty-one articles have been selected by two authors and sorted by four types of tobacco control: tobacco prices, anti-smoking campaigns for young people, mass media intervention and public smoking bans. Price/tax increase has deterrent effect on smoking initiation but does not promote smoking cessation; intervention on young people could reduce the smoking initiation if carried out at an early age and if acted on social skills and with peer-led approach, as opposed to restraining measures which hare generally easily circumvented by young people. The mass media campaigns showed positive effect on attempts to quit among smokers if carried forward over time and by involving multiple communication channels (TV, internet, radio). The bans in public have little effect on smoking cessation but could improve the overall well-being of non-smokers. Heterogeneous results have been described by different studies probably because of different research methodologies, cultural aspects and the really effective implementation of the rules for each country. In conclusion, comprehensive tobacco control interventions to reduce smoking prevalence and modify the smoking behavior are recommended. Moreover, the use of e-cigarettes and heat-not-burn (HnB) products, as possible helping tool for smoke cessation, currently remains controversial.

EPSILoN: A Prognostic Score Using Clinical and Blood Biomarkers in Advanced Non-Small-cell Lung Cancer Treated With Immunotherapy

BACKGROUND

Second-line immunotherapy (IO) has shown an overall survival benefit. However, only 18% to 20% of patients with advanced non-small-cell lung cancer (aNSCLC) will respond, with a median progression-free survival (PFS) of 2 to 4 months. Thus, biomarkers to select those patients most likely to benefit from IO are greatly needed.

PATIENTS AND METHODS

We conducted a retrospective analysis of 154 patients with aNSCLC who had received anti-programmed cell death 1 therapy as second line or further treatment. We assessed the absolute neutrophil, lymphocyte, monocyte, and eosinophil counts at baseline (T0) and the second (T1) and third (T2) cycles. The neutrophil/lymphocyte ratio (NLR), derived-NLR (dNLR), lymphocyte/monocyte ratio (LMR), and their percentage of change at T1 and T2 compared with T0 were evaluated. The clinical characteristics and lactate dehydrogenase (LDH) level were also considered. Univariate and multivariate analyses were performed. Significant biomarkers for PFS on multivariate analysis were combined in a prognostic score.

RESULTS

For overall survival, the negative prognostic biomarkers were Eastern Cooperative Oncology Group (ECOG) performance status (PS) 2, NLR at T0, and dNLR at T1; the LMR at T0, T1, and T2 was identified as a positive prognostic biomarker. For PFS, the negative prognostic biomarkers were ECOG PS 2, liver metastases, NLR at T0, dNLR at T1 and T2, and ≥ 30% increase of NLR from T0 to T1; the positive prognostic biomarkers were heavy smoking, LDH, and LMR at T2. The ≥ 30% increase of LMR from T0 to T1 and T0 to T2 correlated with the overall response rate. A prognostic score (EPSILoN score; smoking, ECOG PS, liver metastases, LDH, NLR) identified 3 prognostic groups (median PFS, 10.2, 4.9, and 1.7 months, respectively; P < .001).

CONCLUSIONS

The EPSILoN score combines 5 baseline clinical and blood biomarkers and can help to identify patients with aNSCLC who will most likely benefit from second-line IO. Further studies are warranted.

Tobacco control in Europe: A review of campaign strategies for teenagers and adults

BACKGROUND

In Europe the prevalence of tobacco use in adults and adolescents is among the highest within the WHO regions. Many resources have been allocated toward the prevention and support for smoking cessation. However, the implemented strategies in Europe have not been systematically evaluated.

METHODS

A systematic literature review was carried out to identify studies that analyzed the efficacy of the main smoking-prevention campaigns conducted in Europe. PRISMA guidelines were used to systematically review and extract data.

RESULTS

A total of 24 studies meeting inclusion criteria were identified. Each article was thoroughly reviewed and evaluated for quality, design, and methodology, with reference to the main areas of intervention: school (8); mass media (4) and technological tools (4); smoke-free environments (3); packaging (2) and taxes (3). The school programmes focusing on building skills to recognize and resist negative influences, the intensive use of media and technological equipments, health warnings and excise taxes have showed to be effective tools in reducing the tobacco use.

CONCLUSIONS

Intervention programmes to implement tobacco control policies and smoking cessation are active in many European countries. However, these programmes need to be constantly sustained to achieve a long term efficacy.

