Impact of Synchronous versus Metachronous Metastasis on Outcomes in Patients with Metastatic Renal Cell Carcinoma Treated with First-line Immune Checkpoint Inhibitor-based Combinations

BACKGROUND AND OBJECTIVE

The impact of time of metastasis onset with respect toprimary renal cell carcinoma (RCC) diagnosis on survival outcomes is not well characterized in the era of immune checkpoint inhibitor (ICI)-based combinations. Herein, we assessed differences in clinical outcomes between synchronous and metachronous metastatic RCC (mRCC).

METHODS

Data for patients with mRCC treated with first-line ICI-based combination therapies between 2014 and 2023 were retrospectively collected. Patients were categorized as having synchronous metastasis if present within 3 mo of RCC diagnosis; metachronous metastasis was defined as metastasis >3 mo after primary diagnosis. Time to treatment failure (TTF), overall survival (OS), and the disease control rate (DCR) were assessed.

KEY FINDINGS AND LIMITATIONS

Our analysis included 223 eligible patients (126 synchronous and 97 metachronous). Median TTF did not significantly differ between the synchronous and metachronous groups (9 vs 19.8 mo; p = 0.063). Median OS was significantly shorter in the synchronous group (28.0 vs 50.9 mo; p = 0.001). Similarly, patients with synchronous metachronous metastasis (58.7% vs. 78.4%; p = 0.002). On multivariable analyses, synchronous metastasis remained independently associated with worse OS and DCR.

CONCLUSIONS AND CLINICAL IMPLICATIONS

In this hypothesis-generating study, patients with mRCC with synchronous metastasis who were treated with first-line ICI-based combinations have a poorer OS and worse DCR than those with metachronous mRCC. If these results are externally validated, time to metastasis could be included in prognostic models for mRCC.

PATIENT SUMMARY

Our study demonstrates that patients treated with current first-line immunotherapies, who present with metastasis at the initial diagnosis of kidney cancer have worse overall survival compared to those who develop metastasis later. These results can help physicians and patients understand life expectancy.

Real-World Outcomes of Latinx Versus Non-Latinx Patients Treated With First-Line Immunotherapy for Metastatic Renal-Cell Carcinoma

BACKGROUND

There are limited data regarding the impact of ethnicity among patients receiving immune checkpoint inhibitors. We evaluated real-world outcomes between Latinx and non-Latinx patients with metastatic renal-cell carcinoma (mRCC) treated with first-line nivolumab/ipilimumab within 2 different healthcare settings.

METHODS

We performed a retrospective analysis of patients with mRCC who received nivolumab/ipilimumab within the Los Angeles County Department of Health Services (LAC-DHS), a safety-net healthcare system, and the City of Hope Comprehensive Cancer Center (COH), a tertiary oncology center, between January 1, 2015 and December 31, 2021. Progression-free survival (PFS) and overall survival (OS) were determined using the Kaplan-Meier method and covariates were adjusted using multivariate Cox proportional hazards regression.

RESULTS

Of 94 patients, 40 patients (43%) were Latinx while the remainder were non-Latinx (44 pts [46%] White, 7 pts [7%] Asian, and 3 pts [3%] Other). Fifty (53%) and 44 (47%) patients received their care at COH and LAC-DHS, respectively. Most Latinx patients (95%) were treated at LAC-DHS, and most non-Latinx patients (89%) were treated at COH. Pooled analysis by ethnicity demonstrated significantly shorter PFS in Latinx versus non-Latinx patients (10.1 vs. 25.2 months, hazard ratios [HR] 3.61, 95% CI 1.96-6.66, P ≤ .01). Multivariate analysis revealed a HR of 3.41 (95% CI 1.31-8.84; P = .01). At a median follow-up of 11.0 months, the median OS was not reached in either arm at the time of data cutoff.

CONCLUSION

Latinx patients with mRCC had a shorter PFS treated with frontline nivolumab/ipilimumab compared to their non-Latinx counterparts. No difference was observed in OS although these data were immature. Larger studies are needed to further interrogate the social and economic determinants of ethnicity on clinical outcomes in mRCC.

