Improved outcomes with early immunosuppression in patients with immune-checkpoint inhibitor induced myasthenia gravis, myocarditis and myositis: a case series.

PURPOSE: Myasthenia gravis (MG) is a rare but life-threatening complication of immune-checkpoint inhibitor (ICI) therapy and often co-presents with myositis and myocarditis. Previous case series of ICI-related MG have reported high mortality rates. We present a series of ten patients from a tertiary oncology centre outlining outcomes of an early multi-modal immunosuppression strategy. METHODS: We reviewed The Christie Hospital database of immunotherapy-related toxicity from 2017 to 2020. Symptom severity was assessed using the Myasthenia Gravis Foundation of America (MGFA) classification. RESULTS: Ten patients with ICI-related MG were identified. All patients presented following 1 (n = 4) or 2 (n = 6) cycles of ICI. Symptom progression was rapid with a median of 3 days from onset of symptoms to admission. Concomitant myositis and myocarditis were observed in nine patients. AChR or MuSK autoantibodies were positive in six patients. All patients received urgent treatment with intravenous methylprednisolone (IVMP) and eight received intravenous immunoglobulin (IVIG). A single patient died from myasthenia-related symptoms; the remaining 9 patients were successfully discharged. CONCLUSION: In our cohort, we demonstrate good outcomes associated with early intensive immunosuppressive treatment with IVIG and IVMP. An agreed national treatment protocol or clinical discussion forum would be beneficial.

Emergency Presentations of Immune Checkpoint Inhibitor-Related Endocrinopathies.

BACKGROUND: Immune checkpoint inhibitors (ICI) are an important component of anticancer treatment, with indications across an increasing range of oncological diagnoses. ICIs are associated with a range of immune-mediated toxicities. Immune-related endocrinopathies pose a distinct challenge, given the nonspecific symptom profile and potentially life-threatening sequelae if not recognized. OBJECTIVES: To determine the frequency and clinical presentations of immune-mediated endocrinopathies in patients treated with ICIs presenting as emergencies. METHODS: A prospective observational cohort study was undertaken at a specialist oncology hospital in North West England from May 20, 2018 to May 19, 2020. Within the hospital, the Oncology Assessment Unit (OAU) acts as the receiving unit in which assessments are undertaken of all emergency presentations. All patients treated with ICIs presenting to the OAU were included. The primary outcome was diagnosis of an immune-mediated endocrinopathy. Length of inpatient stay, and 7- and 30-day mortality rates were examined. RESULTS: During the study period, 684 patients treated with ICIs presented to the OAU. Twenty-four (3.5%) patients had an acute immune-mediated endocrinopathy, of which 17 had hypophysitis, 4 diabetes mellitus, 2 thyrotoxicosis, and 1 adrenalitis. Median length of stay for patients with hypophysitis was 1 day. No patient with an immune-mediated endocrinopathy died within 30 days of presentation. CONCLUSIONS: Presentations to emergency settings with acute immune-mediated endocrinopathies are rare. Early recognition of immune-mediated toxicities is important, and particularly pertinent in ICI-related endocrinopathies, where even in life-threatening cases, the presentation can be vague and nonspecific.

Emergency ambulatory outpatient management of immune-mediated hypophysitis.

PURPOSE: Immune-mediated hypophysitis is an important toxicity related to immune checkpoint inhibitors (ICI). Optimal management is associated with improved outcomes. It represents a wide spectrum of clinical presentations, and a proportion may be suitable for emergency ambulatory management. METHODS: Emergency ambulatory management of patients presenting with clinical features and findings consistent with ICI-induced hypophysitis was considered at a tertiary cancer/endocrinology hospital. Suitable patients were initially investigated and treated in accordance with the UK emergency management guidelines for ICI induced hypophysitis. After an initial observation period of 4 h, patients were discharged with oral hydrocortisone (20, 10, 10 mg). RESULTS: An initial cohort of 4 patients with emergency presentations of ICI-induced hypophysitis has been managed in an ambulatory fashion in the first 3 months. There were no 30-day readmissions. CONCLUSION: Carefully selected emergency presentations with immune-mediated hypophysitis may be suitable for ambulatory management.

Recommended rejection of the names Malacoplasma gen. nov., Mesomycoplasma gen. nov., Metamycoplasma gen. nov., Metamycoplasmataceae fam. nov., Mycoplasmoidaceae fam. nov., Mycoplasmoidales ord. nov., Mycoplasmoides gen. nov., Mycoplasmopsis gen. nov. [Gupta, Sawnani, Adeolu, Alnajar and Oren 2018] and all proposed species comb. nov. placed therein.

