The effect of PD-L1 testing on the cost-effectiveness and economic impact of immune checkpoint inhibitors for the second-line treatment of NSCLC.

BACKGROUND: Immune checkpoint inhibitors improve outcomes compared with chemotherapy in lung cancer. Tumor PD-L1 receptor expression is being studied as a predictive biomarker. The objective of this study was to assess the cost-effectiveness and economic impact of second-line treatment with nivolumab, pembrolizumab, and atezolizumab with and without the use of PD-L1 testing for patient selection. DESIGN: We developed a decision-analytic model to determine the cost-effectiveness of PD-L1 assessment and second-line immunotherapy versus docetaxel. The model used outcomes data from randomized clinical trials (RCTs) and drug acquisition costs from the United States. Thereafter, we used epidemiologic data to estimate the economic impact of the treatment. RESULTS: We included four RCTs (2 with nivolumab, 1 with pembrolizumab, and 1 with atezolizumab). The incremental quality-adjusted life year (QALY) for nivolumab was 0.417 among squamous tumors and 0.287 among non-squamous tumors and the incremental cost-effectiveness ratio (ICER) were $155 605 and $187 685, respectively. The QALY gain in the base case for atezolizumab was 0.354 and the ICER was $215 802. Compared with treating all patients, the selection of patients by PD-L1 expression improved incremental QALY by up to 183% and decreased the ICER by up to 65%. Pembrolizumab was studied only in patients whose tumors expressed PD-L1. The QALY gain was 0.346 and the ICER was $98 421. Patient selection also reduced the budget impact of immunotherapy. CONCLUSION: The use of PD-L1 expression as a biomarker increases cost-effectiveness of immunotherapy but also diminishes the number of potential life-years saved.

Large current MOSFET on photonic silicon-on-insulator wafers and its monolithic integration with a thermo-optic 2 × 2 Mach-Zehnder switch.

n-channel body-tied partially depleted metal-oxide-semiconductor field-effect transistors (MOSFETs) were fabricated for large current applications on a silicon-on-insulator wafer with photonics-oriented specifications. The MOSFET can drive an electrical current as large as 20 mA. We monolithically integrated this MOSFET with a 2 × 2 Mach-Zehnder interferometer optical switch having thermo-optic phase shifters. The static and dynamic performances of the integrated device are experimentally evaluated.

Pharmacokinetic analysis of coronary venous retroinfusion: a comparison with anterograde coronary artery drug administration using metoprolol as a tracer.

Plasma and myocardial tissue concentrations of metoprolol were studied in ischemic and nonischemic areas of 22 pigs after 90 (n = 19) and 16 (n = 3) min of left anterior descending coronary artery occlusion. Group A (n = 6) received simultaneous intravenous metoprolol (0.2 mg/kg body weight) and tritium-labeled (3H)-metoprolol (0.2 mg/kg) retrogradely into the coronary vein. In group B (n = 5), metoprolol and 3H-metoprolol were administered in the same way, but at half the volume to study the influence of derived coronary venous pressure on the myocardial concentration of drug. In group C (n = 3), metoprolol was given retrogradely and saline solution was infused into the left anterior descending artery before induced death to wash out metoprolol from the coronary veins. To rule out a possible influence of the development of myocardial necrosis on drug distribution, metoprolol was retroinfused after 1 min of arterial occlusion in three pigs (group D). In group E (n = 5), metoprolol (0.2 mg/kg) was infused anterogradely into the left anterior descending artery. Peak plasma concentration was significantly higher after intravenous infusion of metoprolol (1,188 +/- 503 nmol/liter) than after coronary venous infusion (417 +/- 155 nmol/liter; p less than 0.001). In groups A and B, the nonischemic myocardial concentration of metoprolol was 250 to 300 pmol/g, whether the drug was infused intravenously or into the coronary vein. Coronary venous retroinfusion, however, resulted in a substantial accumulation of metoprolol in the ischemic myocardium. In group A pigs, subendocardial myocardial concentration was 16,800 +/- 7,774, mid-myocardial 39,590 +/- 18,043 and subepicardial 57,143 +/- 29,030 pmol/g (mean +/- SE). The ischemic myocardial concentration in pigs from group B was somewhat less pronounced, probably secondary to a lower coronary venous pressure (15 +/- 3 mm Hg) with the lower volume of infusion (6.1 +/- 0.3 ml) in group B compared with 32 +/- 5 mm Hg with a 14 +/- 1 ml infusion in group A. Coronary artery anterograde administration resulted in myocardial ischemic and nonischemic zone drug concentrations similar to those observed after retroinfusion into the coronary vein. With both modes of administration, there was a transmyocardial gradient from a somewhat lower drug concentration in the subendocardium, toward an increasing level in the mid-myocardium, to the highest concentration in the subepicardial zone of the ischemic myocardium. Coronary venous retroinfusion resulted in pronounced drug accumulation in the ischemic myocardium. The derived coronary venous pressure during infusion influenced the concentration of drug.(ABSTRACT TRUNCATED AT 400 WORDS)

