Nivolumab plus chemotherapy or ipilimumab in gastro-oesophageal cancer.

Standard first-line chemotherapy results in disease progression and death within one year in most patients with human epidermal growth factor receptor 2 (HER2)-negative gastro-oesophageal adenocarcinoma1-4. Nivolumab plus chemotherapy demonstrated superior overall survival versus chemotherapy at 12-month follow-up in gastric, gastro-oesophageal junction or oesophageal adenocarcinoma in the randomized, global CheckMate 649 phase 3 trial5 (programmed death ligand-1 (PD-L1) combined positive score ≥5 and all randomized patients). On the basis of these results, nivolumab plus chemotherapy is now approved as a first-line treatment for these patients in many countries6. Nivolumab and the cytotoxic T-lymphocyte antigen-4 (CTLA-4) inhibitor ipilimumab have distinct but complementary mechanisms of action that contribute to the restoration of anti-tumour T-cell function and induction of de novo anti-tumour T-cell responses, respectively7-11. Treatment combining 1 mg kg-1 nivolumab with 3 mg kg-1 ipilimumab demonstrated clinically meaningful anti-tumour activity with a manageable safety profile in heavily pre-treated patients with advanced gastro-oesophageal cancer12. Here we report both long-term follow-up results comparing nivolumab plus chemotherapy versus chemotherapy alone and the first results comparing nivolumab plus ipilimumab versus chemotherapy alone from CheckMate 649. After the 24.0-month minimum follow-up, nivolumab plus chemotherapy continued to demonstrate improvement in overall survival versus chemotherapy alone in patients with PD-L1 combined positive score ≥5 (hazard ratio 0.70; 95% confidence interval 0.61, 0.81) and all randomized patients (hazard ratio 0.79; 95% confidence interval 0.71, 0.88). Overall survival in patients with PD-L1 combined positive score ≥ 5 for nivolumab plus ipilimumab versus chemotherapy alone did not meet the prespecified boundary for significance. No new safety signals were identified. Our results support the continued use of nivolumab plus chemotherapy as standard first-line treatment for advanced gastro-oesophageal adenocarcinoma.

Outcomes in the Asian subgroup of the phase III randomised HIMALAYA study of tremelimumab plus durvalumab in unresectable hepatocellular carcinoma.

BACKGROUND & AIMS: In the global, phase III HIMALAYA study in unresectable hepatocellular carcinoma (uHCC), STRIDE (Single Tremelimumab Regular Interval Durvalumab) improved overall survival (OS) vs. sorafenib; durvalumab was noninferior to sorafenib. HBV is the predominant HCC aetiology in most of Asia vs. HCV or nonviral aetiologies in Western countries and Japan. This analysis evaluated safety and efficacy outcomes for STRIDE and durvalumab monotherapy vs. sorafenib, in HIMALAYA participants enrolled in Asia, excluding Japan. METHODS: In HIMALAYA, participants were randomised to STRIDE, durvalumab, or sorafenib. The Asian subgroup in this analysis included participants enrolled in Hong Kong, India, South Korea, Taiwan, Thailand, and Vietnam. OS, objective response rate (ORR; per Response Evaluation Criteria in Solid Tumors, version 1.1), and safety were assessed in the Asian subgroup and in an exploratory subgroup of participants in Hong Kong and Taiwan. RESULTS: The Asian subgroup included 479 participants randomised to STRIDE (n=156), durvalumab (n=167), or sorafenib (n=156). OS was improved for STRIDE vs. sorafenib (HR 0.68; 95% CI 0.52-0.89]). The OS HR for durvalumab vs. sorafenib was 0.83 (95% CI 0.64-1.06). In Hong Kong and Taiwan (n=141), OS HRs for STRIDE vs. sorafenib and durvalumab vs. sorafenib were 0.44 (95% CI 0.26-0.77) and 0.64 (95% CI 0.37-1.08), respectively. In the Asian subgroup, ORR (including unconfirmed responses) was numerically higher for STRIDE (28.2%) and durvalumab (18.6%) vs. sorafenib (9.0%), and Grade 3/4 treatment-related adverse events were numerically lower for STRIDE (19.9%) and durvalumab (13.3%) vs. sorafenib (30.5%). CONCLUSIONS: STRIDE improved outcomes vs. sorafenib in the Asian subgroup. These results support the benefits of STRIDE for participants with uHCC globally, including the Asia-Pacific region. CLINICAL TRIAL NUMBER: NCT03298451 IMPACT AND IMPLICATIONS: The global, phase III HIMALAYA study found that the STRIDE (Single Tremelimumab Regular Interval Durvalumab) regimen improved overall survival (OS), including long-term OS, vs. sorafenib, and that durvalumab monotherapy was noninferior to sorafenib in participants with unresectable hepatocellular carcinoma (uHCC). However, there are differences in the aetiology and clinical practices related to HCC in parts of Asia, compared to Western countries and Japan, which could lead to differences in treatment outcomes between these regions. The results of this analysis demonstrate the benefits of STRIDE for participants in the Asia-Pacific region, consistent with the full, global study population. Overall, these findings continue to support the use of STRIDE in a diverse population, reflective of uHCC globally.

