Real-world data on efficacy and safety of pembrolizumab in the first-line treatment of metastatic lung cancer in patients with PD-L1 expression >0% - a single center experience

OBJECTIVE

With the advent of immunotherapy, there has been a significant improvement in the outcomes of non-small cell lung cancer treatment. Several clinical trials have confirmed the efficacy and safety of pembrolizumab, but research with real-world data is needed to confirm the findings from clinical trials.

PATIENTS AND METHODS

In this retrospective study, data on the treatment of lung cancer with pembrolizumab were analyzed in 78 patients who started pembrolizumab therapy as first-line treatment for metastatic disease at University Hospital Centre Osijek, from May 15, 2018, until December 31, 2021. November 30, 2022, was set as the last date of data monitoring. Patients who had received less than 3 cycles of pembrolizumab were excluded from the study. The main objectives of the study were OS (overall survival) and PFS (progression-free survival). The differences in the incidence and type of adverse events between the two groups of patients were also compared.

RESULTS

Kaplan-Meier analysis of the survival determined that the median OS was 20 months and PFS was 13 months. Although OS and PFS are longer in patients with PD-L1 (programmed death-ligand 1) ≥ 50%, the differences are not statistically significant. The most commonly reported adverse events related to pembrolizumab treatment were gastrointestinal adverse events. No significant differences were found in the frequency of occurrence of certain adverse events between the two groups of patients.

CONCLUSIONS

This study demonstrates that real-world data for pembrolizumab treatment of non-small cell lung cancer confirm the efficacy and safety indicated by clinical trials. Nevertheless, it is necessary to assess the patient's general condition more objectively before starting the treatment.

Endocannabinoids, Anandamide and 2-Arachidonoylglycerol, as Prognostic Markers of Sepsis Outcome and Complications

Background: One of the major challenges in improving sepsis care is early prediction of sepsis complications. The endocannabinoid system has been intensely studied in recent years; however, little is known about its role in sepsis in humans. This study aimed to assess the prognostic role of endocannabinoids, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), as early predictors of mortality, invasive mechanical ventilation (IMV) requirement, and length of stay (LOS) in patients with sepsis. Materials and Methods: In total, 106 patients with confirmed sepsis were enrolled in this study. The patients were divided into groups according to mortality outcome (survival, N=53; nonsurvival, N=53), IMV requirement (IMV group, N=26; non-IMV group, N=80), and LOS (LOS <10 days, N=59; LOS ≥10 days, N=47). Patients' clinical status was assessed along with laboratory biomarkers as well as AEA and 2-AG concentration measurements early on admission to emergency units. AEA and 2-AG levels were measured by enzyme-linked immunosorbent assay (ELISA) using an ELISA processor, EtiMax 3000 (DiaSorin, Saluggia, Italy). The predictive value of AEA and 2-AG for the studied sepsis outcomes and complications was analyzed using univariate and multivariate analyses and receiver operating characteristic (ROC) curve analysis. Results: Two endocannabinoids showed no significant difference between survivors and nonsurvivors, although an AEA concentration <7.16 μg/L predicted mortality outcome with a sensitivity of 57% (95% confidence interval [CI] 42-71) and specificity of 80% (95% CI 66-91). AEA concentrations ≤17.84 μg/L predicted LOS ≥10 days with sensitivity of 98% (95% CI 89-100) and specificity of 34% (95% CI 22-47). When analyzing IMV requirement, levels of AEA and 2-AG were significantly lower within the IMV group compared with the non-IMV group (5.94 μg/L [2.04-9.44] and 6.70 μg/L [3.50-27.04], p=0.043, and 5.68 μg/L [2.30-8.60] and 9.58 μg/L [4.83-40.05], p=0.002, respectively). The 2-AG showed the best performance for IMV requirement prediction, with both sensitivity and specificity of 69% (p<0.001). Endocannabinoid AEA was an independent risk factor of LOS ≥10 days (odds ratio [OR] 23.59; 95% CI 3.03-183.83; p=0.003) and IMV requirement in sepsis (OR 0.79; 95% CI, 0.67-0.93; p=0.004). Conclusion: Low AEA concentration is a prognostic factor of hospital LOS longer than 10 days. Lower AEA and 2-AG concentrations obtained at the time of admission to the hospital are predictors of IMV requirement.