Changes in Perception of Cure Among Patients With Genitourinary Cancers Initiating Immune Checkpoint Inhibitors: A Longitudinal Study

BACKGROUND

We explored changes in perceptions of cure among patients with genitourinary (GU) cancers starting Immune checkpoint inhibitors (ICIs) therapy.

MATERIALS AND METHODS

This longitudinal study assessed patients before starting therapy and 3-months later with a questionnaire that included patient perceptions of ICIs and the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety scale. General linear modeling was used to investigate changes in expectation of cure over time, and chi-square tests were used to determine the association between expectation of cure and perceptions of ICIs and anxiety.

RESULTS

A total of 45 patients were recruited (73% male, 84% diagnosed with renal cell carcinoma). The proportion of patients who possessed an accurate expectation of cure increased over time (55.6%-66.7%, P = .001). An accurate expectation of cure was associated with lower rates of anxiety over time. Patients with inaccurate expectation of cure reported more severe side effects and worse self-reported ECOG score at the follow-up assessment (P = .04).

CONCLUSION

We found that patients with GU metastatic cancer treated with ICI therapy have increasingly accurate expectations of cure over time. Accurate expectation of cure is associated with decreased anxiety. Further research is needed to fully explore this dynamic over time and help inform interventions that can help patients develop accurate expectations.

Procedure to explore a ternary mixture diagram to find the appropriate gradient profile in liquid chromatography with fluorescence detector. Application to determine four primary aromatic amines in napkins

The purpose of this work is to develop a tool to search for a gradient profile with ternary or binary mixtures in liquid chromatography, that can provide well-resolved chromatograms in the shortest time for multianalyte analysis. This approach is based exclusively on experimental data and does not require a retention time model of the compounds to be separated. The methodology has been applied for the quantification of four primary aromatic amines (PAAs) using HPLC with fluorescence detector (FLD). Aniline (ANL), 2,4-diaminotoluene (TDA), 4,4'-methylenedianiline (MDA) and 2-aminobiphenyl (ABP) have been selected since their importance in food contact materials (FCM). In order to achieve that, partial least squares (PLS) models have been fitted to relate CMP (control method parameters) and CQA (critical quality attributes). Specifically, PLS models have been fitted using 30 experiments for each one of the four CQA (resolution between peaks and total elution time), considering 33 predictor variables (the composition of the methanol and acetonitrile in the mobile phase and the time of each one of the 11 isocratic segments of the gradient). These models have been used to predict new candidate gradients, and then, some of those predictions (the ones with resolutions above 1.5, in absolute value, and final time lower than 20 min) have been experimentally validated. Detection capability of the method has been evaluated obtaining 1.8, 189.4, 28.8 and 3.0 µg L^-1 for ANL, TDA, MDA and ABP, respectively. Finally, the application of chemometric tools like PARAFAC2 allowed the accurate quantification of ANL, TDA, MDA and ABP in paper napkins in the presence of other interfering substances coextracted in the sample preparation process. ANL has been detected in the three napkins analysed in quantities between 33.5 and 619.3 µg L^-1, while TDA is present in only two napkins in quantities between 725.9 and 1908 µg L^-1. In every case, the amount of PAAs found, exceeded the migration limits established in European regulations.

Characteristics associated with common reasons to pursue genomic profiling among patients with metastatic genitourinary cancers

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Background: Patients with cancer may possess limited knowledge of emerging modalities in oncology, including genomic profiling (GP) tests, which can create barriers to shared decision making. Effective provider communication can address such barriers but little is understood regarding patients’ perceptions of GP. Methods: In this cross-sectional study, patients who were diagnosed with advanced genitourinary cancers (bladder, renal, and prostate cancers), and were referred for GP responded to a survey to assess reasons to pursue such testing. Clinicopathologic characteristics were collected via chart review. Kolmogorov-Smirnov tests were used to assess associations between reasons to pursue GP and patient characteristics. Results: Data was obtained from a sample of 126 patients (gender: 75% M, 25% F; average age: 67; marital status: 78% married; education: 76% some college; histology: 67% renal cell carcinoma, 19% urothelial, and 14% prostate). The most common reasons to pursue GP by patient response were: to guide treatment (73%), to improve treatment response (32%), to follow physician’s indication (27%), to predict treatment response (23%), to learn about their disease (19%), and to contribute to the science (12%). Notably, older age was significantly associated with three reasons (guide treatment, P = 0.001; physician’s indication, P = 0.03; contribute to the science, P = 0.001). No association was found among younger patients. A higher level of education was associated with the desire to guide treatment (P = 0.001). In contrast, a lower level of education was associated with physician’s indication (P = 0.002). Conclusions: This study highlights important associations between reasons to pursue GP and age and level of education. Differing strategies for information delivery could be considered when communicating GP benefits to older patients and to patients with lower levels of education.