Coronary venous retroinfusion of deferoxamine reduces infarct size in pigs.

The efficacy of coronary venous retroinfusion of the iron chelator deferoxamine was studied in 24 pentobarbital-anesthetized open chest pigs with a 60 min occlusion of the left anterior descending coronary artery followed by 3 h of reperfusion. Eight retrogradely treated pigs were given 10 mg/kg body weight of deferoxamine by way of the anterior interventricular vein and eight systemically treated pigs received the same doses of deferoxamine intravenously. Drug infusions lasted for 5 min, beginning 15 min before reperfusion. Eight control pigs received systemic intravenous saline solution. Myocardial area at risk and necrotic area were assessed by the monastral blue dye and the triphenyltetrazolium chloride staining method, respectively. There were no significant differences in hemodynamics or regional myocardial function (sonomicrometry) among the groups. Infarct size expressed as percent of risk area was 73.9 +/- 13.5% in the control group, 70.6 +/- 16.4% in the systemically treated group and 48.5 +/- 21.4% (p less than 0.05) in the retrogradely treated group. In conclusion, deferoxamine significantly reduced infarct size after coronary occlusion only when given regionally by way of the coronary vein. Because there was no significant hemodynamic effect caused by deferoxamine infusion, it is suggested that this drug prevents postischemic reperfusion injury by a direct cardioprotective effect.

Retrograde coronary venous administration of recombinant tissue-type plasminogen activator: a unique and effective approach to coronary artery thrombolysis.

Recent studies of interventional therapy by way of the coronary venous system have demonstrated that it can protect acutely ischemic myocardium. To evaluate the efficacy of coronary venous retroinfusion compared with systemic intravenous administration of recombinant tissue-type plasminogen activator (rt-PA), 14 dogs were studied with a copper coil-induced thrombus in the left anterior descending coronary artery. The rt-PA (24,000 fluorescence units/kg) was administered continuously, either intravenously (n = 8) or retrogradely (n = 6), for 30 min beginning 60 min after coronary occlusion. Thrombolysis was determined by repetitive coronary angiography. All dogs were killed 3 h after termination of rt-PA infusion and infarct size was measured by the triphenyltetrazolium chloride staining technique. Complete thrombolysis occurred in five of the six dogs in the retroinfusion group and four of the eight dogs in the systemic intravenous infusion group. Partial lysis was achieved in two dogs treated by intravenous infusion. Lysis did not occur in one dog treated with retroinfusion and in two dogs treated with intravenous infusion. Time to thrombolysis was 13.4 +/- 2.3 min in the retroinfusion group versus 27.8 +/- 4.8 min in the intravenous group (p less than 0.001). Myocardial functional recovery in the ischemic zone measured by two-dimensional echocardiography 60 min after reperfusion was significant only in the retroinfusion group (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Cloning and nucleotide sequence of the major capsid proteins of Lactobacillus bacteriophage phi gle.

Bacteriophage phi gle was induced from a lysogenic Lactobacillus strain Gle. phi gle genome is double-stranded DNA of approximately 42.5 kilo-base (kb) pairs. SDS poly-acrylamide gel electrophoresis demonstrated that the phage particles contain 4 major structural (capsid) proteins, gpB, gpG, gpO, and gpP, whose molecular weights (MW) are estimated to be 64, 43, 29 and 26 kilodaltons (kDa), respectively. More than 16 minor proteins ranging from 113 to 9.6 kDa were also detected. The genes for the major capsid proteins were cloned and each DNA sequence was determined. N-terminal amino acid alignments determined by protein sequencing completely coincided with those deduced from the nucleotide sequences.

