Occurrence of type 1 and type 2 diabetes in patients treated with immunotherapy (anti-PD-1 and/or anti-CTLA-4) for metastatic melanoma: a retrospective study

Abstract

Anti-PD-1 and anti-CTLA-4 antibodies cause immune-related side effects such as autoimmune type 1 diabetes (T1D). It has also been suggested that by increasing TNF-α, IL-2 and IFN-γ production, anti-PD-1 and/or anti-CTLA-4 treatment could affect pancreatic beta cell function and insulin sensitivity. This study was based on a retrospective observational analysis from 2 July 2014 to 27 June 2016, which evaluated the occurrence of T1D and changes in glycemia and C-reactive protein (CRP) plasma concentrations in patients undergoing anti-PD-1 and/or anti-CTLA-4 treatment for melanoma at the Saint Louis Hospital. All cases of T1D that developed during immunotherapy registered in the French Pharmacovigilance Database (FPVD) were also considered. Among the 132 patients included, 3 cases of T1D occurred. For the remaining subjects, blood glucose was not significantly affected by anti-PD-1 treatment, but CRP levels (mg/l) significantly increased during anti-PD-1 treatment (p = 0.017). However, 1 case of type 2 diabetes (T2D) occurred (associated with a longer therapy duration). Moreover, glycemia of patients pretreated (n = 44) or concomitantly treated (n = 8) with anti-CTLA-4 tended to increase during anti-PD-1 therapy (p = 0.068). From the FPVD, we obtained 14 cases of T1D that occurred during immunotherapy and were primarily characterized by the rapidity and severity of onset. In conclusion, in addition to inducing this rare immune-related diabetes condition, anti-PD-1 treatment appears to increase CRP levels, a potential inflammatory trigger of insulin resistance, but without any short-term impact on blood glucose level.

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Nalbuphine as an adjuvant to 0.25% levobupivacaine in ultrasound-guided supraclavicular block provided prolonged sensory block and similar motor block durations (RCT)

Abstract

Purpose

Prolonged postoperative analgesia with early motor recovery for early rehabilitation is a challenge in regional block. The purpose of this study is to evaluate the effect of adding 20 mg nalbuphine to 25 ml of 0.25% levobupivacaine in supraclavicular brachial plexus block.

Methods

One hundred thirty-five (135) patients scheduled for hand and forearm surgeries with supraclavicular block were randomly allocated into three equal groups. Group L received 25 ml of 0.5% levobupivacaine + 1 ml normal saline; group H received 25 ml of 0.25% levobupivacaine + 1 ml normal saline; and group N received 25 ml of 0.25% levobupivacaine + 1 ml (20 mg) nalbuphine. Onset time and duration of sensory and motor block, and time to first analgesic dose were recorded.

Results

Sensory block onset was comparable between the three groups. Motor block onset in group L and group N was comparable (13.16 ± 3.07 and 13.84 ± 3.05 min, respectively) and was shorter than that in group H (15.71 ± 2 0.91 min). Sensory block duration in group L and group N was comparable (522.22 ± 69.57 and 533.78 ± 66.03 min, respectively) and was longer than that in group H (342.67 ± 92.80 min). Motor block duration in group N and group H was comparable (272.00 ± 59.45 and 249.78 ± 66.01 min, respectively) and was shorter than that in group L (334.67 ± 57.90 min). Time to first analgesic dose was significantly longer in group N (649.78 ± 114.76 min) than that of group L and group H (575.56 ± 96.85 and 375.56 ± 84.49 min, respectively) and longer in group L when compared to group H.

Conclusions

Adding 20 mg nalbuphine to 25 ml of 0.25% levobupivacaine in supraclavicular block provided prolonged duration of sensory block with similar duration of motor block.

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Spinal anesthesia for surgery longer than 60 min in infants: experience from the first 2 years of a spinal anesthesia program

Abstract

Purpose

Spinal anesthesia (SA) is being increasingly used in infants to avoid the potential negative neurocognitive effects of general anesthesia (GA). However, SA has been reported to provide a relatively short duration of surgical anesthesia.

Methods

We retrospectively reviewed SA cases for surgical procedures lasting more than 60 min in children up to 3 years old. All patients received bupivacaine 0.5% (1 mg/kg up to 7 mg) with clonidine 1 µg/kg ± epinephrine. The primary outcome was success of SA without subsequent conversion to GA.

Results

Thirty-five patients met inclusion criteria (all males, age 7 ± 5 months, weight 8 ± 2 kg). Procedures included male genital, groin and multiple site surgeries. Average surgical duration was 71 ± 12 min (range 60–111 min). SA was successful in 31 of 35 patients (89%; 95% confidence interval 78, 99%). The cause of failure was rarely due to the duration of surgery (1 of 4 patients). Six patients with successful SA required sedation with dexmedetomidine ± fentanyl. Differences in procedure duration and patient characteristics were not statistically significant between successful and failed SA.