Antioxidative effects of supplementing linseed oil-enriched diets with α-tocopherol, ascorbic acid, selenium, or their combination on carcass and meat quality in broilers

In a previous study, we examined the synergistic effects of the dietary supranutritional supplementation with vitamin E, vitamin C, and Se on the in vivo antioxidative status of broilers under conditions of dietary oxidative stress induced by feeding a diet high in n-3 PUFA. In this study, we examined the effect of their inclusion on the quality characteristics and oxidative stability of raw or cooked meat, both fresh or after a long-term frozen storage. Four hundred 21-day-old Ross 308 male broilers were allocated to 5 experimental groups fed 5% linseed oil-enriched finisher diets (days 21 to 40): Cont (recommended levels of vitamin E, C, and selenium), +E (200 IU vitamin E/kg feed), +C (250 mg vitamin C/kg feed), +Se (0.2 mg selenium/kg feed), or +ECSe (concentrations as in the sole supplementation, combined). Animal performance and carcass characteristics were monitored at the age of 40 D. Breast meat samples of 12 chickens per group were analysed fresh, fresh after frozen storage, cooked fresh, and cooked after frozen storage (2 × 2 factorial design) for parameters of meat quality (water-holding capacity—WHC, pH, and color) and oxidative stability (concentrations of vitamin E, malondialdehyde—MDA, antioxidant capacity of the water-soluble compounds—ACW, and fatty acid composition).

Vitamin E alone (+E) and combined with Se and vitamin C (+ECSe) increased the α-tocopherol concentration in breast muscle, and showed similar protective effects against lipid peroxidation measured as MDA regardless of the frozen storage or cooking. The sole supplementation of vitamin C or selenium showed no effects on the meat quality parameters. In conclusion, the dietary supranutritional inclusion of vitamin E inhibited the lipid peroxidation in fresh, frozen stored, cooked fresh, and frozen stored meat in broilers fed with diets rich in n-3 PUFAs. Even though no clear synergistic effects of the supranutritional supplementation of vitamin C and Se with vitamin E were detected, their dietary inclusion did not negatively affect broilers carcass and meat quality parameters.

Effects of supplementation with α-tocopherol, ascorbic acid, selenium, or their combination in linseed oil-enriched diets on the oxidative status in broilers

A trial was conducted to investigate whether, and if so to what extent, the combined supplementation of vitamin E, vitamin C, and selenium was superior to their sole supplementation concerning the oxidative stress induced by a high n-3 dietary polyunsaturated fatty acids (PUFA) intake in broilers. Four hundred 21-day-old Ross 308 male broilers were allocated to 5 experimental groups fed the following linseed oil (5%)-enriched finisher diets: Cont (no supplement), +E (200 IU vitamin E/kg feed), +C (250 mg vitamin C/kg feed), +Se (0.2 mg selenium/kg feed), or +ECSe (concentrations as in the sole supplementation, combined). Analyses of malondialdehyde (MDA), vitamin C, and α- and γ-tocopherols in plasma, antioxidant capacity of water- (ACW) and lipid- (ACL) soluble compounds in serum, and glutathione peroxidase (GPx) and superoxide dismutase (SOD) activities in whole blood were performed. In breast muscle, analyses of MDA, α- and γ-tocopherols, ACW, selenium, and fatty acid (FA) composition were carried out. Birds fed the combination of antioxidants showed reduced average daily gain (ADG) and average daily feed intake (ADFI) and, as +E, lower MDA and γ-tocopherol, together with raised α- tocopherol levels in plasma and lower MDA and raised α- tocopherol levels in breast muscle compared to the control. The combination of antioxidants in the +ECSe group raised GPx activity in whole blood compared to the control. In conclusion, results indicated that vitamin E is the most effective antioxidant to alleviate oxidative stress caused by high dietary PUFA and that the supplementation with additional vitamin C and selenium did not have clear synergistic effect.

Chlamydophila pneumoniae and Mycoplasma pneumoniae were not identified in sinus mucosa of patients with chronic rhinosinusitis

Chronic rhinosinusitis is a symptomatic inflammation of the mucosa of the nose and paranasal sinuses lasting for at least 12 weeks. Atypical bacteria Chlamydophila pneumoniae and Mycoplasma pneumoniae are important causes of human respiratory tract infection. Also, they were identified in bronchial respiratory epithelium of patients with chronic obstructive pulmonary disease or asthma. Having in mind the unified airway concept, it is also possible that these bacteria can cause persistent infection of sinus mucosa in patients with chronic rhinosinusitis. Sixty consecutive patients with chronic rhinosinusitis who underwent the functional endoscopic sinus surgery due to medical therapy failure were included in the study. During the operation, sinuses were irrigated with sterile 0.9% NaCl solution and this lavage was immediately aspirated. Aspirates were used for the detection of C. pneumoniae and M. pneumoniae DNA using real-time PCR. C. pneumoniae and M. pneumoniae DNA were not detected in samples analysed. Atypical bacteria C. pneumoniae and M. pneumoniae did not cause persistent infection of sinus mucosa in patients with chronic rhinosinusitis.