Changes in perception of immunotherapy over time among patients with advanced genitourinary cancers

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Background: Previous studies have shown that a significant proportion of patients with metastatic genitourinary cancers harbor inaccurate expectations of cure prior to starting treatment with immunotherapy. This study sought to compare changes in perceptions of immunotherapy reported before, and three months after, the start of therapy, as well as treatment side-effects and quality of life. Methods: This longitudinal study enrolled patients diagnosed with advanced genitourinary cancers (bladder, renal, and prostate cancers) prior to commencing immunotherapy. Patients’ perceptions were assessed prior to starting treatment (T0) and three months later (T1). Patients responded to the same survey at both time points assessing expectations of side effects, clinical outcomes (expectation of cure) and quality of life (Functional Assessment of Chronic Illness Therapy-General). Results: Among the 30 patients enrolled, the median age was 67 years old (range, 44-91); most were male (70%), married (80%), and well-educated (70%). Renal cell carcinoma (70%) was the most common form of cancer. Before starting immunotherapy (T0), patients expected (1) fewer side effects (83%) compared with other types of cancer treatment, (2) great efficacy in preventing tumor progression (90%). and (3) increased survival (90%). Notably, the expectation of cure with immunotherapy treatment had changed over time (T0 = 24% vs T1 = 7%; P = 0.001) and overall quality of life had increased (median at T0 = 90 vs T1 = 98; P = 0.01). Three months into treatment (T1), patients perceived themselves as less active (T0 = 70% vs T1 = 63%; P = 0.02), however just 16% reported severe side effects, including fatigue (10%) and diarrhea (10%). In general, patients were satisfied with the management of these side effects (60%). The majority of patients perceived improvement in their condition (50%) and were satisfied with their treatment (60%). Conclusions: This longitudinal study suggests that inaccurate perceptions of cure with immunotherapy may recede over time, with an increased proportion of patients estimating a more accurate (and lower) chance of cure after 3 months of treatment. Patients also reported improved quality of life despite these adjusted expectations of cure.

Comparison of Two Extubation Techniques in Critically Ill Adult Subjects: The ExtubAR Randomized Clinical Trial

BACKGROUND

Two orotracheal extubation techniques are described in the literature: the traditional technique and the positive-pressure technique. Although prior studies reported better clinical outcomes with the positive-pressure extubation technique, its superiority has not been extensively studied yet. This study was to determine whether the positive-pressure orotracheal extubation technique, compared with the traditional orotracheal extubation technique, reduces the incidence of major postextubation complications (up to 60 min) in critically ill adult subjects.

METHODS

This was a multi-center randomized clinical trial. Subjects age > 18 y, requiring invasive mechanical ventilation through an endotracheal tube, who met the orotracheal extubation criteria were included and randomized to traditional extubation group (removing the endotracheal tube by applying continuous endotracheal suctioning during the entire procedure) or positive-pressure group (application of pressure support mode at 15/10 cm H₂O during cuff deflation and extubation). The primary measure was postextubation major complications, defined as the clinical evidence of at least one of the following: desaturation, upper-airway obstruction, or vomiting.

RESULTS

A total of 725 subjects was randomly assigned to the traditional extubation group (n = 358) and positive-pressure group (n = 367). Seventeen subjects were eliminated and not included in the per-protocol analysis. Of 708 subjects, 185 (26.1%) developed at least one major complication. The incidence was 27.8% (96/345) in the traditional group compared with 24.5% (89/363) in the positive-pressure group. No statistically significant differences were observed between the 2 groups (absolute risk 3% [95 CI -3 to 10]; relative risk, 0.88 [95 CI 0.69-1.13], P = .32).

