Acute Pancreatitis

Posted by • November 17th, 2016

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Approximately 80% of patients admitted with acute pancreatitis have mild, self-limited disease and are discharged within several days. Mortality associated with acute pancreatitis has decreased over time, and the overall mortality is now approximately 2%. A new Review Article summarizes recent changes in the management of acute pancreatitis, encompassing fluid resuscitation, antibiotic use, nutritional support, and treatment of necrosis, and also addresses common misunderstandings and areas of controversy.

Clinical Pearl

What are some of the factors that might contribute to unexplained pancreatitis?

The cause of acute pancreatitis often cannot be established, and the proportion of persons who are considered to have idiopathic acute pancreatitis increases with age. A number of potential factors might contribute to unexplained pancreatitis, including unidentified genetic polymorphisms, exposure to smoking and other environmental toxins, and effects of coexisting diseases that are commonly associated with acute pancreatitis (e.g., obesity and diabetes).

Clinical Pearl

What is the role of prophylactic antibiotics in acute pancreatitis?

Although the development of infected pancreatic necrosis confers a significant risk of death, well-designed trials and meta-analyses have shown no benefit of prophylactic antibiotics. Prophylaxis with antibiotic therapy is not recommended for any type of acute pancreatitis unless infection is suspected or has been confirmed.

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Morning Report Questions

Q: Should patients with acute pancreatitis receive enteral or parenteral nutrition? 

A: Total parenteral nutrition is now known to be more expensive, riskier, and no more effective than enteral nutrition in patients with acute pancreatitis. In patients with mild acute pancreatitis who do not have organ failure or necrosis, there is no need for complete resolution of pain or normalization of pancreatic enzyme levels before oral feeding is started. A low-fat soft or solid diet is safe and associated with shorter hospital stays than is a clear-liquid diet with slow advancement to solid foods. Most patients with mild acute pancreatitis can be started on a low-fat diet soon after admission, in the absence of severe pain, nausea, vomiting, and ileus (all of which are unusual in mild cases of acute pancreatitis). A need for artificial enteral feeding may be predicted by day 5, on the basis of symptoms that continue to be severe or an inability to tolerate attempts at oral feeding. Although nasojejunal tube feeding is best for minimizing pancreatic secretion, randomized trials and a meta-analysis have shown that nasogastric or nasoduodenal feeding is clinically equivalent. Total parenteral nutrition should be reserved for the rare cases in which enteral nutrition is not tolerated or nutritional goals are not met. Unfortunately, total parenteral nutrition continues to be used frequently in patients with acute pancreatitis.

Q: What is the risk of recurrent gallstone pancreatitis if cholecystectomy is delayed?

A: Cholecystectomy prevents recurrent gallstone pancreatitis. A delay of cholecystectomy for more than a few weeks places the patient at a high (up to 30%) risk for relapse. Cholecystectomy performed during the initial hospitalization for mild pancreatitis due to gallstones reduces the rate of subsequent gallstone-related complications by almost 75%, as compared with cholecystectomy performed 25 to 30 days after discharge. For patients with severe or necrotizing pancreatitis, cholecystectomy may be delayed in order to address other clinically significant conditions or provide time for the pancreatic inflammation to diminish, allowing for better operative exposure.

Ustekinumab for Crohn’s Disease

Posted by • November 17th, 2016

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In a previous phase 2b trial, intravenous ustekinumab induction therapy in patients with Crohn’s disease that was refractory to treatment with tumor necrosis factor (TNF) antagonists showed a significant benefit in terms of clinical response but not remission, and subcutaneously administered maintenance doses of ustekinumab were efficacious during a period of 22 weeks. Feagan et al. randomly assigned patients to receive a single intravenous dose of ustekinumab (either 130 mg or approximately 6 mg per kilogram of body weight) or placebo in two induction trials. The UNITI-1 trial included 741 patients who met the criteria for primary or secondary nonresponse to TNF antagonists or had unacceptable side effects. The UNITI-2 trial included 628 patients in whom conventional therapy failed or unacceptable side effects occurred. Patients who completed these induction trials then participated in IM-UNITI, in which the 397 patients who had a response to ustekinumab were randomly assigned to receive subcutaneous maintenance injections of 90 mg of ustekinumab (either every 8 weeks or every 12 weeks) or placebo. The research is summarized in a new Original Article.

