Systemic therapy treatment patterns in patients with advanced non-small cell lung cancer (NSCLC): PIvOTAL study

The aim of this multinational retrospective cohort study, conducted at academic and community oncology centres, was to describe real‐world treatment patterns for patients with a confirmed diagnosis of advanced/metastatic (stage IIIB/IV) non‐small cell lung cancer (NSCLC) who initiated first‐line systemic therapy from January 2011 through June 2014. The study included 1265 patients in Italy, Spain, Germany, Australia, Korea, Taiwan and Brazil. The proportion of patients with squamous versus non‐squamous NSCLC was approximately 20% versus 75%, and associated patient demographic characteristics were similar in all countries, excepting race. Patients with squamous NSCLC were predominantly male and current/ex‐smokers. Biomarker tests were performed for the majority of patients with non‐squamous NSCLC, ranging from 54% (Brazil) to 91% in Taiwan, where, of those tested, 68% with non‐squamous NSCLC had positive epidermal growth factor receptor (EGFR)‐mutation status; in other countries the EGFR‐positive percentages ranged from 17% (Spain/Brazil) to 40% (Korea). Platinum‐based regimens were the most common first‐line therapy in all countries except Taiwan, where gefitinib was the most common first‐line agent. Median overall survival ranged from 9.3 months (Brazil) to 25.5 months (Taiwan). The diagnostic and treatment patterns recorded in this study were heterogeneous but largely in line with NSCLC guidelines during the study period.

Robotic transanal surgery (RTAS) with utilization of a next-generation single-port system: a cadaveric feasibility study

PURPOSE

Transanal surgery remains both an innovative approach to rectal pathology and a demonstrated technical challenge. Improved technology using a single-port system robotic platform (SPS) offers a promising option for this surgery.

METHODS

SPS robotic system was utilized to perform submucosal, full-thickness and cylindrical excision on four cadavers. Operative performance and surgeon fatigue were measured.

RESULTS

On all types of resections, the SPS system performed well. There were no piecemeal or fragmented resections. Closure was judged to be good to excellent in all cases. Surgeon assessment of setup and performance of the SPS was excellent in all cases.

CONCLUSIONS

SPS robotic transanal surgery represents an exciting new option for transanal surgery.

Implementation of a 'care bundle' improves the management of patients admitted to hospital with decompensated cirrhosis

BACKGROUND

Since 1970, there has been a 400% increase in liver-related deaths due to the increasing prevalence of chronic liver disease in the United Kingdom (UK). The 2013 UK National Confidential Enquiry into Patient Outcome and Death report found that only 47% of patients who died from alcohol-related liver disease received 'good care' during their hospital stay.

AIM

To develop a 'care bundle' for patients with decompensated cirrhosis, aiming to ensure that evidence-based treatments are delivered within the first 24 h of hospital admission.

METHODS

This work gives practical advice about how to implement the bundle and examines its effects on patient care at three National Health Service Hospital Trusts in the UK by collecting data on patient care before and after introduction of the bundle.

RESULTS

Data were collected on 228 patients across three centres (59% male, median age 53 years). Alcohol-related liver disease was the aetiology of chronic liver disease in 85% of patients. The overall mortality rate during hospital admission was 15%. The audits demonstrated improvements in patient care for patients with a completed care bundle who were significantly more likely to have a diagnostic ascitic performed within the first 24 h (P = 0.020), have an accurate alcohol history documented (P < 0.0001) and be given antibiotics as prophylaxis against infection following a variceal haemorrhage (P = 0.0096). In Newcastle, the bundle completion rate increased from 25% to 90% during the review periods.

CONCLUSIONS

The introduction of a care bundle was associated with increased rates of diagnostic paracentesis and antibiotic prophylaxis with variceal haemorrhage in patients with decompensated cirrhosis.

TACTIC: a multicentre, open-label, single-arm phase II trial of panitumumab, cisplatin, and gemcitabine in biliary tract cancer

PURPOSE

The phase II TACTIC trial prospectively selected patients with KRAS wild-type advanced biliary tract cancer for first-line treatment with panitumumab and combination chemotherapy.

METHODS

Of 78 patients screened, 85 % had KRAS wild-type tumours and 48 were enrolled. Participants received cisplatin 25 mg/m(2) and gemcitabine 1000 mg/m(2) on day 1 and day 8 of each 21-day cycle and panitumumab 9 mg/kg on day 1 of each cycle. Treatment was continued until disease progression, unacceptable toxicity, or request to discontinue. The primary endpoint was the clinical benefit rate (CBR) at 12 weeks (complete response, partial response, or stable disease). CBR of 70 % was considered to be of clinical interest. Secondary outcomes were progression-free survival, time to treatment failure, overall survival, CA19.9 response and safety.