Distribution, seroprevalence and risk factors for bovine brucellosis in Brazil: Official data, systematic review and meta-analysis.

Bovine brucellosis is an endemic disease in Brazil, and evidence-based assessments of the available literature on its seroprevalence and risk factors are limited. The aim of this study was to systematically review and summarize studies related to seroprevalence and risk factors of bovine brucellosis in the entire Brazil, in addition to comparing published data with the most recent official reports. Articles available in scientific databases and published between October 2006 and October 2021 were evaluated. Forty-five publications were included in the meta-analysis on the seroprevalence of brucellosis and 29 publications in the review on risk factors. The largest number of publications was found for the State of Mato Grosso do Sul (n=4), and the highest and lowest seroprevalences were observed in Acre (11%; 95% CI: 8.0-14.0%) and in the Federal District (0.4%; 95% CI: 0.2-0.7%). The main risk factors were the purchase of animals for breeding, vaccination, the number of heifers (female ≥2 years), the presence of calving paddocks and the occurrence of abortions. The need for new official studies has been suggested to determine the true prevalence of bovine brucellosis in Brazil, supported by the National Program for the Control and Eradication of Animal Brucellosis and Tuberculosis.

Atezolizumab, vemurafenib, and cobimetinib in patients with melanoma with CNS metastases (TRICOTEL): a multicentre, open-label, single-arm, phase 2 study.

BACKGROUND: Targeted therapy and immunotherapy have shown intracranial activity in melanoma with CNS metastases, but there remains an unmet need, particularly for patients with symptomatic CNS metastases. We aimed to evaluate atezolizumab in combination with cobimetinib or vemurafenib plus cobimetinib in patients with melanoma with CNS metastases. METHODS: TRICOTEL was a multicentre, open-label, single-arm, phase 2 study done in two cohorts: a BRAFV600 wild-type cohort and a BRAFV600 mutation-positive cohort, recruited at 21 hospitals and oncology centres in Brazil, France, Germany, Hungary, Italy, Spain, and Switzerland. Eligible patients were aged 18 years or older with previously untreated metastatic melanoma, brain metastases of 5 mm or larger in at least one dimension, and an Eastern Cooperative Oncology Group performance status of 2 or less. Patients in the BRAFV600 wild-type cohort received intravenous atezolizumab (840 mg, days 1 and 15 of each 28-day cycle) plus oral cobimetinib (60 mg once daily, days 1-21). Patients in the BRAFV600 mutation-positive cohort received intravenous atezolizumab (840 mg, days 1 and 15 of each 28-day cycle) plus oral vemurafenib (720 mg twice daily) plus oral cobimetinib (60 mg once daily, days 1-21); atezolizumab was withheld in cycle 1. Treatment was continued until progression, toxicity, or death. The primary outcome was intracranial objective response rate confirmed by assessments at least 4 weeks apart, as assessed by independent review committee (IRC) using modified Response Evaluation Criteria in Solid Tumours version 1.1. Because of early closure of the BRAFV600 wild-type cohort, the primary endpoint of intracranial objective response rate by IRC assessment was not done in this cohort; intracranial objective response rate by investigator assessment was reported instead. Efficacy and safety were analysed in all patients who received at least one dose of study medication. This trial is closed to enrolment and is registered with ClinicalTrials.gov, NCT03625141. FINDINGS: Between Dec 13, 2018, and Dec 7, 2020, 65 patients were enrolled in the BRAFV600 mutation-positive cohort; the BRAFV600 wild-type cohort was closed early after enrolment of 15 patients. Median follow-up was 9·7 months (IQR 6·3-15·0) for the BRAFV600 mutation-positive cohort and 6·2 months (3·5-23·0) for the BRAFV600 wild-type cohort. Intracranial objective response rate was 42% (95% CI 29-54) by IRC assessment in the BRAFV600 mutation-positive cohort and 27% (95% CI 8-55) by investigator assessment in the BRAFV600 wild-type cohort. Treatment-related grade 3 or worse adverse events occurred in 41 (68%) of 60 patients who received atezolizumab plus vemurafenib plus cobimetinib in the BRAFV600 mutation-positive cohort, the most common of which were lipase increased (15 [25%] of 60 patients) and blood creatine phosphokinase increased (11 [18%]). Eight (53%) of 15 patients treated with atezolizumab plus cobimetinib in the BRAFV600 wild-type cohort had treatment-related grade 3 or worse adverse events, most commonly anaemia (two [13%]) and dermatitis acneiform (two [13%]). Treatment-related serious adverse events occurred in 14 (23%) of 60 patients who received triplet therapy in the BRAFV600 mutation-positive cohort and two (13%) of 15 in the BRAFV600 wild-type cohort. No treatment-related deaths occurred. INTERPRETATION: Atezolizumab plus vemurafenib and cobimetinib provided intracranial activity in patients with BRAFV600-mutated melanoma with CNS metastases. FUNDING: F Hoffmann-La Roche.

