Severe infusion reaction due to nivolumab: A case report

BACKGROUND

Nivolumab is an anti-PD1 immune checkpoint inhibitor commonly used for the treatment of solid organ and hematological malignancies. Severe infusion reaction due to nivolumab is quite rare.

CASE

We report a case of severe infusion reaction due to nivolumab necessitating ICU admission and withdrawal of further nivolumab use in a patient with metastatic non-small cell lung cancer.

CONCLUSION

Our knowledge and expertise with the use of immune checkpoint inhibitors are still evolving. This report highlights one of the rare possible side-effects that clinicians and patients may have to face with increasing indications and use of nivolumab in day to day practice.

P4718Inadequate response of pulmonary artery pressure after percutaneous mitral valvuloplasty: determinant factors and prognostic impact

Introduction

Pulmonary hypertension (HP) has long been known to be a marker of poor outcome in patients with mitral stenosis (MS). Percutaneous mitral valvuloplasty (PMV) is currently the treatment of choice for MS, which results in improvement in HP. However, despite the successful valve opening, the regression of PH may be incomplete. This has been attributed to irreversible morphologic changes within the pulmonary vasculature.

Purpose

To assess the clinical, echocardiographic and hemodynamic parameters associated with an inadequate response of the pulmonary artery pressure (PAP) immediately after a successful PMV, and also the impact of residual PH on long-term outcome in these patients.

Methods

181 patients undergoing PMV for rheumatic MS were enrolled. Invasive hemodynamic and echocardiographic measures were examined in all patients. Inadequate response of PAP was defined as the mean pulmonary artery pressure (mPAP) values unchanged at the end of the procedure. Long-term outcome was a composite endpoint of death, mitral valve replacement, repeat PMV, new onset of atrial fibrillation (AF), or stroke.

Results

The mean age was 44.1±12.6 years, and 157 patients were women (86.7%). In the overall population, mPAP decreased from 33.4±13.1 mmHg pre to 27.6±9.8 mmHg post (p<0.001), as mitral valve increased from 0.96±0.2 cm2 pre to 1.68±0.2 cm2 post (p<0.001) PMV. Following PMV, 10 patients developed severe mitral regurgitation and were excluded from the analysis. Of the 171 patients analyzed, 52 (30%) did not present reduction of mPAP immediately after the PMV. Transmitral pressure gradients were significantly greater and mitral valve area was smaller in those patients with unchanged mPAP after PMV than in those whose PAP had decreased. Systolic, diastolic and mPAP pressures as well as left atrial pressure were higher in those patients who had improvement in pulmonary pressures after PMV. Multivariate analysis revealed the following independent predictors of unchanged mPAP: AF (Odds ratio [OR] 2.7, 95% [confidence interval] CI 1.1 to 6.4), mitral valve area (OR 1.3, 95% CI 1.1 to 1.5), maximum mitral valve leaflets displacement (OR 0.8, 95% CI 0.7 to 0.9), and left ventricular compliance after PMV (OR 0.8, 95% CI 0.6 to 0.9). During a mean follow-up of 28 months, the endpoint was reached in 48 patients (26%). The pulmonary pressure response to PMV was not predictor of long-term events.

Conclusions

In a large cohort of patients with MS undergoing PMV, mean pulmonary artery pressure values do not reduce immediately after the procedure in 30% of the cases, despite adequate opening of the valve. The factors associated with inadequate PAP response following PMV were presence of AF, larger mitral valve area, reduced valve leaflets mobility and post procedural low left ventricular compliance. The early non-reduction of mPAP after PMV is not associated with adverse outcome.