Clinical Pearl

What are some of the limitations of current therapies for Crohn’s disease?

Crohn’s disease is a chronic inflammatory disease of the gastrointestinal tract that is treated with glucocorticoids, immunosuppressants, TNF antagonists, or integrin inhibitors. The drawbacks of these agents include an increased risk of infection and cancer and limited efficacy.

Clinical Pearl

What is ustekinumab?

Ustekinumab is a monoclonal antibody to the p40 subunit of interleukin-12 and interleukin-23 that has been approved for use in the treatment of psoriasis and psoriatic arthritis. In previous trials involving patients with psoriasis in which ustekinumab was administered subcutaneously for up to 5 years, the drug was not associated with an increased risk of serious adverse events.

Morning Report Questions

Q: Is ustekinumab effective as induction and maintenance therapy in Crohn’s disease?

A: At week 0 in the trial by Feagan et al., patients in both induction trials were randomly assigned, in a 1:1:1 ratio, to receive a single intravenous infusion of 130 mg of ustekinumab, a weight-range–based dose that approximated 6 mg of ustekinumab per kilogram of body weight, or placebo. (The administration of 6 mg of ustekinumab per kilogram meant that patients weighing ≤55 kg received 260 mg, those weighing >55 kg and ≤85 kg received 390 mg, and those weighing >85 kg received 520 mg.) In the maintenance trial, patients who had a response to ustekinumab induction therapy at week 8 were randomly assigned, in a 1:1:1 ratio, to receive subcutaneous injections of 90 mg of ustekinumab every 8 weeks, 90 mg of ustekinumab every 12 weeks, or placebo through week 40. In both induction trials, the primary end point was clinical response at week 6, which was defined as a decrease from baseline in the Crohn’s Disease Activity Index (CDAI) score of at least 100 points or a total CDAI score less than 150. In the maintenance trial, the primary end point was clinical remission at week 44 (CDAI score <150). Both ustekinumab induction regimens showed consistent benefit over placebo, irrespective of previous treatment or response to a TNF antagonist. Ustekinumab was significantly better than placebo with respect to the primary and all major secondary end points for induction at both doses, with the highest rates of response and remission observed with the dose of 6 mg per kilogram. At week 44 of the maintenance trial, among those who had a response to ustekinumab during induction, both subcutaneous ustekinumab doses showed significantly higher efficacy than placebo.

Q: Did the trial by Feagan et al. raise new safety concerns regarding the use of ustekinumab in patients with Crohn’s disease?

A: In the trial by Feagan et al., there were no deaths, and rates of overall adverse events, serious adverse events, and adverse events within 1 hour after infusion occurred at similar rates across groups. The rates of adverse events were similar for subcutaneous maintenance therapy with ustekinumab and placebo, and there was no apparent relationship between dose and safety. The adverse events observed in these trials are consistent with 5 years of cumulative data acquired for patients with psoriasis (who received subcutaneous doses ≤90 mg) and 2 years of safety data for patients with psoriatic arthritis.

Effect of Short-Term vs. Long-Term Blood Storage on Mortality after Transfusion

Posted by • November 16th, 2016

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The FDA currently allows donated units of blood to be stored for 42 days. However, questions remain about whether older blood (within the 42-day limit) is harmful. Laboratory studies have shown that older blood has decreased levels of 2,3-diphosphoglycerate, decreased nitric oxide metabolism, impaired membrane deformability, and increased adherence to the endothelium, all of which theoretically decrease oxygen delivery to tissues. A retrospective study in cardiac surgery patients reported an association between older blood and increased mortality. However, several randomized trials in various patient populations, including pre-term infants and critically ill adults, have not.