The consensus of the members of the International Committee on Systematics of Prokaryotes' Subcommittee on the taxonomy of Mollicutes is that recently proposed sweeping changes to nomenclature of members of the Mycoplasmatales, specifically involving introduction of the names Malacoplasma gen. nov., Mesomycoplasma gen. nov., Metamycoplasma gen. nov., Metamycoplasmataceaefam. nov., Mycoplasmoidaceaefam. nov., Mycoplasmoidalesord. nov., Mycoplasmoides gen. nov., Mycoplasmopsis gen. nov., and all proposed species or subspecies comb. nov. placed therein, should be rejected because they violate one or more essential points of the International Code of Nomenclature of Prokaryotes.

Early Versus Late Paravertebral Block for Analgesia in Video-Assisted Thoracoscopic Lung Resection. A Double-Blind, Randomized, Placebo-Controlled Trial.

OBJECTIVES: Paravertebral local analgesia is effective in providing pain relief after video assisted thoracoscopic surgery. This randomized, double-blind pilot clinical trial investigated the effect of early perioperative delivery of paravertebral local analgesia to reduce postoperative pain after video assisted thoracoscopic lung resection and the feasibility of a larger trial. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: University hospital, single institution. PARTICIPANTS: Patients over 18 years of age having video assisted lung resection surgery. INTERVENTIONS: 90 patients undergoing video assisted lung resection were randomized to receive bupivacaine via paravertebral catheter either before lung resection (early; n = 47) or at the end of the operation (late; n = 43). The primary outcome measure was pain on coughing during the first 24 postoperative hours. The 95% confidence interval for a median difference was calculated using the Hodges-Lehman median difference method. MEASUREMENTS AND MAIN RESULTS: There was no difference in pain scores between groups over the first 24 postoperative hours. The median (range) morphine equivalent consumption after 24 hours was 34 (7.3-105) mg with early paravertebral bupivacaine and 40.7 (3-91) mg after late paravertebral bupivacaine. The prevalence of chronic pain at 12 months postoperatively was 8.7% with early paravertebral bupivacaine and 25.8% with late paravertebral bupivacaine; the difference was not statistically significant. CONCLUSIONS: The authors found no difference in acute postoperative pain, but the decrease in morphine consumption and prevalence of chronic pain with early paravertebral bupivacaine, although not statistically significant, may warrant further investigation with a larger trial.

Immune checkpoint inhibitor-mediated hypophysitis: no place like home.

Ambulatory emergency care forms a fundamental part of the strategy of trying to ensure safe and sustainable acute care services. Immune checkpoint inhibitor(ICI)-mediated hypophysitis is an important life-threatening complication of therapy. Patients presenting with clinical features and findings consistent with ICI-mediated hypophysitis were considered in the current study. In the absence of severe features (sodium <125 mmol/L, hypotension, reduced consciousness, hypoglycaemia and/or visual field defect), patients were administered a single intravenous dose of hydrocortisone (100 mg), observed for at least 4 h and then discharged on oral hydrocortisone (20 mg, 10 mg and 10 mg). Patients were then seen urgently in the endocrinology outpatient setting for further management. Fourteen patients (median age 64, 10 male) were managed using the pathway. All patients had biochemically confirmed adrenocorticotropic hormone (ACTH) deficiency. Seven of the 14 were treated with combination ICI therapy, with four having pan-anterior hypopituitarism. There were no 30-day readmissions or any associated hypophysitis-related mortality. All patients continued ICI therapy without interruption.

Safety by design: Biosafety and biosecurity in the age of synthetic genomics.

Technologies to profoundly engineer biology are becoming increasingly affordable, powerful, and accessible to a widening group of actors. While offering tremendous potential to fuel biological research and the bioeconomy, this development also increases the risk of inadvertent or deliberate creation and dissemination of pathogens. Effective regulatory and technological frameworks need to be developed and deployed to manage these emerging biosafety and biosecurity risks. Here, we review digital and biological approaches of a range of technology readiness levels suited to address these challenges. Digital sequence screening technologies already are used to control access to synthetic DNA of concern. We examine the current state of the art of sequence screening, challenges and future directions, and environmental surveillance for the presence of engineered organisms. As biosafety layer on the organism level, we discuss genetic biocontainment systems that can be used to created host organisms with an intrinsic barrier against unchecked environmental proliferation.

Detecting drug diversion in health-system data using machine learning and advanced analytics.

