Search

The standard-of-care for muscle-invasive bladder cancer is radical surgery with neoadjuvant cisplatin-based chemotherapy. Despite curative intent from these interventions, relapse rates post-surgery remain high, with approximately 50% of patients developing local or distant recurrence within 2 years of surgery and a 5-year survival of only 50–60%. Identifying patients who are high risk for relapse post-surgery is a priority. Monitoring patients for circulating tumor DNA (ctDNA) is a minimally invasive approach that appears attractive for selecting patients potentially suitable for adjuvant treatment with checkpoint inhibitors. IMvigor011 (NCT04660344) is a global, double-blind, randomized phase III study assessing the efficacy of atezolizumab (anti-PD-L1) versus placebo in patients with high-risk muscle-invasive bladder cancer who are ctDNA positive post-cystectomy. The primary end point is disease-free survival in participants who are ctDNA positive within 20 weeks of cystectomy.

BackgroundImmune checkpoint inhibitor-associated acute kidney injury (ICPi-AKI) has emerged as an important toxicity among patients with cancer.MethodsWe collected data on 429 patients with ICPi-AKI and 429 control patients who received ICPis contemporaneously but who did not develop ICPi-AKI from 30 sites in 10 countries. Multivariable logistic regression was used to identify predictors of ICPi-AKI and its recovery. A multivariable Cox model was used to estimate the effect of ICPi rechallenge versus no rechallenge on survival following ICPi-AKI.ResultsICPi-AKI occurred at a median of 16 weeks (IQR 8–32) following ICPi initiation. Lower baseline estimated glomerular filtration rate, proton pump inhibitor (PPI) use, and extrarenal immune-related adverse events (irAEs) were each associated with a higher risk of ICPi-AKI. Acute tubulointerstitial nephritis was the most common lesion on kidney biopsy (125/151 biopsied patients [82.7%]). Renal recovery occurred in 276 patients (64.3%) at a median of 7 weeks (IQR 3–10) following ICPi-AKI. Treatment with corticosteroids within 14 days following ICPi-AKI diagnosis was associated with higher odds of renal recovery (adjusted OR 2.64; 95% CI 1.58 to 4.41). Among patients treated with corticosteroids, early initiation of corticosteroids (within 3 days of ICPi-AKI) was associated with a higher odds of renal recovery compared with later initiation (more than 3 days following ICPi-AKI) (adjusted OR 2.09; 95% CI 1.16 to 3.79). Of 121 patients rechallenged, 20 (16.5%) developed recurrent ICPi-AKI. There was no difference in survival among patients rechallenged versus those not rechallenged following ICPi-AKI.ConclusionsPatients who developed ICPi-AKI were more likely to have impaired renal function at baseline, use a PPI, and have extrarenal irAEs. Two-thirds of patients had renal recovery following ICPi-AKI. Treatment with corticosteroids was associated with improved renal recovery.

Junior doctors describe a need for greater support and training in end of life care (EoLC) communication skills. The Second Conversation project was designed by a multi-professional steering group as a workplace based training intervention for junior doctors to improve their skills and confidence in undertaking EoLC conversations. Qualitative interviews were carried out with 11 junior doctors and five senior doctors across two sites who took part in, or facilitated, a ‘second conversation’. This is a three-step training intervention that involves 1) observation – the junior doctor observes an EoLC conversation between a senior doctor and patient/caregiver; 2) direct experience – the junior doctor undertakes a follow-up second conversation with the patient/caregiver; and 3) reflection – the junior doctor discusses and reflects on the experience with a senior colleague. Interviews were analysed using framework analysis and findings informed iterative changes to the intervention and its implementation using ‘Plan, Do, Study, Act’ cycles. Benefits that were identified included the flexibility of the intervention and its positive impact on the confidence and skills of junior doctors. The Second Conversation was felt to be of most value to newly qualified doctors and worked well on wards where length of stay was longer and EoLC conversations frequently happen. Further evaluation and exploration of patient and caregiver experiences is required.