West Nile virus outbreak in humans in Croatia, 2012

During August and September 2012, seven cases of West Nile neuroinvasive disease were identified in three north-eastern counties of Croatia. Four cases were reported in Osijek-Baranja County, two in Brod-Posavina County and one in Vukovar-Srijem County. The median age of the patients was 62.7 years. All patients were hospitalized for 2-5 weeks. The patients from Slavonski Brod had more severe clinical presentation of disease with prolonged hospitalization. Medical entomological research was carried out in 64 localities, where 1785 mosquitoes were captured. Among the analyzed mosquitoes, 114 were determined to be Culex pipiens and subjected to molecular characterization for the presence of virus. No viral RNA was detected in mosquitoes. Subsequent public health measures taken include mosquito control in all settlements where disease was detected.

[Antisynthetase syndrome - a case report]

Twenty-eight year-old woman with predominant signs of polymyositis, pulmonary interstitium involvement and with positive anti-Jo1 antibodies was suspected for antisynthetase syndrome. Over the next three months sores and ulcerations have appeared at the fingertips. In the later course of the disease clinical picture of mixed connective tissue disease associated with interstitial lung disease, with a dominant picture of systemic sclerosis have emerged. She was treated with glucocorticoides and immunosuppressive therapy. Patient condition was mostly stable, without significant progression of lung lesions. Early diagnosis and treatment antisynthetase syndrome significantly contributes to more favorable course and outcome of disease. A prerequisite for that are well-defined diagnostic criteria and an appropriate choice of treatment.

Effects of probiotic and phytogenic products on performance, gut morphology and cecal microflora of broiler chickens

Abstract. The trial involved 684 Cobb 500 broiler chicks in order to investigate the effects of probiotics and phytogenic additives on performance, gut morphology and cecal microbial concentrations. Birds were assigned to three treatments: control feed, treatment with addition of probiotics in feed and water and treatment with addition of phytogenic blend in feed. The results showed a significant improvement (P<0.01) in body weight gain and a numerical, but non significant (P>0.05) improvement in feed conversion ratio by adding both probiotics and phytogenics in feed. There were no statistically significant differences among treatments regarding total aerobes, anaerobes, lactic acid bacteria, bifidobacteria, enterococci, and Escherichia coli populations (P>0.05) in cecum of broilers. The gut morphology examination showed that probiotics had beneficial effect on jejunum morphology causing a significant (P<0.005) increase in villus height and villus surface area compared to other two groups. On the other hand, phytogenic additive had no effect (P>0.05) on villus height or villus surface area, but reduced the villus/crypt ratio (P<0.05), which may indicate that the improved production results in the group with added phytogenics are not directly connected with changes in gut integrity, but with other physiological mechanisms.

[ISKRA guidelines on antimicrobial treatment and prophylaxis of urinary tract infections--Croatian national guidelines]

These guidelines refer to diagnosis, antimicrobial treatment and prophylaxis of urinary tract infections in adults and children older than 12 years of age and cover lower urinary tract in females, uncomplicated pyelonephritis, complicated UTI with or without pyelonephritis, asymptomatic bacteriuria and recurrent UTI. These guidelines do not cover sexually transmitted diseases. The guidelines are primarily intended for use by general practitioners and specialists working in primary health care and hospitals. The members of the Working Group for the development of guidelines on antimicrobial treatment and prophylaxis of urinary tract infections were appointed by the Croatian Ministry of Health and Social Welfare. The project was financially supported by the Dutch government and professional assistance was provided by international consultants. The evidence for this guidelines is based on a systematic review of the literature, local antibiotic resistance data, the existing clinical protocols on the treatment and prophylaxis of UTIs, as well as suggestions and comments made by colleagues physicians during more than 50 continuous medical education courses held in the last three years on antimicrobial treatment and prophylaxis of UTIs. Draft version of the guidelines was available for comments on the web site http://iskra.bfm.hr and during the two-month piloting period the guidelines were widely presented to general practitioners, specialists working in primary care and hospitals--urologists, gynecologists, infectious disease specialists, nephrologists. The final version of the guidelines was approved by the Intersectoral Coordination Mechanism for the Control of Antimicrobial Resistance (ISKRA) Board.