In the Informing Fresh versus Old Red Cell Management (INFORM) Trial, published in this week’s NEJM, investigators performed the largest trial to date to assess the effects of the age of transfused blood on patient outcomes. In this study, 20,858 patients requiring blood transfusion in six hospitals across four countries from 2012 to 2015 were randomized to receive either the freshest available blood in the bank (median storage, 11 days) or the oldest blood in the bank (median storage, 23 days). Only patients with the most common blood types, types A and O, were included in the primary analysis because the increased availability of these donated blood units was expected to allow at least a 10-day mean difference between the oldest and freshest blood in the blood banks.

The primary outcome, in-hospital mortality, did not differ between patients who received the freshest blood and those who received the oldest blood (9.1% vs 8.7%, P=0.34). Furthermore, there were no significant mortality differences in three pre-specified high-risk subgroups including patients in the ICU, patients with cancer, and those undergoing cardiothoracic surgery. When these analyses were repeated by blood type, the results were similar.

In an accompanying editorial, Drs. Aaron Tobian and Paul Ness from the Division of Transfusion Medicine at Johns Hopkins University praise the study design for its large size, evaluating many more patients than all previous trials combined and thereby allowing a robust mortality analysis. They also highlight the pragmatic design of the INFORM trial, noting its potential “as a model for other trials” by using electronic data, waived consent, and an easily-assessed outcome (mortality), all of which markedly reduced cost. However, the editorialists caution, “Even though the results of the INFORM trial should end the debate regarding whether short-term or long-term storage of blood is advantageous, the question is still open as to whether the transfusion of red cells during the last week of storage (35 to 42 days) poses more risk than the transfusion of blood stored for shorter intervals.”

The INFORM study answers important questions about outcomes for patients receiving blood transfusions of varying degrees of freshness using a pragmatic trial design. The large number and diversity of patients allows for greater generalizability, and further affirms previous studies that demonstrate no difference in mortality outcomes. John Jarcho, deputy editor at NEJM, noted, “This large trial should really settle the question of whether current storage policies are adequate to maintain the quality of the blood supply.”

wei-koWei Ko is a 4th year medical student at the University of Massachusetts Medical School

Take the Case Challenge: A Man with Acute Liver Injury

Posted by • November 14th, 2016

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A 50-year-old man was admitted to the hospital because of increased levels of aminotransferases, hyperbilirubinemia, anemia, and acute kidney injury. What is the most likely diagnosis?

Read the case description then vote and comment on what you think the diagnosis is. Review the answers in the full text of the case to be published in the November 24 issue and continue following the conversation on Facebook and Twitter with #NEJMCases.

Heart Failure with Preserved Ejection Fraction

Posted by • November 10th, 2016

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Epidemiologic studies indicate that up to 50% of patients with heart failure have a preserved ejection fraction, and this proportion has increased over time. In observational studies, rates of hospitalization and death among patients who have heart failure with a preserved ejection fraction approach those among patients who have heart failure with a reduced ejection fraction, but in clinical-trial populations, outcomes are better in patients who have heart failure with a preserved ejection fraction. Management of heart failure with preserved ejection fraction includes diuretics, treatment of coexisting conditions, aerobic exercise, self-care, and disease management programs, but medications that are effective for reduced ejection fraction have not been beneficial. A new Clinical Practice article explains further.

Clinical Pearl

• How is heart failure with a preserved ejection fraction defined?

In observational studies and clinical trials, the value used to define a “preserved” ejection fraction has ranged from 40 to 55%, but current guidelines recommend a partition value of 50%. An ejection fraction of 40 to 49% is a gray area.

Clinical Pearl

Is the pathophysiology of heart failure with a preserved ejection fraction well understood?