RESULTS

Thirty-four patients had a clinical benefit at 12 weeks, an actuarial rate of 80 % (95 % CI 65-89 %). 46 % had a complete or partial response. Median progression-free survival was 8.0 months (95 % CI 5.1-9.9) and median overall survival 11.9 months (95 % CI 7.4-15.8). Infection accounted for 27 % of the grade 3 or 4 toxicity, with rash (13 %), fatigue (13 %), and hypomagnesemia (10 %) among the more common grade 3 or 4 non-haematological toxicities.

CONCLUSION

A marker-driven approach to patient selection was feasible in advanced biliary tract cancer in an Australian population. The combination of panitumumab, gemcitabine, and cisplatin in KRAS wild-type cancers was generally well tolerated and showed promising clinical efficacy. Further exploration of anti-EGFR therapy in a more selected population is warranted.

Acceptability of delivery modes for lifestyle advice in a large scale randomised controlled obesity prevention trial

BACKGROUND

Preventing obesity is an international health priority and women living in rural communities are at an increased risk of weight gain. Lifestyle programs are needed as part of a comprehensive approach to prevent obesity. Evaluation provides a unique opportunity to investigate and inform improvements in lifestyle program implementation strategies. The Healthy Lifestyle Program for rural women (HeLP-her Rural) is a large scale, cluster randomized control trial, targeting the prevention of weight gain. This program utilises multiple delivery modes for simple lifestyle advice (group sessions, phone coaching, text messages, and an interactive program manual). Here, we describe the acceptability of these various delivery modes.

METHODS

A mixed-method process evaluation was undertaken measuring program fidelity, recruitment strategies, dose delivered, program acceptability and contextual factors influencing program implementation. Data collection methodologies included qualitative semi-structured interviews for a sub-group of intervention participants [n = 28] via thematic analysis and quantitative methods (program checklists and questionnaires [n = 190]) analysed via chi square and t-tests.

RESULTS

We recruited 649 women from 41 rural townships into the HeLP-her Rural program with high levels of program fidelity, dose delivered and acceptability. Participants were from low socioeconomic townships and no differences were detected between socioeconomic characteristics and the number of participants recruited across the towns (p = 0.15). A face-to-face group session was the most commonly reported preferred delivery mode for receiving lifestyle advice, followed by text messages and phone coaching. Multiple sub-themes emerged to support the value of group sessions which included: promoting of a sense of belonging, mutual support and a forum to share ideas. The value of various delivery modes was influenced by participant's various needs and learning styles.

CONCLUSION

This comprehensive evaluation reveals strong implementation fidelity and high levels of dose delivery. We demonstrate reach to women from relatively low income rural townships and highlight the acceptability of low intensity healthy lifestyle programs with mixed face-to-face and remote delivery modes in this population. Group education sessions were the most highly valued component of the intervention, with at least one face-to-face session critical to successful program implementation. However, lifestyle advice via multiple delivery modes is recommended to optimise program acceptability and ultimately effectiveness.

TRIAL REGISTRY

Australia & New Zealand Clinical Trial Registry. Trial number ACTRN12612000115831, date of registration 24/01/2012.

Denosumab for the prevention of skeletal complications in metastatic castration-resistant prostate cancer: comparison of skeletal-related events and symptomatic skeletal events

In this analysis of a phase III trial in patients with castration-resistant prostate cancer and bone metastases, treatment with denosumab reduced the risk of skeletal complications vs zoledronic acid regardless of whether the end point was defined as SSE or SRE. Both SSEs and SREs were associated with development of moderate/severe pain among patients with no/mild pain at baseline.

Background

In a phase III trial in patients with castration-resistant prostate cancer (CRPC) and bone metastases, denosumab was superior to zoledronic acid in reducing skeletal-related events (SREs; radiation to bone, pathologic fracture, surgery to bone, or spinal cord compression). This study reassessed the efficacy of denosumab using symptomatic skeletal events (SSEs) as a prespecified exploratory end point.

Patients and methods

Patients with CRPC, no previous bisphosphonate exposure, and radiographic evidence of bone metastasis were randomized to subcutaneous denosumab 120 mg plus i.v. placebo every 4 weeks (Q4W), or i.v. zoledronic acid 4 mg plus subcutaneous placebo Q4W during the blinded treatment phase. SSEs were defined as radiation to bone, symptomatic pathologic fracture, surgery to bone, or symptomatic spinal cord compression. The relationship between SSE or SRE and time to moderate/severe pain was assessed using the Brief Pain Inventory Short Form.

