Immune checkpoint inhibitors for patients with advanced lung cancer and oncogenic driver alterations: results from the IMMUNOTARGET registry

Background

Anti-PD1/PD-L1 directed immune checkpoint inhibitors (ICI) are widely used to treat patients with advanced non-small-cell lung cancer (NSCLC). The activity of ICI across NSCLC harboring oncogenic alterations is poorly characterized. The aim of our study was to address the efficacy of ICI in the context of oncogenic addiction.

Patients and methods

We conducted a retrospective study for patients receiving ICI monotherapy for advanced NSCLC with at least one oncogenic driver alteration. Anonymized data were evaluated for clinicopathologic characteristics and outcomes for ICI therapy: best response (RECIST 1.1), progression-free survival (PFS), and overall survival (OS) from ICI initiation. The primary end point was PFS under ICI. Secondary end points were best response (RECIST 1.1) and OS from ICI initiation.

Results

We studied 551 patients treated in 24 centers from 10 countries. The molecular alterations involved KRAS (n = 271), EGFR (n = 125), BRAF (n = 43), MET (n = 36), HER2 (n = 29), ALK (n = 23), RET (n = 16), ROS1 (n = 7), and multiple drivers (n = 1). Median age was 60 years, gender ratio was 1 : 1, never/former/current smokers were 28%/51%/21%, respectively, and the majority of tumors were adenocarcinoma. The objective response rate by driver alteration was: KRAS = 26%, BRAF = 24%, ROS1 = 17%, MET = 16%, EGFR = 12%, HER2 = 7%, RET = 6%, and ALK = 0%. In the entire cohort, median PFS was 2.8 months, OS 13.3 months, and the best response rate 19%. In a subgroup analysis, median PFS (in months) was 2.1 for EGFR, 3.2 for KRAS, 2.5 for ALK, 3.1 for BRAF, 2.5 for HER2, 2.1 for RET, and 3.4 for MET. In certain subgroups, PFS was positively associated with PD-L1 expression (KRAS, EGFR) and with smoking status (BRAF, HER2).

Conclusions

: ICI induced regression in some tumors with actionable driver alterations, but clinical activity was lower compared with the KRAS group and the lack of response in the ALK group was notable. Patients with actionable tumor alterations should receive targeted therapies and chemotherapy before considering immunotherapy as a single agent.

Patient-derived xenografts effectively capture responses to oncology therapy in a heterogeneous cohort of patients with solid tumors

Background

While patient-derived xenografts (PDXs) offer a powerful modality for translational cancer research, a precise evaluation of how accurately patient responses correlate with matching PDXs in a large, heterogeneous population is needed for assessing the utility of this platform for preclinical drug-testing and personalized patient cancer treatment.

Patients and methods

Tumors obtained from surgical or biopsy procedures from 237 cancer patients with a variety of solid tumors were implanted into immunodeficient mice and whole-exome sequencing was carried out. For 92 patients, responses to anticancer therapies were compared with that of their corresponding PDX models.

Results

We compared whole-exome sequencing of 237 PDX models with equivalent information in The Cancer Genome Atlas database, demonstrating that tumorgrafts faithfully conserve genetic patterns of the primary tumors. We next screened PDXs established for 92 patients with various solid cancers against the same 129 treatments that were administered clinically and correlated patient outcomes with the responses in corresponding models. Our analysis demonstrates that PDXs accurately replicate patients' clinical outcomes, even as patients undergo several additional cycles of therapy over time, indicating the capacity of these models to correctly guide an oncologist to treatments that are most likely to be of clinical benefit.

Conclusions

Integration of PDX models as a preclinical platform for assessment of drug efficacy may allow a higher success-rate in critical end points of clinical benefit.

Nocturnal ischemic events in patients with obstructive sleep apnea syndrome and ischemic heart disease: effects of continuous positive air pressure treatment

OBJECTIVES

To investigate the occurrence of nocturnal ischemic events in patients with obstructive sleep apnea syndrome (OSAS) and ischemic heart disease (IHD).

BACKGROUND

Although previous reports documented nocturnal cardiac ischemic events among OSAS patients, the exact association between obstructive apneas and ischemia is not yet clear. It is also not known what differentiates between patients showing nocturnal ischemia and those that do not.