The fundamental pathophysiology perturbation leading to heart failure with a preserved ejection fraction remains incompletely defined, but traditionally it has been attributed to hypertensive left ventricular remodeling. Systemic microvascular endothelial inflammation related to coexisting conditions has been proposed as an additional mechanism leading to myocardial inflammation and fibrosis, increases in oxidative stress, and alterations in cardiomyocyte signaling pathways. These alterations promote cardiomyocyte remodeling and dysfunction as well as microvascular dysfunction and rarefaction in cardiac and skeletal muscle.

Morning Report Questions

Q: Are circulating levels of natriuretic peptides elevated in patients with heart failure and preserved ejection fraction?

A: Ventricular wall stress and thus circulating levels of natriuretic peptides are lower in patients who have heart failure with a preserved ejection fraction than in patients who have heart failure with a reduced ejection fraction. Levels of natriuretic peptides may be normal in up to 30% of patients who have heart failure with a preserved ejection fraction, particularly in those who are obese or have purely exertional symptoms. The higher the natriuretic peptide level, the more likely it is that the patient has heart failure. However, some elderly patients or patients who have atrial fibrillation without heart failure may have natriuretic peptide levels that are similar to those of patients with heart failure.

Q: What is the role of angiotensin antagonists, spironolactone, and beta-blockers in the management of heart failure with a preserved ejection fraction?

A: Since no therapy has been shown to improve outcomes in patients who have heart failure with a preserved ejection fraction, current therapy includes the relief of volume overload (when present), treatment of coexisting conditions, additional strategies that may increase exercise tolerance or reduce symptoms, and strategies to manage chronic disease and prevent hospitalizations. Individually or in a meta-analysis, three randomized trials of angiotensin antagonists (angiotensin-converting–enzyme [ACE] inhibitors or angiotensin-receptor antagonists) involving patients who had heart failure with a preserved ejection fraction did not show significant effects of these agents on composite end points of all-cause or cardiovascular mortality and hospitalizations for heart failure. The mineralocorticoid-receptor antagonist spironolactone did not reduce rates of the primary composite outcome of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for heart failure in these patients. Spironolactone reduced the rate of hospitalization for heart failure but not the rate of death from any cause or hospitalization for any cause, and it increased the rate of renal dysfunction and hyperkalemia. Analyses that were limited to patients who were enrolled in centers in the Americas (which had higher event rates) showed beneficial effects of spironolactone on the composite primary end point, but these post hoc analyses must be interpreted with caution. The effect of beta-blockers in patients with heart failure and a preserved ejection fraction has not been evaluated in an adequately powered study, and the limited available data are conflicting. Thus, the use of angiotensin antagonists and beta-blockers in the treatment of patients who have heart failure with a preserved ejection fraction should be limited to patients who have alternative indications for their use.

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Semaglutide in Patients with Type 2 Diabetes

Posted by • November 10th, 2016

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Regulatory guidance specifies the need to establish cardiovascular safety of new diabetes therapies in patients with type 2 diabetes in order to rule out excess cardiovascular risk. The preapproval Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 Diabetes (SUSTAIN-6) conducted by Marso et al. was designed to assess the noninferiority of semaglutide as compared with placebo in terms of cardiovascular safety in patients with type 2 diabetes. Patients with type 2 diabetes at high cardiovascular risk received either once-weekly semaglutide, a glucagon-like peptide 1 analogue, or placebo. The rate of a first occurrence of cardiovascular death, nonfatal MI, or nonfatal stroke was significantly lower with semaglutide. Research is summarized in a new Original Article.

Clinical Pearl

To what class of drug does semaglutide belong?

Semaglutide, a glucagon-like peptide 1 (GLP-1) analogue with an extended half-life of approximately 1 week (which permits once-weekly subcutaneous administration), is currently in development but not yet approved for the treatment of type 2 diabetes. In the SUSTAIN-6 trial, patients were randomized in a 1:1:1:1 ratio to receive either 0.5 mg or 1.0 mg of once-weekly subcutaneous semaglutide or volume-matched placebo, which maintained blinding within dose.

Clinical Pearl

Is semaglutide noninferior to placebo with respect to cardiovascular safety in patients with type 2 diabetes?