Mushroom poisoning

In the research we included a total of 207 subjects with the dismissal diagnosis of "mycetismus", who were treated at the Department of Infectious Diseases, General Hospital Osijek, during the 1983-1992 period. 32 of them were children. There were 44.93% of men, 39.61% of women and 15.45% of children. The latent time > 6 hours was determined in 51 (25%) and < 6 hours in 75% of subjects. In 156 of patients with the latent time > 6 hours, "false" poisoning occured, while 51 patients experienced real mushroom toxins poisoning. At the admission to the hospital, in patients with the latent time > 6 hours, a pathological PT (protrombine time) was established only in women, leukocytosis in both women and children, increased concentration of GGT (gamma-glutamin-transferase) in men, increased AST (aspartate-aminotransferase) and ALT (alanin-aminotransferase) only in women, and increased urea in both women and children. After 24 hours, control measuring established high values of AST and ALT extended PT uremia and exalted amount of ammonia in blood in 11 of patients (2 men, 7 women and 2 children). They had severe liver and kidney damage, the most probably caused by Amanita phalloides toxins. The latent time lasted 9 to 13 hours. Of the 11 above mentioned patients, 2 women, aged 74 and 43, and one girl, aged 6, died. No pathological laboratory parameters were established in 40 of subjects with the latent time of 6 and more hours, and the disease manifested through vomiting and diarrhea that lasted for several days. These subjects most probably suffered from mushroom toxins poisoning. Mushroom toxins irritate the mucuous membrane of the gastrointestinal tract, and there are many such poisonous mushrooms. There were no mortalities in this group of subjects.

Human leptospirosis in eastern Croatia, 1969-2003: epidemiological, clinical, and serological features

This survey presents epidemiological, serological and clinical features of 270 patients (85% males, 18% children) treated for leptospirosis from 1969 to 2003 at the Clinic for Infective Diseases, University Hospital Osijek, Osijek, eastern Croatia. 75% of the admissions were between July and October. The route of transmission was mostly by indirect contact with domestic animals, less frequently by direct contact with urine or tissue of infected animals. Clinical presentation included signs and symptoms with expected and common frequency, with the exception of jaundice (62%) and aseptic meningitis (60%), which occurred with higher incidence than previously reported. Acute renal failure ensued in 53% of patients, 7% of whom required haemodialysis. No deaths were observed. Therapy consisted of antimicrobials (penicillin and doxycycline) and symptomatic measures. Diagnosis was confirmed by microscopic agglutination test (MAT). There were in total 18 serological types of Leptospira detected, and types L. sejroe, L.pomona, L. australis and L. icterohaemorrhagiae prevailed. During the last 10 y some new types were observed. Leptospirosis was not rare in the region of eastern Croatia, and its course could be life-threatening if not recognized and adequately treated.

[The biggest epidemic of hemorrhagic fever with renal syndrome in Croatia]

INTRODUCTION

The largest outbreak of hemorrhagic fever with renal syndrome (HFRS) to date occurred in Croatia in the year 2002. The epidemic started in winter, lasted throughout spring to summer months, ending not earlier than November.

AIM

The aim of this study was to investigate and analyze the basic epidemiologic and clinical features of HFRS in Croatia by uniform and standardized prospective-retrospective analysis of all patients affected by the epidemic.

PATIENTS AND METHODS

When the epidemic started, a patient questionnaire with questions on the basic demographic data, site of infection and other epidemiologic characteristics, clinical symptoms, disease severity and laboratory results was designed. Data on 401 patient with a clinical diagnosis of HFRS were collected. The etiologic diagnosis of the disease was confirmed by ELISA, and in some patients by indirect immunofluorescence test (IFT). The results were analyzed using a descriptive statistical method.