METHODS

Fifty-one sleep apnea patients (age 61.3+/-8.3) with IHD participated in the study (after withdrawal of beta-adrenergic blocking agents and anti-anginotic treatment). All patients underwent whole-night polysomnography including ambulatory blood pressure recordings (30 min interval) and continuous Holter monitoring during sleep. A control group of 17 OSAS patients free from IHD were also similarly studied. Fifteen of the 51 patients were also recorded under continuous positive airway pressure (CPAP).

RESULTS

Nocturnal ST segment depression occurred in 10 patients (a total of 15 events, 182 min), of whom six also had morning ischemia (06-08 am). Five additional patients had only morning ischemia. No ischemic events occurred in the control group. Age, sleep efficiency, oxygen desaturation, IHD severity and nocturnal-double product (DP) values were the main variables that significantly differentiated between patients who had ischemic events during sleep and those who did not. Nocturnal ischemia predominantly occurred during the rebreathing phase of the obstructive apneas, and it is characterized by increased heart rate (HR) and DP values. Treatment with continuous positive airway pressure significantly ameliorated the nocturnal ST depression time from 78 min to 33 min (p<0.001) as well as the maximal DP values (14,137+/-2,827 vs. 12,083+/-2,933, p<0.001).

CONCLUSIONS

Exacerbation of ischemic events during sleep in OSAS may be explained by the combination of increased myocardial oxygen consumption as indicated by increased DP values and decreased oxygen supply due to oxygen desaturation with peak hemodynamic changes during the rebreathing phase of the obstructive apnea. Treatment with CPAP ameliorated the nocturnal ischemia.

Melatonin effect on seizures in children with severe neurologic deficit disorders

PURPOSE

Recently, melatonin has been associated with antiepileptic activity, most probably because of its antioxidant activity as a free radical scavenger. This study aimed to expand the clinical experience with melatonin as an antiepileptic drug (AED) in humans.

METHODS

Six children (aged 2-15 years), with severe intractable seizures, were treated with 3 mg of oral melatonin 30 min before bedtime, in addition to their previous AED treatment for 3 months. A diary of clinical seizure activity (time of day, duration, and type) was kept by parents for a month before and during treatment. Five patients underwent a baseline polysomnography, and three also were monitored during melatonin treatment.

RESULTS

With the exception of the parents of one child, all reported a significant clinical improvement in seizure activity during treatment, particularly during the night. Sleep studies showed a decrease in epileptic activity in two of the three patients who were monitored during treatment, and a change of sleep efficiency from 84.2% to 89.7% (NS). Improvement in daytime behavior and in communication abilities was reported by parents, although it was not objectively measured.

CONCLUSIONS

This clinical observation adds to the growing data showing the antiepileptic effect of melatonin. However, owing to the paucity of well-controlled studies, using melatonin as an AED should be limited to this specific group of patients with intractable seizures.

Gastric-outlet obstruction induced by prostaglandin therapy in neonates

BACKGROUND

An infusion of prostaglandin E1 is widely used to maintain patency of the ductus arteriosus in neonates with congenital heart disease. After gastric-outlet obstruction was recognized in several infants who received prostaglandin E1, we studied the association between the drug and this complication.

METHODS

We evaluated all neonates who received prostaglandin E1 in our hospital between October 1, 1989, and September 30, 1991, for clinical, radiologic, or pathological evidence of acute gastric-outlet obstruction.

RESULTS

Of the 74 neonates evaluated, 65 had no signs of gastric obstruction and were considered normal; 5 had clinical and radiologic or pathological evidence of gastric obstruction consistent with the presence of antral mucosal hyperplasia. The remaining four neonates had clinical signs of gastric obstruction, but no radiologic or pathological examinations were performed. The 5 neonates with antral hyperplasia had received prostaglandin E1 for longer periods (mean [+/- SD] duration, 569 +/- 341 hours) than the 65 normal neonates (54 +/- 58 hours, P less than 0.001) or the 4 neonates with clinical signs of gastric obstruction (119 +/- 60 hours, P less than 0.05). The cumulative dose of prostaglandin E1 was higher in the neonates with antral hyperplasia (2982 +/- 1392 micrograms per kilogram of body weight) than in the normal neonates (279 +/- 270 micrograms per kilogram, P less than 0.001) or the neonates with signs of gastric obstruction (528 +/- 306 micrograms per kilogram, P less than 0.01). In two neonates with antral hyperplasia, the cessation of therapy lessened the gastric-outlet obstruction.