The study by Marso et al. confirmed the authors’ primary hypothesis that semaglutide would be noninferior to placebo. Semaglutide-treated patients had a significant 26% lower risk of the primary composite outcome of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke than did those receiving placebo. This lower risk was principally driven by a significant (39%) decrease in the rate of nonfatal stroke and a nonsignificant (26%) decrease in nonfatal myocardial infarction, with no significant difference in the rate of cardiovascular death. Similar risk reductions were observed with both doses of semaglutide. The number of patients who would need to be treated to prevent one event of the primary outcome over a period of 24 months was 45 on the basis of Kaplan–Meier estimates. The risk reduction for the primary outcome was seen despite an increase in pulse rate, a class effect for GLP-1–receptor agonists.

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Morning Report Questions

Q: Does the use of semaglutide in patients with type 2 diabetes improve microvascular outcomes?

A: In the study by Marso et al., semaglutide-treated patients had a lower risk of new or worsening nephropathy, according to differences in macroalbuminuria, but a higher risk of diabetic retinopathy complications than did those receiving placebo. Although the overall number of retinopathy events was low, there was an unexpected higher rate of retinopathy complications (vitreous hemorrhage, blindness, or the need for treatment with an intravitreal agent or photocoagulation) in the semaglutide group. An association between rapid glucose lowering and worsening of retinopathy has been reported in patients with type 1 diabetes. The applicability of such an association to the finding in SUSTAIN-6 is unclear, and a direct effect of semaglutide cannot be ruled out.

Q: How does semaglutide compare to other GLP-1–receptor agonists?

A: With the exception of complications of retinopathy, semaglutide had a safety profile in SUSTAIN-6 similar to that of other GLP-1–receptor agonists. The rate of malignant neoplasms was similar in the pooled semaglutide group and the pooled placebo group, although the highest rate was observed with the semaglutide dose of 1.0 mg. The rate of pancreatic cancer — an event of interest for this drug class — was lower with semaglutide, and no medullary thyroid carcinomas were reported in this trial. Pancreatitis occurred in low yet similar numbers of patients in the two pooled groups.

Nivolumab for Recurrent Squamous-Cell Carcinoma of the Head and Neck

Posted by • November 9th, 2016

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A 62-year-old man with a history of smoking and excess alcohol use presented with a two-month history of hoarseness and dysphagia and was diagnosed with laryngeal squamous cell carcinoma. Five months after completing concurrent cisplatin and radiation therapy, he returns to his oncologist with lung metastases. He asks about additional therapeutic options for his cancer diagnosis. How would you advise him?

This patient is one of 52,000 people in the United States diagnosed every year with squamous-cell carcinoma of the head and neck (SCCHN). SCCHN is a worldwide condition that arises from squamous cells lining mucosal surfaces of the head and neck. It is associated with alcohol and tobacco use, poor oral hygiene, consuming certain preserved foods, chewing betel nuts, and infection with human papillomavirus or Epstein-Barr virus. Recurrent SCCHN is thought to be driven by immune evasion via tumor expression of ligands (PD-L1) for the immune-checkpoint receptor programmed death-1 (PD-1). Therefore, nivolumab — an anti–PD-1 monoclonal antibody — represents a potential therapeutic candidate. Nivolumab has been approved for treatment of metastatic melanoma, non-small cell lung cancer, and renal cell carcinoma.

In this week’s issue of NEJM, Ferris and colleagues compared the efficacy of nivolumab to single-agent systemic chemotherapy in a phase 3 randomized, controlled, open-label study in 361 patients with recurrent SCCHN whose disease had progressed within six months after platinum-based chemotherapy. Patients in the nivolumab group received intravenous nivolumab (3 mg/kg) every two weeks. Patients in the single-agent chemotherapy group received a weekly dose of intravenous methotrexate (40–60 mg/m2), docetaxel (30–40 mg/m2), or cetuximab (250 mg/m2) after a loading dose of 400 mg/m2. The primary endpoint was overall survival, defined as the time from randomization to date of death from any cause. Secondary endpoints were progression-free survival, objective tumor response based on imaging, safety, and quality of life.