Plain language summary of the HIMALAYA study: tremelimumab and durvalumab for unresectable hepatocellular carcinoma (liver cancer).

WHAT IS THIS SUMMARY ABOUT?: This is a summary of results from a phase 3 clinical study called HIMALAYA. HIMALAYA looked at treatment with one dose of a medication called tremelimumab combined with multiple doses of a medication called durvalumab (the STRIDE regimen) or multiple doses of durvalumab alone. These treatments were compared with a medication called sorafenib in participants with unresectable hepatocellular carcinoma (HCC). HCC is a type of liver cancer that is difficult to treat because it is often diagnosed when it is unresectable, meaning it can no longer be removed with surgery. Sorafenib has been the main treatment for unresectable HCC since 2007. However, people who take sorafenib may experience side effects that can reduce their quality of life, so alternative medicines are being trialed. Tremelimumab and durvalumab are types of drugs called immunotherapies, and they both work in different ways to help the body's immune system fight cancer. WHAT WERE THE RESULTS OF THE STUDY?: Participants who took STRIDE lived longer than participants who took sorafenib, whilst participants who took durvalumab alone lived a similar length of time as participants who took sorafenib. Participants who took STRIDE or durvalumab had a lower relative risk of experiencing worsening in their quality of life than participants who took sorafenib. The side effects that participants who received STRIDE or durvalumab experienced were expected for these types of treatments and could mostly be managed. WHAT DO THE RESULTS OF THE STUDY MEAN?: Overall, STRIDE is more effective than sorafenib for people with unresectable HCC.

Atezolizumab, vemurafenib, and cobimetinib in patients with melanoma with CNS metastases (TRICOTEL): a multicentre, open-label, single-arm, phase 2 study.

BACKGROUND: Targeted therapy and immunotherapy have shown intracranial activity in melanoma with CNS metastases, but there remains an unmet need, particularly for patients with symptomatic CNS metastases. We aimed to evaluate atezolizumab in combination with cobimetinib or vemurafenib plus cobimetinib in patients with melanoma with CNS metastases. METHODS: TRICOTEL was a multicentre, open-label, single-arm, phase 2 study done in two cohorts: a BRAFV600 wild-type cohort and a BRAFV600 mutation-positive cohort, recruited at 21 hospitals and oncology centres in Brazil, France, Germany, Hungary, Italy, Spain, and Switzerland. Eligible patients were aged 18 years or older with previously untreated metastatic melanoma, CNS metastases of 5 mm or larger in at least one dimension, and an Eastern Cooperative Oncology Group performance status of 2 or less. Patients in the BRAFV600 wild-type cohort received intravenous atezolizumab (840 mg, days 1 and 15 of each 28-day cycle) plus oral cobimetinib (60 mg once daily, days 1-21). Patients in the BRAFV600 mutation-positive cohort received intravenous atezolizumab (840 mg, days 1 and 15 of each 28-day cycle) plus oral vemurafenib (720 mg twice daily) plus oral cobimetinib (60 mg once daily, days 1-21); atezolizumab was withheld in cycle 1. Treatment was continued until progression, toxicity, or death. The primary outcome was intracranial objective response rate confirmed by assessments at least 4 weeks apart, as assessed by independent review committee (IRC) using modified Response Evaluation Criteria in Solid Tumours version 1.1. Because of early closure of the BRAFV600 wild-type cohort, the primary endpoint of intracranial objective response rate by IRC assessment was not done in this cohort; intracranial objective response rate by investigator assessment was reported instead. Efficacy and safety were analysed in all patients who received at least one dose of study medication. This trial is closed to enrolment and is registered with ClinicalTrials.gov, NCT03625141. FINDINGS: Between Dec 13, 2018, and Dec 7, 2020, 65 patients were enrolled in the BRAFV600 mutation-positive cohort; the BRAFV600 wild-type cohort was closed early after enrolment of 15 patients. Median follow-up was 9·7 months (IQR 6·3-15·0) for the BRAFV600 mutation-positive cohort and 6·2 months (3·5-23·0) for the BRAFV600 wild-type cohort. Intracranial objective response rate was 42% (95% CI 29-54) by IRC assessment in the BRAFV600 mutation-positive cohort and 27% (95% CI 8-55) by investigator assessment in the BRAFV600 wild-type cohort. Treatment-related grade 3 or worse adverse events occurred in 41 (68%) of 60 patients who received atezolizumab plus vemurafenib plus cobimetinib in the BRAFV600 mutation-positive cohort, the most common of which were lipase increased (15 [25%] of 60 patients) and blood creatine phosphokinase increased (ten [17%]). Eight (53%) of 15 patients treated with atezolizumab plus cobimetinib in the BRAFV600 wild-type cohort had treatment-related grade 3 or worse adverse events, most commonly anaemia (two [13%]) and dermatitis acneiform (two [13%]). Treatment-related serious adverse events occurred in 14 (23%) of 60 patients in the BRAFV600 mutation-positive cohort and two (13%) of 15 in the BRAFV600 wild-type cohort. One death in the BRAFV600 mutation-positive cohort (limbic encephalitis) was considered to be related to atezolizumab treatment. INTERPRETATION: Adding atezolizumab to vemurafenib plus cobimetinib provided promising intracranial activity in patients with BRAFV600-mutated melanoma with CNS metastases. FUNDING: F Hoffmann-La Roche.

Pembrolizumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.

BACKGROUND: The combination of pembrolizumab and axitinib showed antitumor activity in a phase 1b trial involving patients with previously untreated advanced renal-cell carcinoma. Whether pembrolizumab plus axitinib would result in better outcomes than sunitinib in such patients was unclear. METHODS: In an open-label, phase 3 trial, we randomly assigned 861 patients with previously untreated advanced clear-cell renal-cell carcinoma to receive pembrolizumab (200 mg) intravenously once every 3 weeks plus axitinib (5 mg) orally twice daily (432 patients) or sunitinib (50 mg) orally once daily for the first 4 weeks of each 6-week cycle (429 patients). The primary end points were overall survival and progression-free survival in the intention-to-treat population. The key secondary end point was the objective response rate. All reported results are from the protocol-specified first interim analysis. RESULTS: After a median follow-up of 12.8 months, the estimated percentage of patients who were alive at 12 months was 89.9% in the pembrolizumab-axitinib group and 78.3% in the sunitinib group (hazard ratio for death, 0.53; 95% confidence interval [CI], 0.38 to 0.74; P<0.0001). Median progression-free survival was 15.1 months in the pembrolizumab-axitinib group and 11.1 months in the sunitinib group (hazard ratio for disease progression or death, 0.69; 95% CI, 0.57 to 0.84; P<0.001). The objective response rate was 59.3% (95% CI, 54.5 to 63.9) in the pembrolizumab-axitinib group and 35.7% (95% CI, 31.1 to 40.4) in the sunitinib group (P<0.001). The benefit of pembrolizumab plus axitinib was observed across the International Metastatic Renal Cell Carcinoma Database Consortium risk groups (i.e., favorable, intermediate, and poor risk) and regardless of programmed death ligand 1 expression. Grade 3 or higher adverse events of any cause occurred in 75.8% of patients in the pembrolizumab-axitinib group and in 70.6% in the sunitinib group. CONCLUSIONS: Among patients with previously untreated advanced renal-cell carcinoma, treatment with pembrolizumab plus axitinib resulted in significantly longer overall survival and progression-free survival, as well as a higher objective response rate, than treatment with sunitinib. (Funded by Merck Sharp & Dohme; KEYNOTE-426 ClinicalTrials.gov number, NCT02853331.).

Detection of Leptospira spp. in genitourinary tract of female goats managed in the brazilian semiarid.

Studies related to the prevalence of leptospirosis in the semiarid region showed that even during long periods of drought, the disease has a remarkable frequency in herds in the region. It is a neglected disease and the extent of its effects in the Brazilian semiarid region is not known. The dynamics of this agent is well studied in the urinary tract, however, there are not many studies regarding the genital tract in female goats. Observing this scenario, the present work aimed to diagnose Leptospira spp. in female goats kept in the Brazilian semiarid region by means of serological, molecular and isolation techniques. Blood samples, vaginal fluid, urine and fragments of organs from the genitourinary tract were collected from 40 goats destined for slaughter. Microscopic agglutination test (MAT) was used as a serological technique, with a battery of 24 serovars. The Polymerase Chain Reaction (PCR) of the vaginal fluid, urine and organ fragments was performed, as well as the bacterial growth of these same products in a selective medium. Isolation positive samples were subjected to PCR. It was observed that two (5%) animals were serologically positive for the Pyrogenes serogroup. A total of 29 (72.5%) animals were PCR positive, with DNA present in 51/160 (31.8%) samples from the genital tract and 34/120 (28.3%) from the urinary tract, with no statistical difference. For bacterial growth, 22/40 (55%) animals were positive for growth, with morphology being observed in 19/160 (11.8%) for the genital tract and 16/120 (13.3%) for the urinary tract, with no statistical difference. Two uterus samples showed 99% similarity with L. interrogans after sequencing. Thus, female goats kept under semiarid conditions were positive for Leptospira spp, with positive samples from both the urinary and genital tracts, which possible is an alternative way of adapting and maintaining the agent for severe and adverse conditions.

Development of a core outcome set for basal cell carcinoma.

BACKGROUND: There is variation in the outcomes reported in clinical studies of basal cell carcinoma. This can prevent effective meta-analyses from answering important clinical questions. OBJECTIVE: To identify a recommended minimum set of core outcomes for basal cell carcinoma clinical trials. METHODS: Patient and professional Delphi process to cull a long list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed important (score, 7-9, with 9 being the maximum) by 70% of each stakeholder group. RESULTS: Two hundred thirty-five candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in 2 Delphi rounds. Twenty-seven outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting included complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including cosmetic outcome. LIMITATIONS: English-speaking patients and professionals rated outcomes extracted from English language studies. CONCLUSION: A core outcome set for basal cell carcinoma has been developed. The use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.