PURPOSE: The theft of drugs from healthcare facilities, also known as drug diversion, occurs frequently but is often undetected. This paper describes a research study to develop and test novel drug diversion detection methods. Improved diversion detection and reduction in diversion improves patient safety, limits harm to the person diverting, reduces the public health impact of substance use disorder, and mitigates significant liability risk to pharmacists and their organizations. METHODS: Ten acute care inpatient hospitals across 4 independent health systems extracted 2 datasets from various health information technology systems. Both datasets were consolidated, normalized, classified, and sampled to provide a harmonious dataset for analysis. Supervised machine learning methods were iteratively used on the initial sample dataset to train algorithms to classify medication movement transactions as involving a low or high risk of diversion. Thereafter, the resulting machine learning model classified the risk of diversion in a historical dataset capturing 8 to 24 months of history that included 27.9 million medication movement transactions by 19,037 nursing, 1,047 pharmacy, and 712 anesthesia clinicians and that included 22 known, blinded diversion cases to measure when the model would have detected the diversion compared to when the diversion was actually detected by existing methods. RESULTS: The machine learning model had 96.3% accuracy, 95.9% specificity, and 96.6% sensitivity in detecting transactions involving a high risk of diversion using the initial sample dataset. In subsequent testing using the much larger historical dataset, the analytics detected known diversion cases (n = 22) in blinded data faster than existing detection methods (a mean of 160 days and a median of 74 days faster; range, 7-579 days faster). CONCLUSION: The study showed that (1) consolidated datasets and (2) supervised machine learning can detect known diversion cases faster than existing detection methods. Users of the technology also noted improved investigation efficiency.

Writing's on the wall: improving the WHO Surgical Safety Checklist.

BACKGROUND AND PROBLEM: The WHO Surgical Safety Checklist has been shown to improve patient safety as well as improving teamwork and communication in theatres. In 2009, it was made a mandatory requirement for all NHS hospitals in England and Wales. The WHO checklist is intended to be adapted to suit local settings and was modified for use in Gloucestershire Hospitals NHS Foundation Trust. In 2018, it was decided to review the use of the adapted WHO checklist and determine whether improvements in compliance and engagement could be achieved. AIM: The aim was to achieve 90% compliance and engagement with the WHO Surgical Safety Checklist by April 2019. METHODS: In April 2018, a prospective observational audit and online survey took place. The results showed compliance for the 'Sign In' section of the checklist was 55% and for the 'Time Out' section was 91%. Engagement by the entire theatre team was measured at 58%. It was proposed to move from a paper checklist to a wall-mounted checklist, to review and refine the items in the checklist and to change the timing of 'Time Out' to ensure it was done immediately prior to knife-to-skin. RESULTS: Following its introduction in September 2018, the new wall-mounted checklist was reaudited. Compliance improved to 91% for 'Sign In' and to 94% for 'Time Out'. Engagement by the entire theatre team was achieved 100% of the time. Feedback was collected, adjustments made and the new checklist was rolled out in stages across all theatres. A reaudit in December 2018 showed compliance improved further, to 99% with 'Sign In' and to 100% with 'Time Out'. Engagement was maintained at 100%. CONCLUSIONS: The aim of the project was met and exceeded. Since April 2019, the new checklist is being used across all theatres in the Trust.

Inferring the Minimal Genome of Mesoplasma florum by Comparative Genomics and Transposon Mutagenesis.

The creation and comparison of minimal genomes will help better define the most fundamental mechanisms supporting life. Mesoplasma florum is a near-minimal, fast-growing, nonpathogenic bacterium potentially amenable to genome reduction efforts. In a comparative genomic study of 13 M. florum strains, including 11 newly sequenced genomes, we have identified the core genome and open pangenome of this species. Our results show that all of the strains have approximately 80% of their gene content in common. Of the remaining 20%, 17% of the genes were found in multiple strains and 3% were unique to any given strain. On the basis of random transposon mutagenesis, we also estimated that ~290 out of 720 genes are essential for M. florum L1 in rich medium. We next evaluated different genome reduction scenarios for M. florum L1 by using gene conservation and essentiality data, as well as comparisons with the first working approximation of a minimal organism, Mycoplasma mycoides JCVI-syn3.0. Our results suggest that 409 of the 473 M. mycoides JCVI-syn3.0 genes have orthologs in M. florum L1. Conversely, 57 putatively essential M. florum L1 genes have no homolog in M. mycoides JCVI-syn3.0. This suggests differences in minimal genome compositions, even for these evolutionarily closely related bacteria. IMPORTANCE The last years have witnessed the development of whole-genome cloning and transplantation methods and the complete synthesis of entire chromosomes. Recently, the first minimal cell, Mycoplasma mycoides JCVI-syn3.0, was created. Despite these milestone achievements, several questions remain to be answered. For example, is the composition of minimal genomes virtually identical in phylogenetically related species? On the basis of comparative genomics and transposon mutagenesis, we investigated this question by using an alternative model, Mesoplasma florum, that is also amenable to genome reduction efforts. Our results suggest that the creation of additional minimal genomes could help reveal different gene compositions and strategies that can support life, even within closely related species.

Adrenal pseudoaneurysm due to blunt trauma.

Blunt trauma to adrenal glands causing pseudoaneurysm is relatively uncommon. We report a case of an adrenal pseudoaneurysm in a young man who had a blunt abdominal trauma. The pseudoaneurysm was embolized. Pseudoaneurysm formation is a significant, albeit rare complication and can lead to adrenal hemorrhage. Currently, best treatment option is embolization. There is little known about natural course of a pseudoaneurysm, and there are no controlled trails in regard to follow up computed tomography (CT) scans in blunt solid organ injury.