CONCLUSIONS

Despite the trend toward the positive-pressure group, no statistically significant differences were observed. Our findings agree with the literature in that positive-pressure extubation is a safe procedure; therefore, both techniques may be used during extubation in critically ill adult patients.

Subjective versus objective determination of bladder emptying following urogynecological surgery: "do you feel that you completely emptied your bladder?"

INTRODUCTION AND HYPOTHESIS

We tested the hypothesis that women can subjectively determine if they have emptied their bladder after a spontaneous voiding attempt following urogynecological surgery to rule out post-operative urinary retention as determined by a voiding trial.

METHODS

This is a prospective observational study of women undergoing urogynecological surgery at two academic institutions from June 2016 to March 2019. Following surgery, subjects underwent a voiding trial followed by measurement of the PVR via ultrasound bladder scan or straight catheterization. A successful voiding trial was defined as a PVR of ≤150 ml. Subjects were queried about their subjective sensation of bladder emptying; "Do you feel that you completely emptied your bladder?" Their responses were either "Yes", "No" or "I don't know". Their subjective responses were correlated with the voiding trial results using a Chi-squared analysis for sensitivity, specificity, and positive (PPV) and negative predictive values (NPV).

RESULTS

A total of 266 subjects were included in the final evaluation. The screening subjective question had a sensitivity of 85.7% (CI 71.46 to 94.57%), a specificity of 91.5% (CI 87.01 to 94.79%), a PPV of 65.4% (CI 54.78 to 74.77%), and an NPV of 97.14% (CI 94.18 to 98.62%) to detect a failed voiding trial.

CONCLUSIONS

The NPV of the subjective question regarding bladder emptying in the post-operative urogynecological setting is high at >97%, suggesting that it might be reasonable to forgo a formal voiding trial in patients who subjectively feel that they have emptied their bladder.

Immune gene expression in gilthead seabream (Sparus aurata) after Lymphocystis disease virus (LCDV-Sa) challenge resulting in asymptomatic infection

AIMS

To determine the immune gene expression response of gilthead seabream (Sparus aurata) that is experimentally infected with the lymphocystivirus LCDV-Sa.

METHODS AND RESULTS

Viral DNA and transcripts were detected by qPCR in all samples from fish injected with LCDV-Sa, demonstrating that the virus establish a systemic and asymptomatic infection. The expression of 23 immune-related genes was also analysed by RT-qPCR in the head kidney (HK) and intestine at several times post-infection (dpi). In HK, the expression of five type I interferon (IFN)-related genes (ifn, irf3, mx2, mx3 and isg15), il10 and ck10 was upregulated at 1-3 dpi, while genes related to the inflammation process (tnfα, il1ß, il6, casp1) were not differentially expressed or even downregulated. The expression profile in the intestine was different regarding type I INF-related genes. An upregulated c3 and ighm expression was observed in both HK and intestine at 3-8 dpi. Finally, the transcription of nccrp1 and mhcIIα was induced in HK, whereas tcrβ expression was downregulated in both organs.

CONCLUSIONS

LCDV-Sa seems to trigger an immune response in gilthead seabream characterized by a partial activation of type I IFN system and a lack of systemic inflammatory response which may be related to viral persistence.

SIGNIFICANCE AND IMPACT OF THE STUDY

The immune response observed in gilthead seabream infected by LCDV-Sa could be implicated in the establishment of an asymptomatic persistent infection.

Addressing the impact of mercury estuarine contamination in the European eel (Anguilla anguilla L., 1758) - An early diagnosis in glass eel stage based on erythrocytic nuclear morphology

The decline of the European eel (Anguilla anguilla L., 1758) population throughout Europe has been partially attributed to pollution. As glass eel estuarine migration may represent a considerable threat, the impact of mercury (Hg) contamination at this stage was evaluated through an in situ experiment (7days). Total Hg (tHg) bioaccumulation was evaluated concomitantly with erythrocytic nuclear morphology alterations: erythrocytic nuclear abnormalities assay (ENA), frequency of immature erythrocytes (IE) and the erythrocytic maturity index (EMI). The ENA results suggested a genotoxic pressure at the most contaminated sites, in line with the tHg increase. The EMI data, together with IE frequency, showed that fish exposed to high levels of Hg exhibited alterations of haematological dynamics, translated into an erythropoiesis increment. Despite the presence of these compensatory mechanisms, the present findings suggest a harmful impact of Hg on genome integrity at this early development stage, potentially affecting eels' condition and ultimately the population sustainability.