Hybrid open and endovascular repair of recurrent visceral aortic patch aneurysmal expansion after previous thoracoabdominal aortic aneurysm repair: case report and description of technique

The rate of morbidity and mortality in patients undergoing open repair for thoracoabdominal aortic aneurysm (TAAA) still remains too high, ranging from 2% to 40%. In recent years "hybrid" techniques have been developed (EVAR and retrograde surgical revascularization) for the treatment of TAAA. This procedure has proved to be more effective to reduce the high risks of complication related to this kind of operation resulting in a lower morbidity and mortality rates when compared to traditional surgical techniques. A 77-year old patient who had previously been undergone surgical exclusion of a TAAA by using a straight aorto to aortic bypass graft (end to end fashion) with visceral patch, was referred to our behalf for the presence of a recurrent Crawford Type IV aortic aneurysm expansion of 10.5 cm length on diameter. Considering the serious co-morbidities of the patient and the high risk of mortality related to the traditional redo surgery, the hybrid technique was considered to repair this recurrent aneurysm by using a surgical debranching of the visceral and renal arteries from the aorta associated to the their retrograde revascularization before to perform the endovascular exclusion of the aneurysm at the same time in a single operation. Over a period of 12 months the patient was alive in good health, a follow-up by computed tomography (CT) scan confirmed the correct position of the endograft, without endoleaks, the patency of the bypasses and the reduction on diameter of the aneurysmal sac. The combined hybrid procedure (endovascular and open surgical approach) for treatment of complex TAAA is to be considered a feasible and effective surgical technique, but a larger number of cases and a longer follow-up are required either to validate this procedure or to get a more significant and statistical comparison to the traditional approach.

Combined spinal and epidural anesthesia for open abdominal aortic aneurysm surgery in vigil patients with severe chronic obstructive pulmonary disease ineligible for endovascular aneurysm repair. Analysis of results and description of the technique

This study evaluated the feasibility of open infrarenal abdominal aortic aneurysm (AAA) surgery under peridural and spinal anesthesia (vigil patient) alone in high-risk patients with severe chronic obstructive pulmonary disease (COPD) ineligible for endovascular aneurysm repair (EVAR) or open surgery in general anesthesia. Between January 2005 and July 2007, seven patients underwent open AAA surgery with combined spinal and epidural anesthesia ([CSEA] without intubation) alone. Regional abdominal anesthesia was established by spinal anesthesia at L2-3 (levobupivacaine plus fentanyl) associated with peridural anesthesia at T7-8 (levobupivacaine). In this series (6 males and 1 female) the average age was 76.5 years (70-87); the AAA measured 7 cm in diameter on average (range 6-12.2). The survival rate was 100% (7/7 patients) at 6-12 months postoperative; no morbidities occurred during the postoperative phase. Owing to the small size of the series, no statistically significant conclusions can be drawn; even so, repair surgery was found to be effective, without the occurrence of morbidities or mortalities. In high-risk patients (severe COPD), open surgical repair of infrarenal AAA may be done with CSEA alone without intubation when, because of the patient's health, general anesthesia would pose too high a risk or when EVAR is unfeasible. Furthermore, the authors believe that surgical AAA repair under CSEA in vigil patients is a valid treatment option in those subjects with a high operative risk (severe COPD) and untreatable by either open AAA surgery under general anesthesia or EVAR.

Visceral artery aneurysms: series of 17 cases treated in a single center

AIM

The aim of this study is to evaluate early and long term results obtained with a retrospective review in 8-year experience with surgical/endovascular treatment of visceral artery aneurysm (VAA) in a single center.

METHODS

Between 2001 and 2008 in our vascular surgery unit visceral artery aneurysms were diagnosed with CT and/or angiography in 17 patients (9 male), mean age 66 years old (range: 18 to 78). All patients underwent surgical or endovascular treatment of splanchnic artery aneurysm. In 14 patients the localization was single, in 3 it was multiple. The arteries involved were: splenic artery 53%, superior mesenteric artery 17.7%, pancreaticoduodenal artery 17.7%, celiac axis 5.8% and hepatic artery 5.8%. The 29.4% of the patients presented with aneurysm rupture. Coil embolizzation was used in 11.6% of the cases while surgery was used in 88.4% of the cases.

RESULTS

Total survival rate was 94.2%, the survival rate in emergency cases was 80% while it was 100% in elective cases. Follow-up revealed excellent results after an average of 46 months (range: 8-102).

CONCLUSION

The worst prognosis for ruptured cases associated with the good result of the surgical/endovascular treatment in elective cases, suggests active interaction for such pathologies; in emergency cases the mortality incidence is too high. Today endovascular treatment presents lower morbidity and mortality rates and shorter hospitalization, but surgery is still a good therapeutic option for the treatment of the VAA, in subjects with low surgical risk, determining a definitive and long-lasting correction of the aneurysmal pathology and guaranteeing the correct perfusion of the organs, by grafts; moreover many aneurysms are not suitable for endovascular treatment.