Conclusions

SA is a highly successful technique and may offer an alternative to GA in children undergoing appropriate surgery expected to last as long as 60–100 min.

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Dependent functional status is associated with unplanned postoperative intubation after elective cervical spine surgery: a national registry analysis

Abstract

Purpose

The impact of preoperative functional status on 30-day unplanned postoperative intubation and clinical outcomes among patients who underwent cervical spine surgery is not well-described. We hypothesized that functional dependence is associated with 30-day unplanned postoperative intubation and that among the reintubated cohort, functional dependence is associated with adverse postoperative clinical outcomes after cervical spine surgery.

Methods

Utilizing the 2007–2016 American College of Surgeons National Surgical Quality Improvement Program database, we identified adult elective anterior and posterior cervical spine surgery patients by Current Procedural Terminology codes. We performed (1) a Cox Proportional Hazard analysis for the following outcomes: reintubation, prolonged ventilator use, and pneumonia and (2) an adjusted logistic regression analysis among patients that required postoperative reintubation to evaluate the association of functional status with adverse postoperative outcomes.

Results

The sample size was 26,263, of which 550 (2.1%) were functionally dependent. The adjusted model suggested that when compared with functionally independent patients, dependent patients were at increased risk of unplanned 30-day intubation (HR 2.05, 95% CI 1.26–3.34; P = 0.003). The adjusted risk of 30-day postoperative pneumonia was significantly higher in patients with functional dependence (HR 1.61, 95% CI 1.02–2.54, P = 0.036). Among patients that required postoperative reintubation, the odds of 30-day mortality was significantly higher in patients with functional dependence (OR 5.82, 95% CI 1.59–23.4, P < 0.001).

Conclusion

Preoperative functional dependence is a good marker for estimating postoperative unplanned intubation following cervical spine surgery.

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Infants Are More Likely Than Older Children to Have Surgery for Cervical Infections

Objectives. To identify differences in cervical infection management in infants versus older children. Methods. Charts of patients 0–18 years, diagnosed with a cervical infection at our institution between 2004 and 2015, were included. Age, gender, presenting symptoms, comorbidities, CT scan findings and management including admission, procedures, antibiotics, cultures, length of stay, readmission rates, and complications were included. Results. 239 patients were included: mean age was 4.6 years, with 55.6% boys and 44.4% girls. Mean length of stay was 3.2 days, with no significant difference between age categories. 12.55% were readmitted within 30 days with no significant difference when stratified for age (p = 0.268). The most common presenting symptoms were fever (74.3%), swelling (71.4%), and neck pain (48.2%). Infants had fewer symptoms documented than older children. 51% has lateral neck infections, and these were more common in younger children (p

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Evaluation of external reference levels for central venous pressure measurements of severely obese patients in the supine position

Abstract

Purpose

A proper reference level is important for measuring intracardiac pressures, especially for parameters with small normal values such as central venous pressure (CVP). Although several external zero reference levels (eZRLs) have been proposed for non-obese patients, none has been reported for severely obese patients. The aim of this study was to investigate an appropriate eZRL for CVP measurements of severely obese patients.

Methods

Chest computed tomography images of 65 patients with body mass index (BMI) ≥ 35 kg/m² were retrospectively reviewed. The anteroposterior thoracic diameter and height of the mid-right atrium (RA) were measured. Four reported eZRLs for CVP measurements (midthoracic level, two-thirds and four-fifths of the thoracic diameter above table level, and 5 cm below the anterior thorax) were examined for error when predicting the midpoint of the RA.

Results

The median BMI was 36.9 kg/m² [interquartile range (IQR), 36.0–39.2]. There was a significant difference in the calculated errors for the midpoint of the RA among the four eZRLs (Kruskal–Wallis test, P < 0.001). Two-thirds of the thoracic diameter above table level was the most accurate reference level for CVP measurement (Steel–Dwass post hoc analysis, P < 0.001). The Bland–Altman plot showed acceptable agreement for clinical use (mean difference, − 7 mm; 95% limit of agreement, − 23 to 9 mm).

Conclusion

The most accurate eZRL for CVP measurements of severely obese patients in the supine position was two-thirds of the thoracic diameter above table level. This result is consistent with that of a previous report of non-obese patients.

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Oropharyngeal squamous cell carcinoma induces an innate systemic inflammation, affected by the size of the tumour and the lymph node spread

Clinical Otolaryngology, EarlyView.


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