Search and analysis of genes involved in antibiotic resistance in Chilean strains of Piscirickettsia salmonis

Piscirickettsia salmonis is the pathogen causing Piscirickettsiosis. For treatment, the industry mainly uses oxytetracycline and florfenicol, so it is essential to understand the degree of susceptibility of this pathogen to these drugs. But this is still unknown for a large number of P. salmonis strains, as are the molecular mechanisms responsible for greater or lesser susceptibility. However, genes that confer resistance to these antimicrobials have been reported and characterized for this and other bacterial species, among which are membrane proteins that take out the drug. Our results identified differences in the degree of susceptibility to both antibiotics among different Chilean isolated of these bacteria. We analysed 10 available genomes in our laboratory and identified ~140 genes likely to be involved in antibiotic resistance. We analysed six specific genes, which suggests that some of them would eventually be relevant in conferring resistance to both antibiotics, as they encode for specific transporter proteins, which increase the number of transcripts when grown in media with these antibiotics. Our results were corroborated with EtBr permeability analysis, which revealed that the LF-89 strain accumulates this compound and has a reduced capacity to expulse it compared with the field strains.

Comparing the burden of illness of haemophilia between resource-constrained and unconstrained countries: the São Paulo-Toronto Hemophilia Study

INTRODUCTION

Although the regular replacement of clotting factor concentrates (prophylaxis) has been well established as the standard of care for severe haemophilia, the high cost of factor concentrates has limited access to prophylaxis in countries with under-developed or developing economies.

AIMS

We studied the health gap that could be addressed by providing unlimited access to clotting factor concentrates with implementation of long-term prophylaxis initiated from an early age in life.

METHODS

We performed a cross-sectional study of a random, representative sample of boys with moderate and severe haemophilia at three haemophilia treatment centres in Sao Paulo, Brazil, and one centre in Toronto, Canada.

RESULTS

Canadian subjects were more often treated with prophylaxis, and began treatment at an earlier age. Fewer Canadian subjects had bleeds within the preceding 6 months (19 vs. 34, P = 0.003). Canadian subjects had lower (better) Pettersson radiographic scores (1.5 vs. 6.0, P = 0.0016), lower (better) Hemophilia Joint Health Scores (5.5 vs. 10.5, P = 0.0038), higher (better) Activity Scale for Kids scores (96.6 vs. 92.0, P = 0.033), more time spent in vigorous activity, and higher (better) social participation scores.

CONCLUSIONS

Our findings suggest that increasing access to clotting factor concentrates for young boys with severe haemophilia is a global imperative.

[Early child development inequalities and associated factors between public and private providers at metropolitan region in Chile]

Early child development is a population determinant of physical, mental and social health. To know the base line situation prior to the implementation of "Chile grows with you" (Chile Crece Contigo) is key to its evaluation.

OBJECTIVE

To compare early child development and associated factors at baseline in pre-school children from public and private health sectors.

PATIENTS AND METHOD

The sample consisted of 1045 children aged 30-58 months, 52% male, and 671 from the public and 380 from the private sector of the metropolitan region in Chile were evaluated using Battelle Developmental Inventory-1 and a household interview of primary carer.

RESULTS

Abnormal child development was found in 14.4% of children in the private sector compared to 30.4% in the public sector. There were no differences in adaptive area (26.3% vs 29.2%), but there were statistically significant differents in cognitive (8.8% vs 12.1%), social-personal (13.2% vs 32.5%), motor (19.2% vs 35.3%), and communication (19% vs 36.8%) development. The logistic regression showed that, independent of socioeconomic level, the risk factors are: Apgar<7 (OR: 5.4; 95% CI: 1.24-23.84); having childhood chronic diseases (OR: 1.3; 95% CI: 1.11-1.42). Protective factor is: home with resources to learn and play (OR: 0.8; 95% CI: 0.76-0.89).