Isolated aneurysm of the inferior thyroid artery repair with coil embolization

A 68-year-old female patient with a suspected aneurysm of the inferior thyroid artery was admitted to the authors' Unit of emergency after an accident. The echography of the thyroid revealed a ''suspected'' aneurismal dilation of the inferior thyroid artery (max. diameter 30 mm.). The patient underwent an angiograph of the supra-aortic trunk, which detected a small round formation at the base of the left inferior thyroid artery (found to be unaffected by aneurismal pathologies), the aneurysm was excluded by coil embolization. The postoperative course was uneventful and the patient was discharged in one day without complications. The follow-up with colour Duplex, at 4-8 months, showed the normal vascularization of the neck arterial vessels and was confirmed the absence of aneurysmal dilations. Aneurysms of the inferior thyroid artery are extremely rare, in scientific literature only 28 cases have been reported of which 32.9% regard ruptured aneurysms in the thyroid artery and 10.7% led to mortality. They may cause dysphagia and/or respiratory difficulties. Therefore, treatment is always recommended, even in asymptomatic cases, by surgical exclusion or coil embolization.

Dentine removal in the coronal portion of root canals following two preparation techniques

AIM

To measure the root canal area and the reduction of the mesial and buccal/lingual wall thickness at the level of the coronal interference in mesial roots of mandibular molars after instrumentation with a crown-down or a simultaneous root canal preparation technique.

METHODOLOGY

Twenty mesial roots of first mandibular molars with a moderate root canal curvature were embedded in resin and sectioned horizontally at the level of the coronal interference, using a modification of the Bramante technique. After scanning and processing, the sections were reassembled. One root canal of each root was prepared using ProTaper instruments, while Mtwo instruments were used in the other root canal of the same mesial root. After scanning and processing, the data obtained were analysed for two parameters: changes in root canal area after instrumentation (Delta A) and reduction of the mesial and buccal/lingual wall thickness (Delta T). The data were subjected to Student's t-tests for statistical analysis at a significance level of P < 0.05.

RESULTS

No statistically significant differences were found between the two groups with respect to the changes in the areas (Delta A) at the level considered (P = 0.410). No statistically significant differences were noticed between the two groups for dentine thickness (Delta T) of both the mesial wall (P = 0.077) and the buccal or lingual wall (P = 0.171).

CONCLUSIONS

There was no difference between the ProTaper and Mtwo groups for the amount of dentine removed.

[Femoropopliteal arterial thrombosis in a young patient with heterozygous V Leiden factor mutation. Case report]

Activated C protein resistance is a common coagulation defect caused by factor V Leiden mutation and is associated with an augmented risk of predominantly venous thrombosis. Augmented tendency to arterial thrombosis is sporadically reported. This case report describes femoropopliteal thrombosis in a young patient with heterozygous V Leiden factor mutation. Progressive thrombotic occlusion required amputation of the forefoot which resulted in stump dehiscence. Poor blood supply to the perilesional substrate delayed wound healing. An optimal though not yet definitive result was achieved after months of accurate medication. The criticality of lower limb ischemia in an otherwise healthy young patient underscores the grave impact this condition can have on the patient's quality of life and on health care costs.

Pulmonary Alveolar Microlithiasis

Pulmonary alveolar microlithiasis (PAM) is a rare idiopathic disease with unknown etiology and pathogenesis. The present work updates the world literature on PAM up to the end of 2001 by means of a full review, including minor reports in local languages (not English). Excluding secondary cases, a total of 424 cases have been reported worldwide, 269 of which were sporadic and showed a prevalence of the male sex and 155 of which were familial cases and prevalently affected the female sex. The highest number of cases has been reported in Europe, followed by Asia, especially Asia Minor, while the single nations with the greatest number of reported cases are Turkey, then Italy and the USA. The salient clinical features of PAM as described in the literature are analyzed: family history, clinical course, association with other diseases, presence of calcification in other organs. In the first cases, reported in the 60s and 70s, diagnosis was primarily made at autopsy, whereas nowadays diagnostic investigation is made above all by transbronchial biopsy and bronchoalveolar lavage. Radiological imaging is sufficient in cases where other family members are known to be affected, diagnosed by means of invasive techniques. There is no known treatment to date, while lung transplantation is performed in the severest cases. A better knowledge of the epidemiological characteristics of this rare disease could help to diagnose a larger number of cases and to gain insight into its etiology and pathogenesis, which are still unknown.