High-resolution cardiac PET in rabbits: imaging and quantitation of myocardial blood flow.

UNLABELLED: A high-resolution PET system for small animals was tested for its applicability to the investigation of regional myocardial blood flow (MBF) in rabbits. METHODS: Nineteen measurements were performed in 10 closed-chest anesthetized rabbits at baseline and during infusions of adenosine (0.2 mg/kg/min) and propranolol (0.20-1.20 mg slow infusion) to obtain a wide range of MBF. Myocardial blood flow was assessed both by dynamic 13N-ammonia PET and by colored microspheres. Blood was withdrawn directly from the femoral artery, and arterial 13N activity was measured by coincidence type gamma detection system for the input function. Nitrogen-13 myocardial uptake was calculated by dividing the myocardial 13N activity by the integral value of the input function. RESULTS: Three or four contiguous cross-sectional myocardial images were obtained after 13N-ammonia injection. The left ventricular wall and cardiac cavity were clearly visualized. Moreover, initial passage of the tracer through the heart was obtained with serial 10-sec PET images. Nitrogen-13 myocardial uptake correlated well with flow measured with microspheres (r = 0.88). CONCLUSION: Our cardiac PET system can be used for in vivo imaging and quantitation of MBF in small animals and may play an important role in the future study of animal models of cardiovascular diseases.

Uptakes and images of 38K in rabbit heart, kidney, and brain.

UNLABELLED: The purpose of this study was to evaluate the kinetics and image quality of positron-emitting 38K (half-life, 7.6 min) and high-resolution small-animal PET in the heart, kidney, and brain of rabbits. METHODS: Studies were performed with 18 closed-chest anesthetized rabbits at baseline and during infusions of adenosine (0.2 mg/kg/min) and propranolol (0.5-1.0 mg/kg intravenously) using high-resolution small-animal PET. 38K was injected intravenously and dynamic PET imaging of the heart, kidney, or brain was performed for 3 min. Colored microspheres were injected into the left ventricle to measure organ blood flow. Arterial blood was withdrawn directly from the femoral artery, and, after the animals were killed, 38K activities in each organ were measured directly with a well counter. Uptake of 38K was calculated by dividing the 38K activities in each organ by the integral of the input function. The extraction fraction of 38K was estimated by dividing the uptake of 38K in each organ by the organ blood flow, measured by microspheres. RESULTS: The left ventricular myocardium and kidney were clearly visualized, but there was no visual 38K uptake in the brain. For the heart, kidney, and brain, respectively, average blood flow was 2.91 +/- 1.29, 5.49 +/- 0.71, and 0.57 +/- 0.11 mL/min/g, and the extraction fraction of 38K at baseline was 0.55 +/- 0.13, 0.48 +/- 0.13, and 0.022 +/- 0004. The Renkin-Crone model fit the relation between myocardial extraction and flow under a wide range of myocardial blood flow (r = 0.89). CONCLUSION: 38K is a suitable tracer for noninvasively showing the potassium kinetics of the heart, kidney, and brain by PET imaging.

Low-frictional catheter materials by photo-induced graft polymerization.

To develop low-frictional catheters, photo-induced graft polymerization of N,N-dimethylacrylamide (DMAA) was performed on to films and tubes of ethylene-vinyl acetate copolymer (EVA) and poly(vinyl chloride) (PVC). Their surfaces became very slippery, when the materials were preirradiated with UV from a low-pressure mercury lamp, followed by graft polymerization with DMAA in the presence of small amount of riboflavin without degassing. Although no significant difference was observed in surface lubrication between the EVA film and the tube, the latter required an additional procedure for the graft polymerization, that is, removal of air trapped inside the tube. The surfaces of EVA and PVC tubes grafted with DMAA were found to exhibit frictional forces around 0.5 N against a PVC and a silicone surface under wet conditions, whereas the frictional force of the ungrafted tubes against the same substrates was 10 and 20 N for PVC and EVA, respectively.

Polyurethane surface modification by graft polymerization of acrylamide for reduced protein adsorption and platelet adhesion.

Surface modification of polyurethane by glow-discharge treatment and subsequent graft polymerization of acrylamide was studied. The modified hydrophilic surfaces were characterized by the measurements of dynamic contact angle and zeta potentials and examined for protein adsorption behaviour and platelet adhesion. Data from in vitro and ex vivo experiments indicated a reduction of protein adsorption and platelet adhesion for the hydrophillic graft polymers, the extent of which was correlated to polymer graft density.