White matter measures are near normal in controlled HIV infection except in those with cognitive impairment and longer HIV duration

The objective of the current study was to quantify the degree of white matter (WM) abnormalities in chronic and virally suppressed HIV-infected (HIV+) persons while carefully taking into account demographic and disease factors. Diffusion tensor imaging (DTI) was conducted in 40 HIV- and 82 HIV+ men with comparable demographics and life style factors. The HIV+ sample was clinically stable with successful viral control. Diffusion was measured across 32 non-colinear directions with a b-value of 1000 s/mm²; fractional anisotropy (FA) and mean diffusivity (MD) maps were quantified with Itrack IDL. Using the ENIGMA DTI protocol, FA and MD values were extracted for each participant and in 11 skeleton regions of interest (SROI) from standard labels in the JHU ICBM-81 atlas covering major striato-frontal and parietal tracks. We found no major differences in FA and MD values across the 11 SROI between study groups. Within the HIV+ sample, we found that a higher CNS penetrating antiretroviral treatment, higher current CD4+ T cell count, and immune recovery from the nadir CD4+ T cell count were associated with increased FA and decreased MD (p < 0.05-0.006), while HIV duration, symptomatic, and asymptomatic cognitive impairment were associated with decreased FA and increased MD (p < 0.01-0.004). Stability of HIV treatment and antiretroviral CNS penetration efficiency in addition to current and historical immune recovery were related to higher FA and lower MD (p = 0.04-p < 0.01). In conclusion, WM DTI measures are near normal except for patients with neurocognitive impairment and longer HIV disease duration.

Reversible dilated cardiomyopathy associated with amphotericin B therapy

WHAT IS KNOWN AND OBJECTIVE

Amphotericin B (AmB) is commonly used to treat a broad spectrum of fungal infections and leishmaniasis. Its use is limited by numerous adverse effects. Reversible dilated cardiomyopathy associated with AmB is a rare disorder with only four previously reported cases, and all of them referring to patients who presented with a predisposing factor for heart failure.

CASE SUMMARY

A previously healthy 45-year-old man with visceral leishmaniasis treated with AmB developed acute dilated cardiomyopathy. Other causes of heart failure as well-known predisposing factors for this condition were ruled out. As with previously reported cases, the cardiac function of our patient returned to normal shortly after.

WHAT IS NEW AND CONCLUSION

We describe the first case of dilated cardiomyopathy associated with the administration of AmB in a patient without any known predisposing factor for developing cardiac dysfunction. Available evidence suggests that AmB may induce cardiotoxicity. Further investigations are needed to clarify this issue.

Near-total laryngectomy for treatment of advanced laryngeal cancer

BACKGROUND

In order to assess whether near-total laryngectomy (NTL) could successfully reach the cure and preserve the voice in advanced laryngeal cancer, we studied 28 patients with T3/T4 squamous cell carcinoma of the larynx treated with NTL in our institution.

METHODS

A retrospective analysis has been carried out from 1990 through 1994. We classified 24 patients as Stage III and 4 patients as Stage IV. All patients had lateral neck dissection. Survival was analyzed under the Kaplan-Meier method.

RESULTS

Twenty-six patients achieved voice preservation. Two patients in the bilateral neck dissection group had a metastatic lymph node on the opposite side. No patient had local recurrence. Three patients died of the disease, and 1 patient was salvaged with neck dissection. Three-year disease-free survival was 85%.

CONCLUSION

This technique is useful in the treatment of selected cases of advanced laryngeal cancer and achieves local control of the lesion in all cases. The survival is comparable with that of patients submitted to total laryngectomy, regarding the extent of lesion. Voice preservation can be achieved in most cases.

Antioxidant activities of some extracts of Thymus zygis

The antioxidant activities of methanol and ethyl ether extracts obtained from Thymus zygis, collected during the flowering or non-flowering period, were evaluated and compared. To investigate this potential, extracts were tested on their capacity to react with diphenylpicrylhydrazyl (DPPH) in a homogeneous medium, and to inhibit Fe2+/ascorbate-induced membrane lipid peroxidation, as estimated by the formation of thiobarbituric acid-reactive substances (TBARS). Although methanol extracts reduce DPPH radicals more efficiently than ethyl ether extracts, suggesting a potent radical scavenger activity, the ethyl ether extracts were found to be most active in inhibiting lipid peroxidation in sarcoplasmic reticulum (SR) membranes. In addition, both extracts present peroxyl and superoxide radical scavenging activities. Peroxyl radicals were generated by the water soluble 2,2'-azobis(2-amidinopropane) dihydrochloride (AAPH) azoinitiator, and the scavenging activities of the extracts were measured by the inhibition of cis-parinaric acid (PnA) fluorescence decay in SR. Superoxide radicals were generated either by an enzymatic or a non-enzymatic system, and the scavenger ability was evaluated by the inhibition of nitroblue tetrazolium reduction. Methanolic extracts are more potent as scavengers of peroxyl and superoxide radicals than the ethyl ether extracts. Apparently, there is a relationship between antioxidant potency and the total phenolic groups content in each extract.