CONCLUSIONS

The administration of prostaglandin E1 to neonates can cause gastric-outlet obstruction due to antral hyperplasia. Neonates who receive prostaglandin E1 at recommended doses for more than 120 hours should be closely monitored for evidence of antral hyperplasia.

Melatonin improves sleep-wake patterns in psychomotor retarded children

Five children with severe psychomotor retardation (mean age 8.2+/-3.6 years) and irregular sleep-wake patterns underwent 1 week of wrist actigraphic monitoring before and after treatment with 3 mg melatonin. Three underwent multiple measurements of urinary sulfatoxymelatonin levels. Urine sulfatoxymelatonin levels were abnormally low, without any significant day/night differences. Melatonin treatment increased nighttime sleep from 5.9+/-0.8 to 7.3+/-0.5 hours (paired t test, P<0.01) and sleep efficiency from 69.3%+/-6.2% to 88.3%+/-2.3% (P<0.01). Daytime sleep decreased from 3.2+/- 1.2 to 1.7+/-1.2 hours (P<0.05). Thus, no change in 24-hour total sleep time (9.1+/-1.5 vs. 9.0+/-1.6 hours) occurred. Administration of 3 mg melatonin to five severely psychomotor retarded children resulted in a significant improvement in their sleep-wake patterns.

Antibiotic susceptibility of Kingella kingae isolates from respiratory carriers and patients with invasive infections

The antimicrobial drug susceptibilities of 145 isolates of Kingella kingae to eight antibiotics were determined by the disc diffusion method. In addition, penicillin MICs were determined by the Etest. Study isolates included 37 from blood, 34 from the skeletal system and 74 from respiratory carriers. All isolates were beta-lactamase negative and susceptible to erythromycin, gentamicin, chloramphenicol, tetracycline and ciprofloxacin. A single isolate exhibited resistance to trimethoprim-sulphamethoxazole, and 56 (38.6%) were resistant to clindamycin. The penicillin MIC(50) was 0.023 mg/L and the MIC(90) was 0.047 mg/L. The distribution of MIC values did not differ according to the site of isolation.

Clinical significance and impact on mortality of extended-spectrum beta lactamase-producing Enterobacteriaceae isolates in nosocomial bacteremia

During an 8-month period, 55 episodes of nosocomial bacteremia caused by Enterobacteriaceae species were identified in a tertiary medical center, of which 26 (47%) were caused by extended-spectrum beta lactamase (ESBL)-producing organisms. ESBL production was associated with resistance to aminoglycosides, fluoroquinolones, tetracycline and co-trimoxazole compared with non-ESBL-producing organisms (p < 0.01). By multivariate analysis, infection with ESBL-producing organisms was associated with previous antibiotic therapy and central venous catheter insertion and mortality was associated with heart failure, malignancy and a prolonged hospital stay. Nineteen (73%) patients infected with ESBL-producing organisms received adequate empirical antibiotic therapy and all 26 received adequate definitive therapy. The in-hospital mortality rate did not differ between patients infected with ESBL producers and those infected by non-ESBL-producing Enterobacteriaceae species [13/26 (50%) and 11/29 (38%), respectively] (p > 0.5).

Contributions of hypoxia and respiratory disturbance index to sympathetic activation and blood pressure in obstructive sleep apnea syndrome

Hypertension is a common finding among obstructive sleep apnea (OSA) patients, and is thought to be caused by sympathetic hyperactivity. The present study compares the contributions of the respiratory disturbance index (RDI) as a reflection of sleep fragmentation, and the magnitude of oxygen desaturation, to sympathetic activation as indexed by urinary norepinephrine concentrations, as well as to morning and evening blood pressure in sleep apnea syndrome patients. Data (polysomnography, blood pressure [BP], and urine catecholamines) of 38 consecutive OSA patients (age, 46+/-14.5 years) were analyzed. Stepwise logistic regression analysis revealed that minimal oxygen saturation level (SaO2min) was a significant predictor of both morning and evening norepinephrine levels, and that 37% of morning systolic BP variance could be accounted for by a combination of age and norepinephrine, while 20% of the diastolic BP variance was accounted for by SaO2min alone. In contrast, RDI entered the prediction equation only when minimal oxygen saturation was rejected first. Our results indicate that the degree of nocturnal hypoxia is more closely associated with the level of sympathetic activation and with daytime level of blood pressure than with sleep fragmentation.

