Incidence risk of PD-1/PD-L1-related pneumonia and diarrhea in non-small cell lung cancer (NSCLC) patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Programmed cell death-1 (PD-1) and programmed cell death ligand-1(PD-L1) inhibitor therapy have been approved for the treatment of many cancers, although their incidence of some side effects was high. We aim to fully investigate the incidence risk of PD-1/PD-L1 inhibitors-related pneumonia and diarrhea in NSCLC patients, as well as treatment-related deaths.

METHODS

PubMed, Medline, Cochrane Library, and Clinical trials.gov databases were searched up to Sep 17, 2020, for clinical trials of PD-1 inhibitors and PD-L1 inhibitors in the treatment of NSCLC. Randomized controlled trials and their references were screened.

RESULTS

Seventeen trials were included in our meta-analysis, including 11,363 patients. PD-1/PD-L1 inhibitors significantly increased the risk of developing all-grade and high-grade (grade ≥ 3) pneumonia (risk ratio [RR] = 2.28; 95% CI: 1.39-3.76; P < 0.01; RR = 2.38; 95% CI: 1.72-3.29; P < 0.01, respectively). The use of PD-1/PD-L1 inhibitor did not increase the risk of developing all-grade and high-grade diarrhea (RR = 0.79; 95% CI: 0.62-1.01; P = 0.06; RR = 0.96; 95% CI: 0.70-1.31; P = 0.78, respectively). There was no significant difference between the rate of death in PD-1 and PD-L1 inhibitors (P = 0.079).

CONCLUSION

These data suggest that PD-1/PD-L1 inhibitors significantly increase the risk of all-grade and high-grade pneumonia in NSCLC patients and PD-1/PD-L1 monotherapy increases the risk of all-grade pneumonia in NSCLC patients compared to PD-1/PD-L1 inhibitor combination regimens. Physicians should pay more attention to NSCLC patients who treated with PD-1/PD-L1 inhibitors.

Severe acute malnutrition and infection

Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.

Thoracopulmonary actinomycosis, a case report of a 42-year-old man with coughing and a bump in his right axilla

The diagnosis of thoracopulmonary actinomycosis is challenging because it is a rare disease, symptoms are aspecific and can mimic a lot of other lung pathologies. Especially the differential diagnosis with pulmonary tuberculosis is difficult because clinical symptoms are often very similar. We present a case of thoracopulmonary abcedating actinomycosis in a young immunocompetent man with no predisposing illness. He was initially treated for pulmonary tuberculosis. He showed good response to IV penicillin, which was later switched to oral amoxicillin when he went home.

Determining the quality of IMCI pneumonia care in Malawian children

BACKGROUND

Although pneumonia is the leading cause of child mortality worldwide, little is known about the quality of routine pneumonia care in high burden settings like Malawi that utilize World Health Organization's Integrated Management of Childhood Illnesses (IMCI) guidelines. Due to severe human resource constraints, the majority of clinical care in Malawi is delivered by non-physician clinicians called Clinical Officers (COs).

AIM

To assess the quality of child pneumonia care delivered by Malawian COs in routine care conditions.

METHODS

At an outpatient district-level clinic in Lilongwe, Malawi, 10 COs caring for 695 children who presented with fever, cough, or difficulty breathing were compared to IMCI pneumonia diagnostic and treatment guidelines.

RESULTS

Fewer than 1% of patients received an evaluation by COs that included all 16 elements of the history and physical examination. The respiratory rate was only determined in 16.1% of patients presenting with cough or difficulty breathing. Of the 274 children with IMCI-defined pneumonia, COs correctly diagnosed 30%, and administered correct pneumonia care in less than 25%. COs failed to hospitalize 40.8% of children with severe or very severe pneumonia.

CONCLUSIONS

IMCI pneumonia care quality at this Malawian government clinic is alarmingly low. Along with reassessing current pneumonia training and supervision approaches, novel quality improvement interventions are necessary to improve care.

CPAP: a guide for clinicians in developing countries

Despite the provision of oxygen, antibiotics and treatment guidelines, the case fatality rate for hypoxaemic pneumonia is still high in many hospitals in developing countries. Methods of delivering continuous positive airway pressure (CPAP) are now available which are simple to use, safe and relatively inexpensive. This paper describes two methods which may be appropriate where resources are limited: (i) bubble-CPAP using oxygen concentrators with an air-oxygen mix function and low resistance nasal oxygen prongs, and (ii) high-flow nasal cannula oxygen therapy. More research is needed on the implementation, cost and effectiveness of CPAP in the management of pneumonia and in neonatal care in developing countries.

Moxifloxacin in lower respiratory tract infections: in silico simulation of different bacterial resistance and drug exposure scenarios

Moxifloxacin has potent bactericidal activity against Streptococcus pneumoniae; a major causative organism of lower respiratory tract infections. This study aims to use the pharmacokinetic/pharmacodynamic indices to predict the therapeutic outcome under different scenarios of moxifloxacin exposure and pneumococcal resistance. STELLA(®) software was used to simulate the pharmacokinetics and pharmacodynamics of moxifloxacin in patients with severe pneumonia and acute exacerbations of chronic bronchitis (AECB). The current dose of moxifloxacin was found to be insufficient for eradication of ciprofloxacin resistant bacteria in ventilated patients with severe bronchopneumonia. This can be attributed to the lower tissue penetration observed in this population. Increasing the dose to 600 mg was able to achieve higher levels of free drug AUC/MIC in both bronchial and plasma compartments. In AECB, moxifloxacin achieved the same AUC/MIC values observed in pneumonia at the different MIC values. This may allow the extrapolation of findings of moxifloxacin studies in pneumonia to the management of patients with AECB.