Phase II consolidation trial with anti-Lewis-Y monoclonal antibody (hu3S193) in platinum-sensitive ovarian cancer after a second remission.

OBJECTIVE: To investigate the efficacy and safety of hu3S193, a humanized anti-Lewis-Y monoclonal antibody, as a consolidation strategy in patients with platinum-sensitive recurrent epithelial ovarian cancer who achieved a second complete response after salvage platinum-doublet chemotherapy. METHODS: This single-arm phase II study accrued patients with recurrent epithelial ovarian cancer with Lewis-Y expression by immunohistochemistry who had achieved a second complete response after five to eight cycles of platinum-based chemotherapy. Patients received intravenous infusions of hu3S193, 30 mg/m2 every 2 weeks starting no more than 8 weeks after the last dose of chemotherapy and continuing for 12 doses, until disease progression, or unacceptable toxicity. The primary endpoint was progression-free survival of the second remission. Secondary objectives were safety and pharmacokinetics. RESULTS: Twenty-nine patients were enrolled. Most had a papillary/serous histology tumor (94%), stage III disease at diagnosis (75%), and five (17%) underwent secondary cytoreduction before salvage chemotherapy. Two patients were not eligible for efficacy but were considered for toxicity analysis. Eighteen patients (62%) completed the full consolidation treatment while nine patients progressed on treatment. At the time of analysis, 23 patients (85%) of the eligible population had progressed and seven of these patients (26%) had died. Median progression-free survival of the second remission was 12.1 months (95% CI: 10.6-13.9), with a 1-year progression-free survival of the second remission rate of 50.1%. The trial was terminated early since it was unlikely that the primary objective would be achieved. The most commonly reported treatment-related adverse events were nausea (55%) and vomiting (51%). CONCLUSIONS: Hu3S193 did not show sufficient clinical activity as consolidation therapy in patients with recurrent epithelial ovarian cancer who achieved a second complete response after platinum-based chemotherapy. TRIAL REGISTRATION: NCT01137071.

Anthelmintic resistance of gastrointestinal nematodes in sheep grazing in irrigated and dry areas in the semiarid region of northeastern Brazil.

This study aimed to determine the AR of gastrointestinal nematodes (GIN) to commercial drugs in sheep flocks naturally infected, grazing in irrigated (IA) and dry (DA) areas of the semiarid region in northeastern Brazil. Fecal egg count reduction tests (FECRT) were performed at 10 farms. From each flock, 36 adult sheep were selected and divided into five groups (G1 (0.08% ivermectin), G2 (10% albendazole), G3 (5% levamisole), G4 (1% moxidectin), G5 (10% closantel) and one control group, G6). All the commercial drugs were found to reduce the number of eggs per gram of feces (EPG). Resistance to ivermectin (37.1%), albendazole (52.1%), and levamisole (52.0%) was detected at all the farms, but nematodes proved to be susceptible to moxidectin (87.9%) and closantel (83.9%). The overall average efficacy of the commercial drugs was significantly higher (P < 0.05) in DA (49.2%), where moxidectin (90.4%) showed high effectiveness. The presence of the parasite Haemonchus contortus predominated at all the farms. The variables irrigated area (P = 0.002), intensive breeding (P = 0.018), uncovered enclosures (P = 0.05), cultivated (P = 0.043) and native/cultivated (P = 0.007) pastures, and rotational grazing (P = 0.013) were significantly associated with GIN infection; irrigated area (P = 0.009), semi-intensive breeding (P = 0.05), rotational grazing (P = 0.045), cultivated (P = 0.021) and native/cultivated (P = 0.04) pastures, and estimated weighing of animals (P = 0.002) were significantly associated with AR. Therefore, improved management practices and strategic deworming must be implemented to prevent the development of AR.

Pembrolizumab plus axitinib versus sunitinib monotherapy as first-line treatment of advanced renal cell carcinoma (KEYNOTE-426): extended follow-up from a randomised, open-label, phase 3 trial.