Impact of 4% chlorhexidine whole-body washing on multidrug-resistant Acinetobacter baumannii skin colonisation among patients in a medical intensive care unit

The prevalence of skin colonisation with Acinetobacter baumannii (ACBA) on admission to the medical intensive care unit (MICU) was studied in an institution endemic for ACBA bloodstream infections (BSIs). The impact of 4% chlorhexidine gluconate (4% CG) whole-body washing on the patients' ACBA skin colonisation was also determined. A prospective cohort trial in a MICU during March 2002 to December 2003 was performed, with a comparison between the prevalence and incidence of ACBA-BSIs obtained after intervention and retrospectively. During the intervention period, ACBA skin-screening swabs were taken from all patients on admission and periodically until discharge. Patients underwent whole-body disinfection with 4% CG immediately after obtaining the initial cultures. Disinfection was carried out on a daily basis until discharge, regardless of colonisation status. Of the 320 patients at ward admission, 55 (17%) yielded ACBA. The prevalence of ACBA colonisation among the remaining MICU patients was 5.5% at 24h and 1% at 48h following the disinfection regimen (P=0.002, OR: 2.4). Following a second screen, 80% of colonised patients were decolonised. Prevalence of ACBA-BSIs decreased from 4.6 to 0.6 per 100 patients (P < or = 0.001; OR: 7.6) and incidence decreased from 7.8 to 1.25 (85% reduction). We conclude that daily whole-body disinfection with 4% CG significantly reduced ACBA skin colonisation. This regimen may be considered in addition to well-known infection control measures, particularly in institutions with endemic rates of multidrug-resistant ACBA-BSIs.

Comparison of glucose levels in dermal interstitial fluid and finger capillary blood

Alternative methods for self-monitoring of blood glucose have been pursued by many researchers, largely in response to evidence gathered in several long-term studies of patients with diabetes mellitus. These studies suggest that long-term complications of the disease may be mitigated if the disease is intensively managed, a component of which is increased monitoring. Many of the alternative methods utilize interstitial fluid (ISF) as the diagnostic fluid, rather than finger blood. A time lag in the distribution of glucose from blood to the interstitium has been observed by many, with estimates of lag time varying from none to 45 min. Dermal ISF was sampled from diabetic subjects in two tests and compared to finger blood glucose. In the first test, data were collected over time in a manner that allowed a cross-correlation analysis to predict an average lag time. Information from this test was then used as input to a data collection format for a method comparison test of 691 patients with diabetes in which ISF data were collected immediately after the finger blood reference and 15 min after the reference. An average lag time of about 25 min was determined from the cross-correlation analysis, with the correlation error reduced by three-fourths within a 15-min lag time. In the method comparison test, the correlation coefficient between finger blood glucose and ISF glucose improved from 0.923 to 0.951, and the percentage of data in the A zone of the Clarke Error Grid rose from 80.2% to 90.6% for the ISF glucose data collected at no lag and 15-min lag, respectively. Dermal ISF glucose measurement might be a reasonable alternative to blood glucose measurement for patients routinely monitoring ambient glycemia, although more testing in the sensitive hypoglycemic range is needed to clarify what might happen in cases of rapidly changing glucose.

Impaired respiratory response to resistive loading during sleep in healthy offspring of patients with obstructive sleep apnea

To evaluate the possibility that healthy offspring of patients with obstructive sleep apnea syndrome (OSAS) may have covert signs of sleep disordered breathing, we compared the respiratory response to inspiratory resistive loads (IRL) in 10 adult offspring of fathers previously diagnosed with OSAS with that of 14 offspring of healthy parents. None of the offspring in either group had any sign of OSAS, and groups were age, weight, and body mass index matched. Both ventilatory response to progressively increasing levels of IRL and the IRL required to produce severe hypopnea (tidal volume [V(T)] < 20% of unloaded magnitude) were determined, during NREM sleep. Offspring of patients with OSAS (OSAS offspring) responded to all levels of IRL with greater decreases in V(T). Their V(T) decreased in the second breath on IRL of 23 cm H2O/l/s by 39 +/- 10%, as compared with a decrease of 19 +/- 4% (mean +/- SD) in the control group (p < 0.05). Severe hypopnea occurred in the OSAS offspring in response to smaller IRL compared to controls (79 +/- 20 and 153 +/- 14 cm H2O/l/s, respectively, p < 0.005). Total upper airway occlusion in response to IRL occurred in three of the OSAS offspring, but in none of the controls. We conclude that apparently healthy offspring of patients with OSAS may inherit subtle defects that reduce their ability to compensate for increased loads and maintain upper airway patency during sleep. We speculate that offspring of OSAS patients with decreased tolerance to IRL may be prone to developing OSAS later on in life.