Among the 240 patients who received nivolumab and the 121 patients who received single-agent chemotherapy, median overall survival was significantly longer in the nivolumab group (7.5 vs. 5.1 months; hazard ratio, 0.70; 97.73% CI: 0.51 to 0.96; P=0.010). Progression-free survival did not differ significantly between the two groups. The authors performed an exploratory biomarker analysis to compare the treatment effect in patients based on their tumor PD-L1 expression status and p16 status. Median overall survival was longer with nivolumab, regardless of tumor PD-L1 expression or p16 status.

Nivolumab was associated with fewer severe adverse events than single-agent chemotherapy (13.1% vs. 35.1%). The most frequently reported adverse events with nivolumab were fatigue, rash, pruritus, nausea, and decreased appetite. Nivolumab was associated with more skin-related side effects and fewer gastrointestinal events than single-agent chemotherapy. Serious adverse events in the nivolumab group included one case of pneumonitis and one report of hypercalcemia. Patients in the nivolumab group reported better quality of life (including physical functioning, pain, sensory problems, and social contact problems) than patients in the single-agent chemotherapy group.

In this study, nivolumab led to improved overall survival, fewer severe adverse events, and better quality of life in patients with recurrent SCCHN refractory to platinum-based chemotherapy. Importantly, nivolumab not only extended overall survival but also contributed to better functioning for patients with this aggressive cancer that often affects vital areas of speech and swallowing.

jenniferyehJennifer Yeh is an eighth-year MD/PhD student at Harvard Medical School. She is originally from Los Angeles, CA, and graduated from the Massachusetts Institute of Technology in 2009. She completed her PhD in Biological & Biomedical Sciences in 2015 on molecular modulators of the oncogenic transcription factor STAT3 in the lab of Dr. David Frank.

Ribociclib for HR-Positive Breast Cancer

Posted by • November 3rd, 2016

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Hortobagyi et al. conducted the Mammary Oncology Assessment of LEE011’s (Ribociclib’s) Efficacy and Safety (MONALEESA-2) trial, which evaluated the efficacy and safety of the combination of ribociclib and letrozole as initial therapy in postmenopausal women with hormone-receptor (HR)–positive, human epidermal growth factor 2 (HER2)–negative advanced breast cancer. In patients with advanced HR-positive, HER2-negative breast cancer, the addition of the cyclin-dependent kinase inhibitor ribociclib to letrozole was associated with a significantly higher rate of progression-free survival than placebo. A new Original Article explains.

Clinical Pearl

What percentage of breast cancers are HR-positive?

Up to 75% of breast cancers express the estrogen receptor or progesterone receptor (HR-positive). Endocrine therapy is the standard of care for postmenopausal women with advanced breast cancer that is HR-positive and HER2-negative, with aromatase inhibitors being the preferred first-line treatment option. However, in the majority of patients, resistance to currently available options eventually develops, which requires the administration of sequential therapy with alternative endocrine regimens.

Clinical Pearl

What is ribociclib?

Ribociclib (LEE011) is an orally bioavailable, selective, small-molecule inhibitor of cyclin-dependent kinases 4 and 6 (CDK4/6) that blocks the phosphorylation of retinoblastoma protein, thereby preventing cell-cycle progression and inducing G1 phase arrest. CDK4/6 in conjunction with their protein regulator, cyclin D1 (encoded by CCND1), a direct transcriptional target of estrogen-receptor signaling, are mediators of cell-cycle progression. CDK4/6 overexpression and CCND1 amplification are frequently encountered in HR-positive breast cancers and are key mediators of endocrine resistance. The inhibition of a pathway consisting of cyclin D, CDK4/6, inhibitor of CDK4 (INK4), and retinoblastoma protein is an effective therapeutic strategy for HR-positive advanced breast cancer, both as a first-line option and in patients in whom disease has progressed while they were receiving endocrine therapy.