The approval of immune checkpoint inhibitors (ICIs) has changed the treatment landscape in many aspects of urothelial cancer (UC), in both non-muscle-invasive bladder cancer and muscle-invasive bladder cancer and has introduced the concept of long-term remission for some patients in the metastatic setting. Front-line chemotherapy remains superior at achieving initial control of disease compared to front-line immune therapy. However, long-term durable responses are limited by chemotherapy resistance. The maintenance approach, sequencing chemotherapy with ICIs, could be considered a best of both worlds approach, achieving initial control with chemotherapy, which is maintained in some individuals with avelumab. However, outcomes for patients with metastatic UC remain poor. There are three steps to improving outcomes for these patients; the first is to develop better drugs and combinations of therapies, the second is the development of novel biomarkers and techniques to better select patients for treatment, and the third area of development is to give the drugs in the most optimal setting.

Background Over recent years there has been a trend towards developing high-quality assessments to assess a doctor's performance in the workplace. Case-based discussion (CbD) is a form of workplace-based assessment that has the potential to provide feedback to trainees on their performance or management of a specific case. The aim of this study was to explore how CbDs are perceived and implemented in practice amongst a UK cohort of medical trainees. Methods This study involved 78 medical trainees at a UK hospital completing a questionnaire rating their last CbD experience, including the duration spent receiving feedback, whether it was pre-planned or ad hoc and how they responded to the feedback received. Focus groups were conducted involving 12 trainees to discuss common themes on feedback arising from the questionnaire, and thematic analysis was carried out following these discussions. Results Only 19 per cent of assessments were pre-planned and the average duration of assessments was 6-10 minutes, with feedback lasting less than 5 minutes. A total of 76 per cent of trainees responded to the feedback they received by completing self-directed learning or by addressing the specific action points arising from the feedback. The focus groups highlighted the barriers to incorporating these assessments into everyday practice, including appreciating the time constraints and the importance of trainer engagement in the assessment process. The aim of this study was to explore how CbDs are perceived and implemented in practice CONCLUSION: This study demonstrates that most trainees appreciate the educational value of CbDs, but more emphasis and training is required in planning these assessments and in providing feedback that is both specific and actionable.

Centre for Rheumatology Research, UCL Division of Medicine, University College London, London, Department of Rheumatology, University Hospitals of Leicester, Leicester, Womens Health, University College London Hospital, London, Obstetrics and Gynaecology, Frimley Park Hospital, Surrey, Department of Rheumatology, University Hospital Birmingham NHS Foundation Trust, Birmingham, Department of Rheumatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK, Department of Rheumatology, Copenhagen University Hospital, Rigshospitalet, Denmark, Department of Rheumatology, Burton Hospitals NHS Trust, Burtonupon-Trent, Rheumatic and Musculoskeletal Disease Unit, Our Lady’s Hospice and Care Services, Dublin, Ireland, Department of Rheumatology, University College London Hospital, London, Department of Rheumatology, Aneurin Bevan University Health Board, Newport, UK, Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust and Division of Immunity and Infection, University of Birmingham, Birmingham, UK

The demand for endoscopic procedures continues to increase and is likely to continue to do so for the foreseeable future. Alongside elective diagnostic procedures, the number of complex and therapeutic procedures is increasing. It is therefore vital that the consent process is comprehensive, and high standards in consenting patients are maintained. Consent is defined as a patient9s agreement to treatment or an intervention proposed by a health professional. Careful patient selection is required when proposing endoscopic procedures with an appreciation of the risks and complications that are involved. This paper addresses the various components of gaining informed consent and the legal issues surrounding this process. Additionally, this article reviews legislation and focuses upon specific instances where further considerations have to be made; in a patient who lacks capacity, in children, in percutaneous endoscopic gastrostomy and in the patient who is a Jehovah9s Witness.