Reduction of blood culture contamination rate by an educational intervention

The efficacy of an educational intervention to prevent blood culture contamination (BCC) in internal medicine was studied in two medical wards in a busy tertiary-care hospital in which blood cultures were obtained by physicians rather than dedicated phlebotomists. Baseline BCC rates were 5.7% and 7.1% in intervention and control wards, respectively (p 0.6), compared with 1.95% and 6.7%, respectively, post-intervention (p < 0.001). Following multivariate analysis, only an absence of intervention was an independent variable associated with BCC. Thus simple educational intervention reduced BCC in internal medicine and was considered to be cost-effective.

Exposure of hospital personnel to Brucella melitensis and occurrence of laboratory-acquired disease in an endemic area

In 1997, 7 cases of laboratory-acquired Brucella melitensis infections were detected among the hospital personnel of a medical centre serving an endemic area in southern Israel. Although the onset of symptoms in 6 of the 7 patients occurred during a 2-week period, suggesting a point source exposure, biotype analysis showed that the outbreak was caused by 3 different B. melitensis serovars, indicating multiple exposures. Review of the laboratory records showed that during 1997, the microorganism was recovered from 146 blood and synovial fluid cultures, and that during the 2 months in which the laboratory-acquired cases occurred (April and June), 53 of 530 positive aerobic blood culture bottles (10.0%) grew B. melitensis. The epidemiological investigation did not reveal the source of the outbreak, and no noticeable breaches in laboratory safety practices could be demonstrated. It is concluded that in areas endemic for brucellosis, hospital personnel are frequently exposed to Brucella microorganisms. Under these circumstances, significant morbidity may occur despite observance of recommended safety practices. Biotyping of Brucella isolates may contribute to the elucidation of complex epidemiological situations.

Long-term follow-up of untreated patients with sleep apnoea syndrome

Obstructive sleep apnoea (OSA) is a common disorder with numerous potential sequelae. Although the majority of these consequences can be reduced with appropriate treatment, only limited data exist regarding the natural progression ofthis disorder in untreated individuals. We hereby report a long-term follow-up of all untreated patients (n = 40) followed-up in the Technion Sleep Clinic, using both subjective and objective measurements. In addition, we report a long-term follow-up of 11 patients who attempted dietary weight loss. The average time interval between the first and second polysomnographies for the untreated group was 5.0 +/- 2.8 yrs, and 2.5 +/- 2.3 yrs for the weight reduction group. There was no significant change in Body Mass Index (BMI) or Respiratory Disturbance Index (RDI) between the two Polysomnographic (PSG) evaluations in the untreated patients. However, eight patients developed hypertension (n=5) or ischaemic heart disease (IHD) (n=3) between the two evaluations. RDI, age and BMI at the time ofthe initial evaluation were not predictive of changes in RDI, snoring intensity or minimal oxygen saturation. However, the patients who developed hypertension/IHD had significantly higher RDI than the patients who did not (46 +/- 27 vs. 23 +/- 17 h(-1), P < 0.005). In the weight-loss group, BMI decreased by a mean of 3.1 kg m(-2), and RDI decreased by 20events h(-1), P<0.05 for both. There was a significant correlation between the weight loss and improvement in RDI (R = 0.75, P = 0.005). We conclude that in untreated obstructive sleep apnoea patients RDI does not necessarily increase over time, but associated hypertension or ischaemic heart disease may develop. When weight loss is successfully achieved, sleep apnoea significantly improves with a high correlation between the extent of weight loss and the improvement in apnoea status.