Embryological fusion between the ducts of the ventral and dorsal primordia of the pancreas occurs in two manners.

The junction between the main pancreatic duct and the accessory duct has been thought to be the site of fusion between the ducts of the ventral and the dorsal primordia of the pancreas. The aim of this study was to investigate the fusion point between the ventral and the dorsal pancreatic ducts and to determine whether there is any relationship between the configuration of the pancreatic ducts and the manner of embryological fusion. Pancreatography was performed at 22 consecutive autopsies. Immunohistochemical staining of pancreatic polypeptide (PP) was performed because PP cells were rich in the ventral pancreas but poor in the dorsal pancreas. We identified two types of fusion. In one type, the ventral and the dorsal pancreatic ducts fuse at their junction (one-point fusion). In the other type, the two ducts fuse not only at the proximal site but at a second, more distal site (two-point fusion). Analysis of the pancreatograms showed that the distance between the junction and the major papilla in two-point fusion is significantly shorter than in one-point fusion (p < 0.01). These results indicate a close correlation between the pattern seen on pancreatograms and the manner of embryological fusion.

Overestimation of myocardial infarct size by histologic measurement in a model of occlusion followed by reperfusion.

We studied 32 transverse left ventricular slices of myocardium from 16 pigs after 45 to 100 minutes of coronary artery occlusion followed by 180 minutes of reperfusion. Infarct area for each slice was determined as follows: (1) grossly, by triphenyl tetrazolium chloride staining of each slice, and (2) microscopically, by complete histologic sectioning of the triphenyl tetrazolium chloride-stained surface of each slice. Planimetry of necrotic and nonnecrotic areas was performed from tracings and photographs of triphenyl tetrazolium chloride-stained slices and from actual histologic sections. When triphenyl tetrazolium chloride and histologic measurements were compared, necrotic tissue area had decreased 11.4% +/- 15.0% (2.59 +/- 1.04 vs 2.09 +/- 0.86 cm2). Nonnecrotic tissue area decreased 20.6% +/- 24.0% (8.31 +/- 3.79 vs 5.16 +/- 2.73 cm2). In this model of ischemia followed by reperfusion, with fixation and processing, viable tissue shrank almost twice as much as necrotic tissue. This differential shrinkage introduces an error resulting in overestimation of infarct size by histologic quantitation.

Life-cycle toxicity of 4-nonylphenol to medaka (Oryzias latipes).

We studied the chronic effects of 4-nonylphenol (4-NP) on reproductive status of medaka (Oryzias latipes) over two generations of continuous exposure. The exposure study of the parental (F0) medaka was begun on embryos within 24 h postfertilization and continued with monitoring through embryological development, hatching, posthatch survival, growth, sexual differentiation, and reproduction under flow-through exposures to mean measured 4-NP concentrations of 4.2, 8.2, 17.7, 51.5, and 183 microg/L for up to 104 d. Eggs spawned from the F0 fish at 102 and 103 d posthatch were also examined for hatchability, survival after hatching, growth, and sexual differentiation until 60 d posthatch. The 183-microg/L treatment significantly reduced the embryo survival and swim-up success of the F0 fish. The cumulative mortality after swim-up of the F0 fish exposed to 17.7 and 51.5 microg/L were significantly higher than the control mortality. No concentration-related effect of 4-NP was observed on the growth of surviving F0 fish at 60 d posthatch. However, the sex ratio estimated from the appearance of their secondary sex characteristics was skewed toward female in the 51.5-microg/L treatment. Additionally, gonadal histology showed that 20% of the fish in the 17.7-microg/L treatment and 40% in the 51.5-microg/L treatment had testis-ova, indicating that 4-NP affects the gonadal development and survival of medaka at similar concentrations in juveniles. The sex ratio of the F0 fish in the 51.5-microg/L treatment was completely skewed toward female; subsequently, the effects on fecundity and fertility in this generation were monitored at mean measured concentrations of 4.2, 8.2, and 17.7 microg/L from 71 to 103 d posthatch. Fecundity was unaffected by any of the treatments examined. The mean fertility in the 17.7-microg/L treatment was reduced to 76% of that in the controls, although no statistically significant differences were determined. Overall, these results indicate that the lowest-observed-effect concentration (LOEC) and no-observed-effect concentration (NOEC) of 4-NP through the life cycle of the F0 medaka were 17.7 and 8.2 microg/L, respectively. In the F1 medaka, no significant effects were observed on hatching success, posthatch mortality, or growth, but sexual differentiation at 60 d posthatch was affected. Induction of testis-ova in the gonads of the F1 fish was observed in both the 8.2- and the 17.7-microg/L concentrations. The results indicate that 4-NP can have significant effects on reproductive potential of medaka at concentrations as low as 17.7 microg/L.