Elective neck dissection in the treatment of T3/T4 N0 squamous cell carcinoma of the larynx

BACKGROUND

This study analyzed pathologic findings of clinically occult cervical lymph nodes of T3/T4 N0 squamous cell laryngeal carcinoma and their impact on locoregional failures and overall survival.

PATIENTS AND METHODS

A retrospective analysis of 76 patients with T3/T4 N0 laryngeal carcinoma was carried out between 1981 and 1989. Sixty-seven patients had transglottic tumor, 31 patients had extralaryngeal spread, 56 patients were T3 N0, and 20 patients were T4 N0. Seventy-five patients had total laryngectomy and 1 had near total laryngectomy. All patients had bilateral elective neck dissection. The chi-square test was applied to factors related to neck metastasis and locoregional failure. Survival was analyzed using the Kaplan-Meier actuarial method; differences were tested using the Wilcoxon signed-rank test.

RESULTS

Eighteen patients had positive surgical margins. Occult neck metastasis was observed in 30%. Univariate analysis showed that cancer stage and cartilage status were not significant to predict neck metastasis. Locoregional recurrence was observed in 28% of patients. Surgical margins, cervical metastasis, lesion extension, and cartilage invasion had significant impact on disease-free survival. The 5-year overall survival was 52%; disease-free survival was 57%.

CONCLUSION

The elective bilateral neck dissection performed in T3/T4 N0 patients yielded a 30% incidence of occult neck metastasis. Classification of transglottic carcinomas into endolaryngeal and exolaryngeal provides a better parameter for predicting neck metastasis than does T status. Disease-free and overall survival were significantly affected by neck metastasis, T stage, exolaryngeal tumor, cartilage infiltration, and surgical margins.

Supraomohyoid neck dissection in the treatment of T1/T2 squamous cell carcinoma of oral cavity

BACKGROUND

Recent studies in patients with previously untreated T1 and T2 squamous cell carcinoma (SCC) of the tongue and floor of the mouth have shown a relationship between tumor thickness, neck metastasis, and survival. Our study was conducted to determine the indication of elective neck dissection in patients with early oral cavity SCC.

PATIENTS AND METHODS

Sixty-seven patients were stratified by stage (T1 and T2 NO), and those in each stage were randomized to receive one of two types of treatment; resection alone (RA) or resection plus elective supraomohyoid neck dissection (RSOND). Fifty-two patients (78%) were men and 15 (22%) were women. The median age was 57 years old (range 34 to 95).

RESULTS

Twenty-six (39%) patients had tumor in the floor of the mouth and 41 (61%), in the tongue. Using the criteria of the Union Internationale Contre le Cancer (UICC), 1987, we classified 31 tumors (46%) as T1 lesions and 36 (54%) as T2 lesions. Thirty patients had a tumor thickness < or = 4 mm and 37 had a tumor thickness > 4 mm. Thirty-three (49%) patients were treated with RA, and 34 patients (51%) were treated with RSOND. Seven (21%) patients of the RSOND group had occult cervical metastasis. There were recurrences in 14 (42%) patients of the RA group and 8 (24%) patients of the RSOND group. The disease-free survival rates at 3.5 years for RA and RSOND patients were 49%, and 72%, respectively. The impact of sex, age, site, cancer stage, and tumor thickness was assessed by the Mantel-Haenszel chi-square procedure. Later stage (P = 0.05) and increased tumor thickness (P = 0.005) were significantly associated with treatment failures.

CONCLUSION

Neck dissection remains mandatory in the early stage of oral SCC, because of better survival rates compared to RA and the poor salvage rate. In particular, patients with tumor thickness > 4 mm treated with RSOND had significant benefit on disease-free survival.

