Immune checkpoint inhibitor associated vitiligo and its impact on survival in patients with metastatic melanoma: an Italian Melanoma Intergroup study

Background

Checkpoint inhibitors in melanoma can lead to self-immune side-effects such as vitiligo-like depigmentation (VLD). Beyond the reported association with favorable prognosis, there are limited data regarding VLD patient features and their echo on the therapeutic outcomes.

Methods

To assess the association between VLD and a series of clinical and biological features as well as therapeutic outcomes, we built an observational cohort study by recruiting patients who developed VLD during checkpoint inhibitors.

Results

A total of 148 patients from 15 centers (101 men, median age 66 years, BRAF mutated 23%, M1c 42%, Eastern Cooperative Oncology Group (ECOG) status 0/1 99%, normal lactate dehydrogenase 74%) were enrolled. VLD was induced by ipilimumab, programmed cell death-1 (PD-1) inhibitors, and their combination in 32%, 56%, and 12%, respectively. The median onset was 26 weeks and it was associated with other skin and nonskin toxicities in 27% and 28%, respectively. After 3 years of VLD onset, 52% (95% confidence interval 39% to 63%) were progression free and 82% (95% confidence interval 70% to 89%) were still alive. The overall response rate was 73% with 26% complete response. Univariable analysis indicated that BRAF V600 mutation was associated with a better overall survival (P = 0.028), while in multivariable analysis a longer progression-free survival was associated with BRAF V600 (P = 0.093), female sex (P = 0.008), and M stage other than 1a (P = 0.024). When VLD occurred, there was a significant decrease of white blood cell (WBC) count (P = 0.05) and derived WBC-to-lymphocytes ratio (dWLR; P = 0.003). A lower monocyte count (P = 0.02) and dWLR (P = 0.01) were also reported in responder patients.

Conclusions

Among VLD population, some features might help to identify patients with an effective response to immunotherapy, allowing clinicians to make more appropriate choices in terms of therapeutic options and duration.

•

This multicentric retrospective study outlined the melanoma profile of 148 patients with vitiligo-like depigmentation (VLD) induced by checkpoint inhibitors.

•

Median VLD onset was 26 weeks and it was associated with other immune toxicities in one-third of cases.

•

After 3 years of VLD onset, 52% and 82% of patients, respectively, were progression free and still alive with a response rate of 73%.

•

Some features such as BRAF V600, female sex, and M stage were associated with better outcomes as well as a specific blood profile.

Managed care for uninsured patients at an academic health center: a case study

In 1997, the University of New Mexico Health Sciences Center ("the Center") created a managed care plan ("the Plan") for its uninsured patients who were county residents. The Plan's features include pooling the resources of existing county safety-net providers, enrolling patients with primary care providers at easily accessible neighborhood-based clinics, and investing in social support services, case management, and 24-hour telephone triage. After two years of the Plan's operation, the utilization of ambulatory care services by Plan enrollees, the number of discharges per 1,000 enrollees from the Center-affiliated University Hospital, and the number of hospital days per 1,000 enrollees had all dropped significantly (p < .001 for all). For the 13,114 enrollees in the Plan, University Hospital saved an estimated $1,904,872 per year in costs. The replacement of unpaid hospital days with paying patients is estimated to have yielded over $695,000 in additional revenues per year. The authors conclude that managing the care of uninsured patients in an academic health center can reduce ambulatory care and inpatient utilization and reduce the cost of care. To achieve these favorable outcomes requires the organization of services to meet the unique needs of the uninsured and underserved population.

Academic models for practice relief, recruitment, and retention at the University of New Mexico Medical Center and East Carolina University School of Medicine

Locum tenens programs were independently developed by the University of New Mexico Health Sciences Center and East Carolina University School of Medicine to address health care needs within their states. The programs represent distinct models to provide locum tenens services for practices in rural and medically underserved regions through collaboration with stage government representatives and agencies. Differences between programs include years of operation, days of coverage provided, types of learners and providers involved, sources of funding, costs of the programs, and extent of institutional support. Common beneficial outcomes of the programs include coverage for struggling practices, training in rural medicine for locum tenens providers, recruitment of physicians to rural practice sites, and improved relationships with program partners. Adequate funding and institutional support are essential for success of locum tenens programs.

Toxic megacolon secondary to acute ischemic colitis

A 72-year-old woman without significant medical history was admitted with abdominal pain, high fever, leukocytosis, bloody diarrhea and marked dilation of the transverse, descending and sigmoid colon. Toxic megacolon was diagnosed and responded well to medical treatment. Seven weeks after her admission, however, the patient developed a stenotic lesion in the sigmoid colon. The lesion was managed surgically. Histological examination of the resected colon revealed resolving ischemic colitis affecting only part of the thickness of the intestinal wall. The patient has been healthy since the surgery, i.e., for two years.

Tribal differences in diabetes: prevalence among American Indians in New Mexico

The prevalence of diagnosed diabetes among American Indians in New Mexico with varied genetic and cultural backgrounds is reported. Utilizing community-based registries, the prevalence in persons ages 35 years and older ranged from 9.8 percent among Jicarilla Apache Indians to 28.2 percent among Zuni Indians. All rates were significantly higher than the U.S. rate of 5.3 percent for the same age group. In addition, in three of the five tribal groups examined, the rates of diagnosed diabetes in Indians less than 35 years of age (range from 0.5 percent to 1.3 percent) were significantly higher than the U.S. rate of 0.4 percent for the same age group. The prevalence rates of diagnosed diabetes found in this study of American Indians in New Mexico were intermediate between those for the United States as a whole and the Pima Indians of southern Arizona. Reasons for the variations and the relative contribution of obesity, fitness, or genetic risk in the development of diabetes need further study.