[Ileocolic intussusception in a recurrent non-Hodgkin's lymphoma; report of a case].

The adult intussusception is rare. Here, we describe a case of an adult patient with ileocolic intussusception secondary to a recurrent lymphoma of the terminal ileum. The patient was a 42-year-old female, who had a history of the subtotal gastrectomy because of the primary gastric lymphoma. Eight months after the operation, she had a relapse in the abdomen and received the combination chemotherapy. She acquired the complete remission, but six months after the completion of the chemotherapy, she suffered from the right lower abdominal pain and diarrhea. Physical examination revealed a soft mass with tenderness in the right iliac fossa. Barium studies and abdominal computed tomography showed an ileocolic intussusception. At laparotomy, a 4.5 cm polypoid tumor was found in the terminal ileum and it passed through the ileocaecal valve to form an intussusception. Histologic examination disclosed the follicular lymphoma of medium-sized cell type. So far as we are aware, this is the first report of an adult patient with intussusception secondary to a lymphoma in Japan.

[A 68-year-old man with speech disturbance as the initial symptom followed by bradykinesia and dementia. Clinical conference].

We report a 68-year-old man with progressive speech disturbance and dementia. He was well until 1995, when he noted an onset of difficulty in speech. He was able to name simple objects and understand language, however, he showed great difficulty in spontaneous speech. In 1998, he visited our service. He was alert and oriented, but he showed moderate degree of dementia. He did not appear to have aphasia but he showed marked dysarthria and slurred speech. He showed limb-kinetic apraxia in his right hand. He showed moderate restriction in his vertical gaze, masked face, and dysphagia. He walked normally. No rigidity, ataxia, or abnormal involuntary movement was noted. He showed grasp response and he was bradykinetic. He was treated with levodopa without effect. His condition deteriorated slowly and he was admitted to our service because of fever on February 13, 1999. He was alert but almost mute. He was unable to look upward or downward. Oculocephalic response was preserved. Axial rigidity was noted but no limb rigidity was present. He walked with small steps. Retropulsion was present. Deep tendon reflexes were diminished and the plantar response was flexor bilaterally. Laboratory examinations were unremarkable and his fever went down within a few days by supportive treatment. He was discharged to his home, where his condition deteriorated further. He developed cardiopulmonary arrest on May 3, 1999 and was brought into ER again. Cardiopulmonary resuscitation was unsuccessful and he was pronounced dead at 7:30 in the morning on the same day. The patient was discussed in a neurological CPC. The chief discussant arrived at the conclusion that this patient had corticobasal degeneration. But he felt that the differential diagnosis from atypical progressive supranuclear palsy, in which cortical pathology and symptoms predominated as in corticobasal degeneration, would be extremely difficult. Most of the participants felt that this patient had corticobasal degeneration, but a few thought that he had atypical PSP. Post-mortem examination revealed asymmetric cortical atrophy, which was accentuated in the left motor cortical area. Microscopic examination of the precentral cortex revealed neuronal loss and gliosis. Ballooned neurons and astrocytic plaques were also seen. The substantia nigra showed marked neuronal loss. Neuropil threads were observed in the nigra. Those threads were positive for anti-tau immunohistochemistry. The internal segment of the globus pallidus, the subthalamic nucleus, and the cerebellar dentate nucleus showed mild to moderate neuronal loss. A few neurofibrillary tangle-positive neurons were seen in these structures. Neuropil threads were also seen throughout. Pathologic changes were consistent with the diagnosis of corticobasal degeneration. One of the participants pointed out that he was able to walk at the time when he was showing marked speech disturbance and limb-kinetic apraxia, which was rather unusual for PSP suggesting corticobasal degeneration.