CONCLUSION

These results are another input about early child development situation and its importance for paediatric social policy.

Deshidratación osmótica de guayaba a vacío pulsante / Pulse vacuum osmotic dehydration of guava

An empirical model to predict the effect of temperature (T, 30-70 °C), exposure time at atmos pheric pressure ( t, 5-105 min) and the number of pulse vacuum cycles ( n, 1-5) during the osmotic dehydration of guavas on weight loss (δ P), water loss (δ W) and solids gain (δ S) was studied in the laboratory. Results show that the three evaluated parameters T, t and n, significantly affect δ P and δ W values. No effect on fruit δ S values was observed.

Feeling like a stranger: negotiations with culture as experienced by Chilean occupational therapists

BACKGROUND

Although occupational therapy has begun to focus on the subject of culture, few studies have examined how occupational therapists outside the English-speaking countries reflect on it.

AIM

To explore how Chilean occupational therapists reflect on their personal and professional experiences in regard to the complexity of culture, and its different understandings and expressions.

METHODS

This qualitative study uses content analysis to establish common trends in participants' experiences. A validation phase and data triangulation were implemented to ensure trustworthiness.

RESULTS

Culture is experienced as a continuous negotiation in personal and professional terms. One central theme, 'negotiating through the dynamism of culture', and three categories, 'dealing with power', 'understanding local and global identities', and 'crossing the boundaries into the client's land', emerged. These experiences are complex, chaotic, and highly context-dependent.

DISCUSSION

During therapeutic encounters, practitioners and clients may experience cultural barriers even if their differences are not obvious in cultural terms. As a result of this finding, we recommend the inclusion of culture and cultural issues in professional training. The impact of a multicultural research team is discussed. Future research should explore how the construct of culture is introduced in occupational therapy professional training in Chile.

Development of a Cultural Awareness Scale for Occupational Therapy Students in Latin America: A Qualitative Delphi Study

Cultural awareness is a key issue in healthcare worldwide. Valid and reliable assessments are needed to assess cultural awareness for occupational therapy students. The purpose of this study was to develop a scale to assess cultural awareness for Latin American occupational therapy students. A Delphi design was implemented considering four rounds with experts from four countries. A 30-item scale in Spanish was developed to assess three categories of items: personal, therapeutic strategies and persons' cultures. The experts highlighted local features for professional practice as a key aspect of the scale. Local differences in practice were considered with the profession's traditions and prevailing knowledge across the scale. A participatory strategy and an international group of experts enriched the cultural relevance. A subsequent study of statistical reliability is required (the scale is not presented in an extended version here). Further research should consider the application of the scale and strategies to improve cultural awareness across the curricula. Copyright © 2016 John Wiley & Sons, Ltd.

Association of glycaemia with perceived threat of illness in patients with type 2 diabetes

BACKGROUND

It is essential to reach glycaemic control in patients with diabetes mellitus to prevent reduced life expectancy and morbidity related to complications. The aim of this study was to determine whether glycaemic control is associated with the perception of illness in type II diabetes mellitus.

METHODOLOGY

Illness perception was assessed in a sample of 242 diabetics attending a Family Health Centre in Chile using the Brief Illness Perception Questionnaire (BIPQ). We considered well-controlled individuals to have glycated haemoglobin below 7%, and we assessed association with the BIPQ score. The data were analysed by logistic regression.

RESULTS

The total BIPQ score was significantly higher (more negative perception) in non-controlled individuals; the most significant differences were found in the following dimensions: consequences (p=0.0003), personal control (p=0.0392), identity (p=0.0006) and emotional affection (p=0.018). The dimensions of timeline, treatment control, concern and coherence showed no differences between the groups. The mean age of well-controlled subjects was significantly higher than the age of non-controlled diabetics. Well-controlled patients had been diagnosed with diabetes for significantly fewer years than had those that were not.

CONCLUSIONS

Perceiving illness as more negative (BIPQ score >37) is highly associated with being a non-controlled diabetic, with more consequences over their daily life, less control over the disease and a higher number of attributable symptoms. When control variables are considered, a negative perception of diabetes has an adjusted OR of 2.14 (CI 95% 1.17-3.92) to have glycated haemoglobin above 7%.