BACKGROUND: The first interim analysis of the KEYNOTE-426 study showed superior efficacy of pembrolizumab plus axitinib over sunitinib monotherapy in treatment-naive, advanced renal cell carcinoma. The exploratory analysis with extended follow-up reported here aims to assess long-term efficacy and safety of pembrolizumab plus axitinib versus sunitinib monotherapy in patients with advanced renal cell carcinoma. METHODS: In the ongoing, randomised, open-label, phase 3 KEYNOTE-426 study, adults (≥18 years old) with treatment-naive, advanced renal cell carcinoma with clear cell histology were enrolled in 129 sites (hospitals and cancer centres) across 16 countries. Patients were randomly assigned (1:1) to receive 200 mg pembrolizumab intravenously every 3 weeks for up to 35 cycles plus 5 mg axitinib orally twice daily or 50 mg sunitinib monotherapy orally once daily for 4 weeks per 6-week cycle. Randomisation was done using an interactive voice response system or integrated web response system, and was stratified by International Metastatic Renal Cell Carcinoma Database Consortium risk status and geographical region. Primary endpoints were overall survival and progression-free survival in the intention-to-treat population. Since the primary endpoints were met at the first interim analysis, updated data are reported with nominal p values. This study is registered with ClinicalTrials.gov, NCT02853331. FINDINGS: Between Oct 24, 2016, and Jan 24, 2018, 861 patients were randomly assigned to receive pembrolizumab plus axitinib (n=432) or sunitinib monotherapy (n=429). With a median follow-up of 30·6 months (IQR 27·2-34·2), continued clinical benefit was observed with pembrolizumab plus axitinib over sunitinib in terms of overall survival (median not reached with pembrolizumab and axitinib vs 35·7 months [95% CI 33·3-not reached] with sunitinib); hazard ratio [HR] 0·68 [95% CI 0·55-0·85], p=0·0003) and progression-free survival (median 15·4 months [12·7-18·9] vs 11·1 months [9·1-12·5]; 0·71 [0·60-0·84], p<0·0001). The most frequent (≥10% patients in either group) treatment-related grade 3 or worse adverse events were hypertension (95 [22%] of 429 patients in the pembrolizumab plus axitinib group vs 84 [20%] of 425 patients in the sunitinib group), alanine aminotransferase increase (54 [13%] vs 11 [3%]), and diarrhoea (46 [11%] vs 23 [5%]). No new treatment-related deaths were reported since the first interim analysis. INTERPRETATION: With extended study follow-up, results from KEYNOTE-426 show that pembrolizumab plus axitinib continues to have superior clinical outcomes over sunitinib. These results continue to support the first-line treatment with pembrolizumab plus axitinib as the standard of care of advanced renal cell carcinoma. FUNDING: Merck Sharp & Dohme Corp, a subsidiary of Merck & Co, Inc.

Prevalence and risk factors associated with swine gastrointestinal nematodes and coccidia in the semi-arid region of northeastern Brazil.

In northeastern Brazil, with has a predominantly dry climate, farmers seek alternative sources of income and livelihood by the rearing pigs. The gastrointestinal parasites that affect these animals represent an obstacle in the production and can cause significant economic loss. This study aimed to determine the prevalence and risk factors associated with gastrointestinal nematodes and Coccidia in swine herds in the Sousa microregion, Paraíba state, northeastern Brazil. This was a cross-sectional study, and the sampling was designed to determine the prevalence of endoparasite-positive farms and pigs. We randomly selected 51 farms and 187 pigs. Fecal samples were collected from each animal, and eggs per gram and oocysts per gram feces were recorded. The data collected in the epidemiological questionnaires were used to determine the possible risk factors associated with endoparasite-positive animal status. The prevalence of gastrointestinal nematodes and Coccidia in the pigs was 79.5% (149/187). Coccidia were the most prevalent parasite found, with 56.6% (106/187) of the pigs testing positive, followed by nematodes 22.9% (43/187). Strongylidae was the most common nematodes found (67.5%, 29/43), followed by Trichuris sp. (30.2%, 13/43) and Ascaris sp. (2.3%, 1/43). In 29 coprocultures, Strongylidae was identified: Oesophagostomum (82.2%, 25/29), Strongyloides (62.0%, 18/29), and Hyostrongylus (27.5%, 8/29). Mixed nematode and coccidial infection were observed in 72.4% (21/29) of the samples. Relevant risk factors were related to the type of management adopted by family farmers. Changes in management measures could improve the health profile of farms.

High frequency of seropositive and carriers of Leptospira spp. in pigs in the semiarid region of northeastern Brazil.

Carrier animals are considered key in the transmission cycle of leptospirosis. Although investigations have been carried out on several species, the role of pigs in the epidemiology of the disease is still poorly studied in the semi-arid region. Thus, the objective of this study was to determine the presence of Leptospira spp. in the genitourinary tract of pigs intended for slaughter. Fifty pigs were used: adults and unvaccinated. Samples of the kidney, urine, and vaginal fluid were collected for the molecular detection of Leptospira spp. and blood samples for the serological test. The molecular test was performed using the polymerase chain reaction (PCR), and the serological test was performed with the microscopic agglutination test (MAT). Samples with DNA amplification were submitted to genetic sequencing. Twenty (40%) animals were found with anti-Leptospira spp. antibodies, and the majority of the reactions (50%) occurred for the serogroup Tarassovi. Leptospiral DNA was found in the tissue of 11 (22%) pigs. The gene from a urine sample was sequenced and showed similarity to L. borgpetersenii. The results evidenced a high rate of porcine carriers; therefore, they appear to be important sources of agent infection, being potential transmitters of the disease to other animal species and man.

Seroepidemiological study of Caseous lymphadenitis in sheep from the Northeast region of Brazil using an indirect ELISA.

