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Introduction: Immune-related hepatitis is an adverse effect following treatment with immune-checkpoint inhibitors, such as ipilimumab, nivolumab and pembrolizumab. International guidelines advise on the use of corticosteroids as first-line treatment, although guidance on how to treat cases resistant to corticosteroids is limited. We aimed to evaluate the presentation and management of patients with grade 3-4 immune-related hepatitis, following treatment with immune-checkpoint inhibitors for stage 4 or unresectable or stage 3 melanoma, with a particular focus on steroid-refractory cases. Methods: A retrospective observational review of patients developing immune-related hepatitis whilst undergoing treatment with immune checkpoint inhibitors for advanced melanoma from July 2014 to February 2020 at a tertiary oncology centre. Results: Forty-one patients developed immune-related hepatitis, of which 83% had been treated with the combination of ipilimumab and nivolumab. The median time to onset of IR-hepatitis was 47 days (range: 4–476), and the median time to peak alanine aminotransferase was 71 days (range: 4–478). Four patients had resolution of grade 3 immune-related hepatitis without the introduction of corticosteroids. A total of 37 patients were treated with corticosteroids. A total of 12 required oral treatment only and 13 were successfully managed as outpatients. Six patients had steroid-refractory immune-related hepatitis; and all received tacrolimus, with one also receiving mycophenolate mofetil and infliximab. Conclusions: This study describes the largest UK series of immune-related hepatitis patients in the literature. We present two important deviations from current guidelines. Firstly, there is some evidence that withholding steroids is possible in grade 3-4 immune-related hepatitis. Secondly, tacrolimus can be used successfully to manage patients resistant to corticosteroids, with the early introduction most beneficial to reduce time on steroids. [ABSTRACT FROM AUTHOR]

Background: Merkel cell carcinoma (MCC) is a rare tumour with neuroendocrine differentiation and high associated mortality. Studies that describe the epidemiology of MCC are often limited by small sample size, short duration of follow-up, absence of nationwide data and paucity of data on different risk factors. Objectives: To determine the incidence, demographics and survival for MCC in England between 2004 and 2018. Methods: This national retrospective cohort study identified all cases of MCC in England from 2004 to 2018 using national population-based data from the National Disease Registration Service. Crude counts, European age-standardized incidence rates (EASRs) and joinpoint analysis were conducted. Patient demographics and treatments received were described. Multivariable Cox regression analysis was used to study risk factors for MCC-specific mortality, by including a priori defined demographic factors, tumour characteristics and immunosuppression. Treatment data were not included in the Cox regression analysis. Results: A total of 3775 MCC tumours were registered. The median age at diagnosis was 81 years (interquartile range 74–87). Overall, 96·6% of patients identified as White ethnicity, and 8·3% of patients were immunosuppressed. The most common site was the face (27·4%). Patients most often presented with stage one disease (22·8%); however, stage was unknown in 31·0%. In total, 80·7% of patients underwent surgical excision, 43·5% radiotherapy and 9·2% systemic therapy. The EASR increased from 0·43 per 100 000 person-years (PYs) to 0·65 per 100 000 person-years between 2004 and 2018, representing a significant annual percentage change of 3·9%. The EASR was greater in men than in women for all years, with an overall male-to-female ratio of 1·41 : 1. The highest EASR was in South West England. Five-year disease-specific survival was 65·6% [95% confidence interval (CI) 63·8–67·4], with a median follow-up of 767 days. MCC-specific mortality increased with age [hazard ratio (HR) 1·02, 95% CI 1·02–1·03], deprivation (HR 1·43, 95% CI 1·16–1·76), immunosuppression (HR 2·80, 95% CI 2·34–3·34) and stage at diagnosis (HR 8·24, 95% CI 5·84–11·6). Conclusions: This study presents the largest national MCC dataset in Europe, and the most complete reporting of MCC incidence and survival ever published. With the EASR of MCC increasing and high associated mortality, this study encourages further research into the pathology, diagnosis and therapeutic options for MCC to support management guidelines. This national retrospective cohort study of Merkel cell carcinoma in England included 3775 tumours over 15 years. The data highlights the increasing incidence, high mortality and current management practices of MCC in England." cd_value_code="text"/> [ABSTRACT FROM AUTHOR]

Uterocutaneous fistula is exceedingly rare, and uniformly follows some type of operative procedure. In this case, a young woman underwent a cesarean delivery at an outlying clinic in rural Nigeria, following which she developed amenorrhea and cyclic pelvic pain. In attempts to resolve her condition, a second laparotomy was performed at the same medical center. She presented to us 2 weeks later, at which time an opening was present at the healing laparotomy scar, severe vaginal scarring and cervical stenosis were present, and marked hematometra was seen on ultrasound. Following a procedure to open her cervix, she began menstruating through a fistulous tract in her abdomen, which we subsequently excised and closed with no further problems for the patient. This case highlights the challenge in developing countries of surgical complications resulting from a lack of appropriately trained physicians in rural medical centers. We suggest that focus on excellent training of our young physicians and the creation of incentives to place and keep fully qualified physicians in such hospitals will improve this situation.

A random trial was performed whereby patients receiving chemotherapy for solid tumor or lymphoma were administered levofloxacin or matching placebo during the expected neutropenic period. Results revealed that the prophylactic use of levofloxacin minimized the occurrence of fever, infection and hospitalization among these patients.