Morning Report Questions

Q: Does the combination of ribociclib and letrozole increase progression-free survival as compared to letrozole plus placebo when used as first-line therapy for HR-positive advanced breast cancer? 

A: At the prospectively planned interim analysis, the authors of the MONALEESA-2 trial found that postmenopausal women with HR-positive, HER2-negative advanced breast cancer who were receiving first-line treatment with ribociclib plus letrozole had a significantly longer duration of progression-free survival than did those receiving placebo plus letrozole, with a 44% lower relative risk of progression. The duration of progression-free survival was longer in all preplanned patient subgroups receiving ribociclib, including those with newly diagnosed or pretreated metastatic disease and those with or without liver or lung metastases. Further analyses of these subgroups are ongoing. Ribociclib plus letrozole was also associated with significantly higher rates of overall response and clinical benefit than was placebo plus letrozole, a finding that was consistent with observations from an earlier phase 1 trial.

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Q: What are some of the adverse events associated CDK4/6 inhibitors?

A: In the MONALEESA-2 trial, the most common grade 3 or 4 adverse events (≥5% of the patients in either group) were neutropenia (59.3% in the ribociclib group and 0.9% in the placebo group), leukopenia (21.0% and 0.6%, respectively), hypertension (9.9% and 10.9%), increased alanine aminotransferase level (9.3% and 1.2%), lymphopenia (6.9% and 0.9%), and increased aspartate aminotransferase level (5.7% and 1.2%). Hematologic adverse events in the ribociclib group reflected on-target CDK4/6 inhibition, which resulted in reversible bone marrow stem-cell quiescence. Elevations in alanine and aspartate aminotransferase levels have also been observed with other CDK4/6 inhibitors in combination with aromatase inhibitors.

Just a Cut

Posted by • November 3rd, 2016

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Vibrio is a gram-negative rod that is typically found in warm saltwater, although it has been isolated in waters as cold as 17°C. Vibrio infections can rapidly progress to septicemia and death and often require major amputation in patients who survive. A 51-year-old surgeon lacerated his left ring finger near the volar distal interphalangeal joint with a fillet knife while cleaning fish after a late summer day of fishing in coastal New England seawaters. Twelve hours later, he awoke with throbbing pain in his fingertip. A new Clinical Problem-Solving article summarizes the case.

Clinical Pearl

What are the clinical signs of infectious flexor tenosynovitis?

The four so-called Kanavel signs for infectious flexor tenosynovitis include flexor-sheath tenderness, circumferential swelling (a “sausage digit”), pain with passive stretch, and flexed posture. All these signs are not necessarily present in patients with tenosynovitis, particularly in those who present early.

Clinical Pearl

What are some of the pathogens to consider when soft-tissue infection develops in a wound that has been exposed to seawater?

The potential inoculation of seawater necessitates special consideration. Streptococcus iniae, which has been linked to exposure to fish, is a potential pathogen. Waterborne pathogens including aeromonas species and Mycobacterium marinum are associated with skin and soft-tissue infections. Aeromonas can cause severe infection with systemic symptoms; aeromonas is most commonly isolated from fresh or brackish water. M. marinum infection typically manifests as a more subacute or chronic infection rather than as a fulminant infection with systemic symptoms. In contrast, vibrio species, particularly Vibrio vulnificus, can cause rapidly progressive infections.

Morning Report Questions

Q: Which vibrio species are associated with soft-tissue infection, and what patient factors increase the risk of death from such infections?

A: V. vulnificus and V. parahaemolyticus species are most frequently associated with soft-tissue infection. V. vulnificus species account for most severe vibrio infections and the majority of deaths that are attributed to these infections in the United States. V. vulnificus infections can rapidly become fatal, progressing from an initial presentation of cellulitis, tenosynovitis, or necrotizing fasciitis to septicemia and death within 48 to 72 hours. Signs and symptoms of vibrio sepsis and necrotizing fasciitis include fevers and chills, localized severe swelling, rapidly painful cellulitis, purpura, and hemorrhagic bullae. According to CDC epidemiologic surveillance data, the mortality rate is 50% among patients presenting with V. vulnificus septicemia and 15% among those with wound infection without septicemia. Underlying immunosuppression, chronic illness, and liver disease are frequently cited risk factors for poor outcomes with vibrio infection, with liver disease in particular conferring a significant increase in the risk of death from wound infection.