The objective of this study was to determine the frequency of seropositivity Corynebacterium pseudotuberculosis in sheep in five states of northeastern Brazil, using an indirect enzyme-linked immunosorbent assay (i-ELISA). Young and adult sheep of both sexes were used. Blood samples were collected from 2638 sheep from 223 herds across all states. For the i-ELISA, antigens produced from the strain of C. pseudotuberculosis BRM 029971, a bacterial isolate from the Northeast region of Brazil, were used. Sensitivity and specificity indexes were calculated for the validation of the test, using as reference 49 and 134 serum samples from sheep known to be positive and negative, respectively. The i-ELISA presented four false-negative and four false-positive results, showing a specificity of 97.01%, a sensitivity of 91.84%, and an accuracy of 95.63%. These results were calculated based on an optical density (OD) cutoff point = 0.138. Of the 2638 sheep tested, 996 (37.76%, 95% CI = 35.93-39.62%) were seropositive, and of the 223 evaluated herds, 210 (94.17%, 95% CI = 90.28-96.56%) seropositive. The i-ELISA showed adequate sensitivity and specificity, proving to be a useful tool in the diagnosis of caseous lymphadenitis (CLA) in sheep. Infection by C. pseudotuberculosis, determined by serology, is disseminated in the sheep herds in the states of Northeast Brazil. Thus, there is a need to implement effective control measures that prevent the spread of infectious agents.

Microbiological, molecular, and histopathological findings in goats experimentally infected with Actinobacillus seminis.

The objective of this study was to experimentally evaluate the pathogenicity of an Actinobacillus seminis isolate named SAAS01 in goats. Animals were challenged with 2 mL of a suspension containing 1,5 × 108 CFU/mL of A. seminis (SAAS01 isolate) through the intrapreputial, epididymis tail, and conjunctival routes. Epididymis and testicular fragments were submitted to histopathological exam, and semen samples underwent microbiological and molecular diagnoses. Clinically, a unilateral increase in firm consistency was observed in the epididymis and testicles of two animals inoculated in epididymis tail and in one animal inoculated through conjunctival sac; this firmness continued until the day of euthanasia. Two goats inoculated through epididymis tail and conjunctival sac routes presented histopathological findings with macroscopically and microscopically significant changes. A. seminis was isolated from semen samples collected from goats inoculated through the epididymis tail and conjunctival sac routes. A. seminis DNA was amplified from six semen samples of three goats inoculated through the epididymis tail, two in conjunctival sac and one through intrapreputial route. The experimental infection model using goats confirmed the pathogenicity of the A. seminis isolate, demonstrating the predilection of the agent for the epididymis, with clinical signs, histopathological lesions, bacterial isolation, and a positive molecular diagnosis.

Strategies of the control of an outbreak of leptospiral infection in dairy cattle in Northeastern Brazil.

The aim of the present study was to describe the strategies of the control of an outbreak of leptospiral infection in dairy cattle in Maranhão State, Northeastern Brazil. In the period from January to July 2015, 18 (17%) out of 106 cows presented abortion, six (5.7%) stillbirth, and 12 (11.3%) repeated estrus, totaling 24 animals with reproductive problems. The diagnosis of leptospirosis was based on serology (microscopic agglutination test-MAT), bacteriological culture, and polymerase chain reaction (PCR). Antibiotic therapy, vaccination protocols, and changes in management practices were suggested as control measures. Of all animals on the farm (n = 280), 136 (48.6%) were seropositive for at least one serovar of Leptospira sp. No pure leptospiral culture was obtained. Eight of the animals with reproductive problems yielded positive PCR results (vaginal fluid of seven animals and urine and vaginal fluid of one animal). Genetic sequencing of a vaginal fluid/urine PCR-positive sample revealed Leptospira borgpetersenii. One year after the adoption of control measures, no reproductive problems were observed. Thus, leptospirosis probably caused the reproductive failures in the herd, and the control and prevention measures implemented were efficient in controlling the disease.

Seroepidemiological characterization and risk factors associated with seroconversion to Corynebacterium pseudotuberculosis in goats from Northeastern Brazil.

Goat breeding in the Northeast region of Brazil plays an important socioeconomic role. However, there are significant losses caused by sanitary deficits and infectious diseases, particularly caseous lymphadenitis (CL). Although CL is considered endemic in Northeastern Brazil, a comprehensive and up-to-date study of this disease in goat herds in this region is necessary. The objective of this study was to determine the farm-level and animal-level seroprevalences for the disease and to identify the possible risk factors that characterize CL in the caprine species of five Northeastern's states (Ceará, Piauí, Rio Grande do Norte, Paraíba, and Sergipe). A total of 2744 goat serum samples from 230 farms were collected between 2010 and 2012. The diagnosis of Corynebacterium pseudotuberculosis infection was performed using the indirect ELISA technique. Farm-level and animal-level seroprevalences were 87.8% and 30.3%, respectively, suggesting that C. pseudotuberculosis is widespread in goat herds of the Northeast region. The risk factors were as follows: absence of forage silage (odds ratio = 5.39), not separating animals by sex (odds ratio = 4.16) or by age (odds ratio = 6.30), not replacing old goat breeders (odds ratio = 7.80), and non-treatment of CL lumps prior to spontaneous rupture (odds ratio = 10.34). This study supports the idea that caseous lymphadenitis is widely disseminated in goats from Northeastern Brazil and based on the risk factor analysis attention should be given to the need to establish adequate control measures, such as incision and early drainage of superficial abscesses, quarantine and elimination of affected animals, periodic inspection of the herd, non-introduction of infected animals, and early disposal of animals with recurrent CL.