RESULTS

HFRS was clinically diagnosed in 401 patients from all over Croatia. A total of 320 (79.8%) cases were reported to the Epidemiology Service of the National Institute of Public Health. The majority of patients (n = 128) were registered in June. Males were three times more affected than females. Apart from its long duration, this epidemic was characteristic for the involvement of general population, with only a small number of the affected from the potential risk groups (forestry workers 28, soldiers 14, farmers 18). The epidemic spread almost throughout inland Coratia. At least 44 patients were infected in the Plitvice Lakes area, 32 in Slunj, 27 on Sljeme, 24 in Velika, and at least 19 in the area of Kutjevo. The youngest patient was aged 4 and the oldest 80 years. The majority of patients were treated in Zagreb (University Hospital for Infectious Diseases--110, Zagreb University Hospital Center--3), followed by Karlovac (71 inpatients and 39 outpatients), Pozega (n = 79), and Rijeka (n = 37). Serologic analysis (ELISA method) detected Puumala virus in 161 and Dobrava virus in only 17 patients. The disease was confirmed by immunofluorescence method in 53 patients (mostly in Kariovac). During the 2002 outbreak, HFRS clinically manifested mostly in a milder form with general symptoms and transitory renal insufficiency, while hemorrhages were rarely recorded. According to our disease severity score, a mild form of the disease was recorded in 65%, moderately severe in 28%, severe in 5% and extremely severe form in 2% of the patients. One patient died. Two thirds of the patients were hospitalized during the febrile stage of the disease. All patients had fever, whereas headache and pain in the lumbar region were recorded in more than 90% of cases, polyuria in 75%, oliguira and vomiting in approximately 50%, respiratory symptoms in 35%, and hemorrhages (mostly on the skin and mucous membranes), vision disturbances, conjunctivitis and diarrhea in approximately 25% of patients. ESR was elevated in 64% and CRP in 93% of patients. Leukocytosis was recorded in 25% and thrombocytopenia in 70% of patients. Increased values of urea and creatinine and signs of liver damage were recorded in approximately 50% of the patients.

CONCLUSION

The largest outbreak of HFRS occurred in Croatia in 2002, with more than 400 diseased throughout Croatia. This epidemic confirmed our previous assumption that the whole Croatia, apart from its narrow coastline area and islands, is a natural focus of HFRS with different causative types of hantaviruses. Efforts should be made to conduct a comprehensive ecologic and mammologic study on hantaviruses and their biologic characteristics in these areas.

Encephalitis or encephalopathy during an influenza-A epidemic

Six female patients with encephalitis, mean age 36.5 (17-60) years, were admitted to the hospital during the 2000-2001 influenza A (H1N1) epidemic in the Osijek--Baranja County. In three (50.0%) patients, the manifestation of encephalitis occurred on day 4 or 5, and in two (33.3%) patients within 24-48 hours of the onset of influenza symptoms. The disease manifestations included headache, elevated body temperature, generalized fatigue, and consciousness disturbance through coma. Three (50.0%) patients had grand mal seizures. Pathologic electroencephalography findings were recorded in all six (100%) patients, whereas computed tomography showed cerebral edema in three (50.0%) patients. Elevated levels of hepatic enzymes and peripheral blood leukopenia were found in two (33.3%) patients in whom encephalitis developed early upon the onset of influenza. One (16.6%) of these patients died, whereas permanent sequels remained in the other two (33.3%) patients.

Intracranial infection as a common complication following war missile skull base injury

The purpose of this paper is to stress the importance of clinical observation, the appropriate antimicrobial therapy, and early surgery in the management of intracranial infection following war missile penetrating skull base injury. There were 21 skull base missile injuries treated surgically in a 4-year period. Careful removal of devitalised brain tissue with dural closure was performed with all patients to prevent the development of intracranial infection. Subsequent clinical and radiological surveillance was performed to detect evidence of infection and abscess formation if fragments were left in place. Broad range antibiotic coverage, and the antioedematous agents were applied in the early postoperative period. Infection about the brain was seen in four cases. We recorded three cases of brain abscess formation, while one patient developed bacterial meningitis. The incidence of infectious complications was relatively high in our series. After the organisms causing infection were known, treatment was modified to be as specific as possible. It was not necessary to reoperate on intracranially retained foreign bodies and fragments since they did not increase the infection rate. However, repeated surgery is necessary for a brain abscess.

Tick-borne encephalitis in eastern Croatia

92 patients treated for tick-borne encephalitis (TBE) in the Department for Infectious Diseases, University Hospital Osijek, over a 22-year period (1973-1995) were analysed. The patients were mostly forestry workers. The appearance of the disease followed the biological activity of the tick, with the largest number of affected individuals recorded between April and August. TBE in eastern Croatia is a relatively frequent infectious disease, appearing almost every year. In a smaller number (9.8%) of cases the clinical picture was aseptic meningitis, while in the majority of patients (90.2%) it presented as an acute meningoencephalomyelitic form. The course was relatively severe in the majority of the patients analysed, with disturbances of consciousness (32.6%) and transitory neurological signs (61.9%). Three patients died (3.3%) in the early phase of the disease. A monophasic course dominated. The clinical and epidemiological data were compared with the cases described in other parts of Croatia and regional differences were seen in the severity of illness. These variations could be due to the previously hypothesized different virus subtypes, or to some other unknown factors.