Q: What antibiotics are used to treat V. vulnificus infection?

A: There are no definitive data from humans to guide appropriate antimicrobial therapy for V. vulnificus infection, but in vitro data and data from studies in mice have both shown efficacy with fluoroquinolones and synergistic effects of tetracycline derivatives with third-generation cephalosporins. Ampicillin–sulbactam does not provide adequate coverage for V. vulnificus.

Fulminant Myocarditis with Combination Immune Checkpoint Blockade

Posted by • November 2nd, 2016

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Oncologists and patients with cancer eagerly await new therapies that efficiently target cancer and avoid damage to normal tissues. In 2015, a randomised controlled trial investigated the role of two immune checkpoint inhibitors: ipilimumab — an anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antibody — and nivolumab — an anti-programmed death-1 (PD-1) antibody. Patients with untreated metastatic melanoma were randomized to receive monotherapy with one of the two agents or a combination of both agents. Results from this seminal study showed that nivolumab alone, or in combination with ipilimumab, led to significantly longer progression-free survival, compared to ipilimumab alone. In subgroup analysis, combination therapy was more effective than monotherapy with either agent in PD-L1-negative tumors. Another important study published in the same year confirmed the benefit of combination therapy compared to ipilimumab alone in metastatic melanoma.

In both studies, combination therapy was associated with higher rates of adverse events than monotherapy. Most adverse events were related to inflammation or “-itis” (including dermatitis, hypophysitis, colitis, hepatitis, and pneumonitis) and were managed with high-dose glucocorticoids that were slowly tapered until resolution of symptoms or biochemical abnormalities.

In this week’s NEJM, Johnson and colleagues report two cases of lethal myocarditis accompanied by myositis in patients treated with nivolumab and ipilimumab. Both patients had metastatic melanoma, presented with severe cardiac symptoms within two weeks of the first dose, and had a history of hypertension but no other cardiac risk factors. In both cases, the electrocardiograms were abnormal with progressive and refractory cardiac rhythm instability associated with a rise in cardiac enzymes and creatinine phosphokinase levels. Although one patient was promptly started on high-dose glucocorticoids, she died from multisystem organ failure. The other patient was treated with a temporary pacemaker, glucocorticoids, and infliximab, but he suffered fatal cardiac arrest.

Postmortem analysis of tissue samples confirmed myocarditis and myositis and excluded viral causes. Investigators reviewed the nature of the immune infiltrates in postmortem myocardial and skeletal samples in both patients. T-cell receptor next generation sequencing was used to assess the distribution, clonality, and diversity of the infiltrating lymphocytes in the tumor and damaged tissues. Selective clonal T-cell populations within the myocardium were identical to those detected in the tumor and skeletal muscle, suggesting that the same T-cell clones recognized antigens that were present on the myocardium, skeletal muscle, and tumor. The manufacturer of these agents (Bristol-Myers-Squibb) reviewed the prevalence of myocarditis in their database of more than 20,000 patients and found that combination therapy resulted in myocarditis in 0.27% of cases and myositis in 0.24% of cases.

As we enter the age of immunotherapy, it is important to adopt a multidisciplinary approach to manage toxicities. Cancer therapies such as anthracyclines, radiotherapy, and tyrosine kinase inhibitors have been associated with cardiac toxicity. Immune mediated myocarditis is a concerning adverse event that can present early, with nonspecific symptoms, and can be fatal. Although immune checkpoint inhibitors improve outcomes for patients with metastatic melanoma, clinicians need to be vigilant about recognizing nonspecific symptoms in patients treated with combination immunotherapy.