Susceptibility among breeds of sheep experimentally infected with Leptospira interrogans Pomona serogroup.

Leptospirosis is a disease that negatively affects the productive and reproductive indices of ruminants. Sheep are considered highly resistant to infection, although susceptibility may vary among breeds. Thus, the aim of the present study was to analyze the susceptibility between sheep breeds to the experimental infection by leptospires of the Pomona serogroup. Pomona serogroup, Kennewicki serovar strain (1 × 107 bacteria) was inoculated via the conjunctival route in 12 sheep divided into two groups, one comprising Santa Inês ewes and the other comprising crossbred sheep. In each group, five ewes were challenged with the bacterial strain and one was used as control. All sheep were monitored for 60 days, during which blood samples were collected for serological diagnosis and urine and vaginal fluid samples for molecular and microbiological analyses. Finally, as ewes were submitted to euthanasia and necropsy, some tissues of interest were collected for microbiological, molecular, and histopathological diagnoses. The groups were compared regarding the number of positive reactions according to diagnostic tests. All sheep in each group presented antibodies to Leptospira in all serological analyses, except animals of the control group. However the Santa Inês sheep presented higher concentration and duration of the titers, and their positive reactions were detected earlier than those in crossbred sheep. The antibody titers in group A (median 200, geometric mean 317.48) were significantly different from the group B (median 800, geometric mean 918.96) at D60 post-infection (P = 0,032). The Santa Inês sheep presented a higher number of positive reactions than did the crossbred sheep in the molecular diagnostic tests. According to the molecular diagnosis, the Santa Inês sheep presented more reactions (urine and vaginal fluid) compared to crossbred ewes, but there was no predominance in the detection of leptospiral DNA when comparing urine and vaginal fluid results, nor even between the number of positive kidneys and uterus. The Santa Inês sheep presented a higher number of positive bacteriological cultures. No sheep in either group presented alterations in anatomopathological and histopathological findings. Pure-bred sheep may be more susceptible than crossbred sheep to infection by Leptospira sp. Our findings emphasize the importance of the genital tract as a site of extraurinary infection and indicate the possibility of venereal transmission in the species.

Spatial analysis for bovine viral diarrhea virus and bovine herpesvirus type 1 infections in the state of Paraíba, northeastern Brazil.

BACKGROUND: Bovine Viral Diarrhea Virus (BVDV) and Bovine Herpesvirus type 1 (BoHV-1) cause reproductive problems in cattle and restrictions on international trade in animals worldwide. Both infections were detected in cattle herds in the Paraíba state, Northeastern Brazil, however, the spatial distribution and geographic identification of positive herds for these viruses has never been examined. Therefore, the aim of this study was to describe the spatial pattern of apparent prevalence estimate and to identify spatial clustering of positive herds of BVDV and BoHV-1 infections in cattle herds from the state of Paraíba, Northeastern Brazil. RESULTS: The herd-level prevalence for BVDV and BoHV-1 infections in Paraíba were, respectively, 65.5% (95% CI: 61.1-69.7) and 87.8% (95% CI: 84.5-90.5). The average apparent within-herd prevalence of BVDV was 31.8% and of BoHV-1 was 62.4%. The predicted prevalence was highest (0.42-0.75) for BVDV in the west, north and eastern part of Sertão and in the central and eastern part of Agreste/Zona da Mata. For BoHV-1, the highest predicted prevalence (0.74-0.97) was in some local areas across Sertão and throughout the eastern part of Agreste/Zona da Mata. Six significant clusters were detected for BVDV, a primary cluster covering the eastern Sertão region, with 11 herds, radius of 24.10 km and risk relative (RR) of 2.21 (P <  0.001) and five smaller significant clusters, involving one or two herds in Agreste/Zona da Mata region with a high RR. A significant clustering of BoHV-1 positive herds (P <  0.001) was detected in Agreste/Zona da Mata region with a radius of 77.17 km and a RR of 1.27, with 103 cases. Consistency was found between kriging and SatScan results for identification of risk areas for BVDV and BoHV-1 infections. CONCLUSIONS: The clusters detected contemplated different areas of the state, with BVDV cluster located in the Sertão and BoHV-1 in Agreste/Zona da Mata stratum. Through the risk mapping, it was possible to identify the areas in which the risk is significantly elevated, coincided with areas where there are borders with other states and in which there is a high movement of animals.