Two components of carbamylcholine-induced loss of nicotinic acetylcholine receptor function in the neuronal cell line PC12

Loss of responsiveness of the neuronal-type nicotinic acetylcholine receptor (nAChR) on PC12 cells, a cell line derived from a rat pheochromocytoma, was induced by exposure to carbamylcholine (carbachol). Nicotinic receptor function was assessed by carbachol-induced 22Na+ uptake. We found that, in addition to classically described desensitization, a second process occurs which results in a nonrecoverable loss of nAChR activity. This second process, which we have labeled inactivation, has a slower onset than the classically described desensitization (t1/2 = 14.7 min for inactivation and 0.78 min for desensitization at 1 mM carbachol). Inactivation could not be explained by inadequate washing, a loss of electrochemical driving force, or a loss of cell viability. The onset of inactivation is dependent on the concentration of desensitizing ligand and is blocked by nicotinic antagonists. No recovery of the loss of activity from inactivation was observed even after 2 hr of incubation in recovery buffer. Inactivation does not appear to require formation of a desensitized state since desensitization was reduced in the absence of Ca2+ whereas inactivation was not affected by the absence of Ca2+. The mechanism which underlies inactivation remains to be determined; however, it is possible that inactivation is the first step in nAChR down-regulation and it may also explain previous observations of rapid and prolonged tolerance to the effects of nicotinic agonists.

Structure-activity relationship for substance P inhibition of carbamylcholine-stimulated 22Na+ flux in neuronal (PC12) and non-neuronal (BC3H1) cell lines

The inhibition of carbamylcholine-stimulated 22Na+ flux by substance P and various peptide analogs was examined in PC12 cells, a line which contains a neuronal-type nicotinic receptor, and BC3H1 cells, a line which contains a muscle-type nicotinic receptor. Substance P produces a noncompetitive inhibition of carbamylcholine-stimulated 22Na+ influx in both cell lines (IC50 = 1.2 microM on PC12 cells and 8.2 microM on BC3H1 cells). The structure-activity relation for substance P analogs was qualitatively similar in both cell lines; however, there were quantitative differences. Substance P was the most potent peptide tested. Analogs of substance P with amino acids removed from the N-terminus resulted in significant decreases in potency, whereas removal of amino acids from the C-terminus resulted in analogs virtually devoid of activity. Compounds purported to be substance P antagonists had actions similar to substance P in reducing carbamylcholine-stimulated 22Na+ flux. The related tachykinins physalaemin and eledoisin had low potencies on both cell lines. These results indicate that the site through which substance P exerts its inhibitory effects on activation of nicotinic receptors is different from the receptors described previously for substance P in more classical systems. In addition, our results indicate that substance P has an effect on both the neuronal-type nicotinic receptor (alpha-bungarotoxin insensitive) expressed on PC12 cells and the muscle-type nicotinic receptor (alpha-bungarotoxin sensitive) expressed on BC3H1 cells.

Detection of recent cannabis use by saliva delta 9-THC radioimmunoassay

A non-invasive saliva sample delta 9-THC radioimmunoassay has been applied to 352 samples from 25 male and 10 female marijuana users after administration of one-half to two standard cigarettes (27 mg delta 9-THC/cigarette) and 72 control negative subjects who ingested a large variety of foods, condiments, or medications in an attempt to demonstrate interferences. The shortest duration of a positive was 2 hrs and the longest was 5 hrs after administration of the cannabis. No positives occurred in control subjects.

Detection of phencyclidine usage by radioimmunoassay of saliva

Paired serum and saliva samples, obtained from 100 emergency department patients suspected of phencyclidine (PCP) intoxication, were analyzed using a specific PCP radioimmunoassay (RIA). Seventy-four of the 100 saliva samples and 75 of the paired serum samples were positive for PCP. The final clinical diagnosis was PCP intoxication in 79 cases. Of these, both serum and saliva tests were positive in 70 cases, only serum was positive in two cases, and both serum and saliva samples were negative in seven cases. The concentration of PCP in the samples did not correlate with the severity of PCP intoxication. In the remaining 21 cases, with no clinical evidence of PCP intoxication, PCP assays were negative in both serum and saliva in 17 cases, three patients had positive saliva and serum tests, and one other patient had a positive PCP saliva assay. Thus, saliva would appear to be as reliable as serum as a specimen for PCP analysis.