Comparison of BACTEC 9240 Peds Plus medium and isolator 1.5 microbial tube for detection of Brucella melitensis from blood cultures

The sensitivity and time to detection of Brucella melitensis by the BACTEC 9240 and the Isolator blood culture systems were compared in a prospective volume-controlled study. Blood sample aliquots, obtained from children with suspected brucellosis, were inoculated into a BACTEC 9240 Peds Plus bottle and into an Isolator 1.5 Microbial Tube. Overall, 122 pairs of blood samples for culture were obtained, and 28 (23%) were positive by at least one method. The BACTEC 9240 system detected all 28 positive cultures (sensitivity, 100%), and the Isolator system detected 22 positive cultures (sensitivity, 79%) (P = 0.023). Among those 22 cultures positive by both methods, 21 (95%) and 15 (68%) were found to be positive within 3 days by the BACTEC and the Isolator systems, respectively; 8 (36%) were found to be positive at least 1 day earlier by the BACTEC instrument, and the remaining 14 were found to be positive by the two systems on the same day (P = 0.045). The BACTEC 9240 blood culture system is more sensitive than the Isolator system for the detection of B. melitensis and is superior in terms of time to detection of the organism.

Changing trends in frequency and antimicrobial resistance of urinary pathogens in outpatient clinics and a hospital in Southern Israel, 1991-1995

In order to monitor changes in the frequency and antimicrobial resistance of urinary pathogens over several years, urinary cultures received from outpatient clinics and from a hospital during a period of one month each in 1991 and 1995 were analyzed at a clinical microbiology laboratory. In 1991 and 1995, 1366 and 1534 significant monomicrobic cultures respectively were reviewed. The frequency of Escherichia coli dropped significantly in the outpatient clinics from 70.5% to 61.2% (p < 0.0001). The frequency of Proteus mirabilis, Morganella morganii, Pseudomonas aeruginosa and other gram-negative bacteria also decreased, but the frequency of Klebsiella spp. and Enterobacter spp. increased from 2.6% to 5.8% (p < 0.0001). In the hospital, the frequency of Enterobacter spp. (p < 0.04), Escherichia coli and Morganella morganii declined from 1991 to 1995, whereas the frequency of Pseudomonas aeruginosa (p = 0.001), Acinetobacter spp. (p < 0.05), Klebsiella spp., Proteus mirabilis and other gram-negative rods increased considerably. The frequency of gram-positive aerobic bacteria rose markedly in outpatient specimens from 6.1% to 13.5% (p < 0.0001), while a decline from 14.4% to 9.3% was noted in hospital specimens (p < 0.02). A significant rise in the resistance of Escherichia coli to gentamicin and ciprofloxacin (p < 0.0001) was detected in outpatient isolates. In the hospital, gram-negative urinary pathogens demonstrated increased resistance to ampicillin (p = 0.042), cefuroxime (p = 0.005), gentamicin (p = 0.002) and ciprofloxacin (p < 0.0001) during the study period. The changing etiology of urinary tract infections and the increasing resistance of organisms indicate that periodic monitoring and possibly also modification of empirical therapy are required.

Hospital-acquired brevundimonas vesicularis septicaemia following open-heart surgery: case report and literature review

Brevundimonas vesicularis (B. vesicularis) is a pseudomonad rarely encountered in human infection. A case of nosocomial septicaemia with this organism following open-heart surgery is presented, with a review of the literature. The isolate demonstrated resistance to ciprofloxacin and aztreonam, which has not yet been reported. Treatment with piperacillin/tazobactam resulted in full recovery. A review of the literature reveals that B. vesicularis is a virulent organism involved in serious infections such as central nervous system infection or bacteraemia, some of which are nosocomial. Meanwhile, empiric therapy for B. vesicularis infection should include a broad-spectrum antimicrobial agent until susceptibility results are known.

Enterococcus hirae septicemia in a patient with end-stage renal disease undergoing hemodialysis

Enterococcus hirae, member of the Enterococcus genus known to cause infection in animals, is rarely encountered in clinical practice. There are no published reports describing clinical features of Enterococcus hirae infection in humans. A case of Enterococcus hirae septicemia in a 49-year-old patient with end-stage renal disease undergoing hemodialysis is reported here. A review of the available literature regarding the clinical spectrum of Enterococcus hirae infection in humans and the antimicrobial susceptibility of Enterococcus hirae is also included.