Left ventricular dysfunction associated with axitinib and nivolumab experience in an advanced renal cell carcinoma.

INTRODUCTION: Tyrosine kinase inhibitors and immune checkpoint inhibitors are widely used in advanced renal cell carcinoma. Here we reported a left ventricular dysfunction associated with axitinib and nivolumab experience in this patient with heart failure. CASE REPORT: A 70-year-old male patient with advanced renal cell carcinoma was treated with interferon alpha-2b 10 million U thrice weekly. After progression, sunitinib provided 18 months of stable disease. In third line, the patient was treated with axitinib 10 mg daily. Under axitinib, the patient presented with dyspnea and palpitations. The diagnostic work-up showed a left ventricular dysfunction with an ejection fraction (EF) of 35% in echocardiography. He was treated with diuretics, acetylsalicylic acid 100 mg and low molecular weight heparin.Management and outcome: After excluding cardiac ischemic and pulmonary pathologies, we concluded a possible adverse event diagnosis of axitinib-related cardiotoxicity. After close follow up for cardiac dysfunction, the patient was treated with nivolumab 3 mg/kg every two weeks. The initial EF was 32%. After three months therapy, the patient was asymptomatic for cardiac dysfunction and EF was 50%. CT scan showed partial response in pulmonary lesions. DISCUSSION: We have limited no data about cardiotoxicity associated axitinib and limited data about ICIPs. Our case is unique by providing data about how to manage a metastatic RCC patient with left ventricular dysfunction under axitinib and how to follow-up the cardiac functions while under nivolumab therapy.

Anatomical characteristics of the tibial medullary canal and their implications for intramedullary fixation.

The use of intramedullary fixation methods in the tibia is limited by the anatomical characteristics of this bone. In this study, the shape and degree of axial lateral rotation of the medullary canal were determined in 45 human dry cadaver bones using X-ray and computed tomography examinations and direct measurement of rotation in inserted nails. Forty bones (88.8%) had slight and five bones (11.1%) had excessive anterior bowing along the tibial shaft. Six of the 45 bones (13.3%) had an extremely narrow medullary canal. Axial lateral rotation was demonstrated in the middle third of the medullary canal, being on average (+/- SD) 32.35 +/- 16.25 degrees (range 10-75 degrees). This study revealed that extreme narrowing of the medullary canal, axial lateral rotation of the medullary canal, and extreme anterior bowing of the tibial shaft are the anatomical characteristics most likely to cause difficulties when using intermedullary fixation in the tibia.

Prevention of postoperative late kyphosis in Pott's disease by anterior decompression and intervertebral grafting.

A total of 185 patients with Pott's disease were operated on between 1973 and 1992. Anterior decompression by preserving the pleura (extrapleural approach) was the preferred method in the thoracic spine. In the lumbar spine the approach was retroperitoneal, and interbody fusion was performed in both for the thoracic and the lumbar regions. Anterior decompression and intervertebral grafting comprised the treatment. In five patients, internal fixation accompanied anterior decompression and intervertebral grafting. The aim of instrumentation was to enhance anterior spinal stability, and Alici spinal instrumentation was the preferred device. Graft destruction and a late increase in kyphosis was prevented by this means. The mean follow-up period was 7.5 years. Thirty-two of the cases were admitted to the clinic because of Pott's paraplegia: 19 of the cases recovered completely following anterior decompression; partial recovery was observed in 5 cases; but 3 cases did not recover. Various complications, including seven deaths, were observed in 42 of the cases.

Ischaemia-reperfusion injury in the rat kidney: the effect of preconditioning.

OBJECTIVES: To design and establish a model to examine whether brief periods of renal artery occlusion (ischaemic preconditioning, IP) confers protection from the effects of a subsequent period of ischaemia and reperfusion of the rat kidney. MATERIALS AND METHODS: Ninety rats were randomized into six groups, i.e. sham-operated controls; IP alone; a 20 or 40 min period of left renal ischaemia (RI) alone; and IP followed by a 20 or 40 min period of RI. Preconditioning involved the sequential clamping of the left renal artery for 4 min and its release for 11 min, a total of four times, a 'critical interval' of 30 min before the ischaemic insult. Left renal tissue integrity was determined by dimercapto-succinic acid (DMSA) radionuclide imaging on a gamma-camera both immediately (day 0) and 2 and 9 days later. Acute tubular necrosis was also assessed histologically. RESULTS: RI for 20 min resulted in a significant decrease in left renal tissue integrity on day 2 only (P < 0.001), whereas RI for 40 min caused significant left renal dysfunction on day 0, day 2 and day 9 (P < or = 0.01). For a given duration of ischaemia, there was no significant difference between results from (IP + RI) rats compared with RI-only rats at any of the three times. There was no significant alteration in renal tissue integrity in the IP-only rats compared with sham-operated controls. Histological findings paralleled the data obtained from DMSA uptake. CONCLUSIONS: The IP regimen and 30 min 'critical interval' confers no protection to the kidney from a 20 or 40 min ischaemic episode. The IP regimen itself appears to have no effect, confirming the validity of our experimental model.

Clinical importance of the minimal cancellous diameter of lower thoracic and lumbar vertebral pedicles.

Transpedicular spinal fixation is a widely used method in vertebral surgery, but it suffers from complications due to mismatches between the screw and pedicle. Therefore, information on minimal cancellous (MCD) and minimal external diameters (MED) of the pedicle is highly important for vertebral surgery. To determine these diameters and their ratios, 2,808 measurements of 1,404 pedicles of 702 human vertebrae were made from Th11 to L5. We found that the mean ratio of MCD to MED was 72.2%, MCD to vertical diameter (VD) was 41.7%, and MCD to transverse diameter (TD) was 62.2% in all levels. We recommend that these results be considered prior to pedicular fixation operations and design of new implantable devices.