[Pulmonary alveolar microlithiasis: clinical and radiological course of three cases according to conventional radiology and HRCT. A hypothesis for radiological classification]

Pulmonary alveolar microlithiasis (PAM) is a rare chronic disease of unknown etiology and pathogenesis. The disease is characterized by the diffuse presence in the alveoli of minute calcific deposits known as microliths. In most cases patients have mild clinical symptoms, contrasting with the severe radiographic appearance: this is a typical feature that should raise the suspicion of PAM. The first to describe the clinical and radiographic aspects of the disease, as well as the first case series, was the radiologist Sosman. In recent years, high resolution computed tomography (HRCT) has made it possible to define the extent and severity of the disease more precisely, and has demonstrated calcifications in anatomical sites that could not be shown by conventional radiology. The present paper describes the radiological evolution of the disease, and suggests a classification based on the radiographic and HRCT follow-up of the three clinical cases: two young patients followed up for 24 and 11 years and one elderly man who is still alive and is the PAM case with the longest survival since diagnosis, over 50 years, to be reported in the international literature.

Pulmonary alveolar microlithiasis: clinical features, evolution of the phenotype, and review of the literature

Pulmonary alveolar microlithiasis (PAM) (MIM 265100) is a rare, autosomal recessive pneumopathy characterized by intra-alveolar formation and accumulation of tiny, roundish corpuscles called "microliths". The name "alveolar microlithiasis" was first used by Puhr in 1933; since then, several reports have appeared, and over 300 individuals with this condition have been reported. We have reviewed the PAM cases in the literature in light of personal experience, focusing on medical implications, disease diagnosis and progression over time, familial predisposition, and geographical and sex distribution. This study confirms autosomal recessive inheritance and does not support the role of other, non-genetic, factors in the pathogenesis of PAM.

Sleep-related breathing disorders in acute respiratory failure assisted by non-invasive ventilatory treatment: utility of portable polysomnographic system

In the majority of patients admitted to an Intensive Care Unit with acute respiratory failure (ARF), the aetiology for ARF is quite evident. In a minority of patients no obvious aetiology is apparent at presentation. In this group a previously unrecognized sleep-related breathing disorder (SRBD) may be the cause of the ARF. In spite of clinical suspicion SRBD remains infrequently diagnosed in ARF also because the technology necessary for this type of diagnosis (polysomnography) is usually unavailable in Intensive Care Units. The aim of this study was to evaluate the utility of portable polysomnography system (PSGp) in a group of patients with ARF of unclear aetiology and with a clinical suspicion of SRBD. We studied a selected group of 14 patients (eight males, six females) admitted to an Intermediate Intensive care unit with varying degree of acute respiratory failure. Mean (SD) age was 57 (13) years, pH 7.28 (0.04), PaO2 5.6 (0.7) kPa), PaO2 (8.8 (1.6) kPa), Body mass index 42.7 (9.6) kg m(-2). The patients had no history of skeletal, neuromuscular or cardiovascular disease. None of them had a history of overt chronic lung diseases or had obvious respiratory tract infections. They were submitted to cardiac and respiratory functional evaluation and to nightly PSGp (VITALOG HMS 5000, Respironics Inc., Redwood City, CA, U.S.A.) which was performed in an intermediate intensive care unit. Ten subjects had obstructive sleep apnoea-hypopnoea syndrome (OSAS), with mean respiratory disorder index h(-1) (RDI) 60.1 (25.9) [in five associated with obesity-hypoventilation syndrome (OHS)]; two had central sleep apnoea with mean RDI 45 (28.3) (one with hypothyroidism and one with cerebral multiple infarctions and right hemidiaphragmatic paralysis) and two had OHS with mean RDI 12.5 (3.5). Nocturnal hypoventilation was present in almost all patients. Continuous positive airway pressure (CPAP) was effective in three patients. Eight patients needed to be treated with BILEVEL (BiPAP, Respironics Inc.) airway positive pressure in timed or spontaneous/timed modes. Two patients required intubation and mechanical ventilatory treatment. In one patient with hypothyroidism was sufficient to institute hormonal therapy. Our study shows that acute respiratory failure due to SRBD is not exceptional in an Intermediate Intensive Care Unit and that if clinical suspicion is strong, portable polysomnography may yield diagnostic confirmation and help in establishing appropriate treatment and in avoiding the invasive ventilatory treatment.

A randomized trial of cefepime and ceftazidime for the treatment of community-acquired pneumonia

We compared the effectiveness and safety of ceftazidime and cefepime in hospitalized patients with community-acquired pneumonia. The 148 enrolled patients received 2 g ceftazidime three times daily or 2 g cefepime twice daily. The clinical success rate was the same for both drugs. Even the microbiological effectiveness was similar. Both drug regimens were well tolerated. We conclude that 2 g ceftazidime three times daily were as effective as 2 g cefepime twice daily for the treatment of community-acquired pneumonia in hospitalized patients. The cost of ceftazidime treatment was, however, higher than the cost of cefepime treatment.