Measurement of delta 9-tetrahydrocannabinol (THC) in whole blood samples from impaired motorists

The major psychoactive cannabinoid in marihuana, delta 9-tetrahydrocannabinol (THC) was measured in 1792 randomly selected blood specimens from erratic motorists arrested for impairment who submitted to blood alcohol sampling. Of these specimens, 14.4% were positive for THC (greater than or equal to 5.5 ng/mL). In those erratic driver specimens negative for alcohol THC positives rose to 23%. Drivers who used marihuana covered a broad age range. Aliquots of hemolyzed blood (10 microL) were analyzed by a sensitive radioimmunoassay (RIA) not requiring extraction. RIA accuracy and specificity were validated by gas liquid chromatography/mass spectroscopy (GLC/MS) split pair analysis (correlation coefficient = 0.93). This initial experience should facilitate and amplify a program designed to set forth the epidemiology of marihuana use in motorists and possible behavioral correlates.

Hemolyzed blood and serum levels of delta 9-THC: effects on the performance of roadside sobriety tests

A pilot study was conducted to ascertain the range of induced hemolyzed blood/serum delta 9-tetrahydrocannabinol (delta 9-THC) concentrations in 58 human subjects. Subjects were tested within 5 min of smoking a delta 9-THC cigarette and then at half-hour intervals to 150 min. The subjects initially demonstrated a broad range of delta 9-THC hemolyzed blood levels, which settled within an hour to levels comparable to those measured in California drivers who had been stopped for impaired driving, arrested, and tested for delta 9-THC. Serum levels, when correlated with performance or roadside sobriety tests, demonstrated a broad range (5 to 183 ng/mL) of delta 9-THC levels and an "adaptation" effect in the subjects' perception of their own impairment. Although this preliminary study was not a double-blind placebo experiment, the overall performance of human subjects demonstrated the "adaptation" effect, which may be a significant factor in making judgments while performing such complex tasks as driving. Also, the effects of the drug extended beyond the period of elevated delta 9-THC blood levels, perhaps because of THC metabolites that may contribute to impairment or the persistence of THC in the central nervous system. This pilot study will lay the groundwork for a program designed to determine the epidemiology and behavior correlates of marijuana use in motorists.

Pregnancy hormone concentrations in marijuana users

The maternal serum concentrations of human chorionic gonadotropin, pregnancy-specific beta-l-glycoprotein, placental lactogen, progesterone, 17-hydroxyprogesterone, estradiol and estriol were measured in 13 women who smoked marijuana regularly throughout pregnancy. Cannabinoid use in these women was confirmed by RIA measurements of their serum delta 9-tetrahydrocannabinol (THC) concentrations. These THC using women were matched within 2 1/2 weeks of gestational age with 13 pregnant non-THC using controls drawn from the same population. Placental protein and steroid hormone concentrations were within established normal ranges for gestational age and there were no significant differences between the groups in the concentrations of any of the protein and steroids measured. In addition, no significant differences between THC users were found following linear regression analysis of placental hormone concentrations as a function of gestational age. Thus, this study suggests that marijuana use during pregnancy does not significantly alter the circulating maternal concentrations of trophoblastic protein hormones or major fetoplacental steroid hormones.

delta 9-Tetrahydrocannabinol by GLC-MS validated radioimmunoassays of hemolyzed blood or serum

A direct radioimmunoassay (RIA) of delta 9-tetrahydrocannabinol (delta 9-THC) in unextracted hemolyzed blood or serum is described. The dose-response curve in the range of 5-50 ng/mL (serum or blood) was linear on log-logit transformation and iterative weighted regression. Validation studies included testing for precision, accuracy and antibody specificity as well as confirmation of RIA results (marijuana smoker samples) by gas liquid chromatography-mass spectroscopy (GLC-MS). This routine method will greatly augment cannabinoid investigative programs.

Evaluation of azoestriol antisera for estriol measurements in pregnancy plasma directly and after extraction

2-(4'-carboxyphenylazo)-estriol antisera were employed to quantitate pregnancy plasma estriol in ether extracts by single phase radioimmune assay without chromatography. Utilizing antiserum which crossreacted minimally even with the monoglucosiduronate metabolites, unextracted plasma estriol measurements were identical statistically to ether extract determinations.