Results

Treatment with denosumab significantly reduced the risk of developing first SSE [HR, 0.78; 95% confidence interval (CI) 0.66–0.93; P = 0.005] and first and subsequent SSEs (rate ratio, 0.78; 95% CI 0.65–0.92; P = 0.004) compared with zoledronic acid. The treatment differences in the number of patients with SSEs or SREs were similar (n = 48 and n = 45, respectively). Among patients with no/mild pain at baseline, both SSEs and SREs were associated with moderate/severe pain development (P < 0.0001). Fewer patients had skeletal complications, particularly fractures, when defined as SSE versus SRE.

Conclusion

In patients with CRPC and bone metastases, denosumab reduced the risk of skeletal complications versus zoledronic acid regardless of whether the end point was defined as SSE or SRE.

The feasibility and clinical efficacy of intravenous iron administration for preoperative anaemia in patients with colorectal cancer

AIM

The study aimed to analyse the feasibility and efficacy of administration of a single intravenous iron infusion (IVI) in the preoperative optimization of colorectal cancer patients with anaemia.

METHOD

Twenty patients were recruited at least 14 days before the planned date of surgery. A single 1000 mg dose of ferric carboxymaltose (Ferinject) was administered as an outpatient procedure. Blood samples were taken at recruitment prior to drug administration (REC), on the day of surgery prior to any intervention (DOS) and on the first postoperative day. Allogeneic red blood cell transfusions (ARBT) and outcomes were recorded from recruitment throughout the study period.

RESULTS

There was a significant median rise in haemoglobin levels (Hb) from REC to DOS of 1.8 g/dl [interquartile range (IQR) 0.75-2.45, P < 0.001] for the entire cohort. Two patients received ARBT preoperatively, and for those not transfused preoperatively (n = 18), this incremental Hb rise remained significant (P < 0.001, median 1.65 g/dl, IQR 0.5-2.3). Of these patients, those who responded to IVI had higher erythropoietin (EPO) levels at recruitment (P < 0.01) and lower recruitment Hb values, transferrin-saturation (TSAT) and C-reactive protein (CRP) levels (P < 0.05). REC Hb (Rs = -0.62, P < 0.01), REC TSAT levels (Rs = -0.67, P < 0.01) and REC EPO (Rs = 0.69, P < 0.01) correlated with the magnitude of treatment change in Hb levels. Five patients received ARBT until the fourth postoperative day, which was significantly fewer than predicted (P < 0.05).

CONCLUSION

IVI can be administered preoperatively in the outpatient clinic to colorectal cancer patients with anaemia, with associated reduction in ARBT use and increase in Hb levels.

Association between temperature, humidity and ebolavirus disease outbreaks in Africa, 1976 to 2014

Ebolavirus disease (EVD) outbreaks have been occurring sporadically in Central Africa since 1976. In 2014, the first outbreak in West Africa was reported in Guinea. Subsequent outbreaks then appeared in Liberia, Sierra Leone and Nigeria. The study of environmental factors underlying EVD epidemiology may provide useful insights into when and where EVD outbreaks are more likely to occur. In this paper, we aimed to investigate the association between climatic factors and onset of EVD outbreaks in humans. Our results suggest lower temperature and higher absolute humidity are associated with EVD outbreak onset in the previous EVD outbreaks in Africa during 1976 to 2014. Potential mechanisms through which climate may have an influence on ebolavirus infection in the natural host, intermediate hosts and humans are discussed. Current and future surveillance efforts should be supported to further understand ebolavirus transmission events between and within species.

Quality of 'commercial-off-the-shelf' (COTS) monitors displaying dental radiographs

BACKGROUND

A computer display monitor used for interpreting dental images should have a maximum luminance of 171 cd/m(2). A monitor used for clinical review should have a maximum luminance of 100 cd/m(2).

OBJECTIVE

To compare luminance and ambient lighting measurements for a selection of computer display monitors in different locations of a dental teaching hospital to available guidelines. To assess six commercial off-the-shelf (COTS) monitors from the radiology department of the dental teaching hospital after calibration to the Digital Imaging and Communications in Medicine Part 14: Greyscale Standard Display Function (DICOM part 14: GSDF).

DESIGN

Data collection.

METHOD

Luminance and illuminance measurements were taken for a selection of monitors used for clinical applications throughout a dental teaching hospital. Conformance data were recorded for six COTS monitors from the radiology department following calibration to the DICOM part 14: GSDF. RESULTS None of the tested monitors had a maximum luminance value that was appropriate for image interpretation and the ambient lighting in the vicinity of the monitors was also set to inappropriate levels for image interpretation. The quality of conformance to the DICOM part 14: GSDF varied among the calibrated COTS monitors in the radiology department.

CONCLUSIONS

: It is important that display devices used for dental radiology are quality assured. Consideration should be given to ensure that monitors used for dental radiological interpretation have a maximum luminance that meets available guidelines. These monitors should be standardised to the DICOM part 14: GSDF and the illumination of the reporting environment should be controlled.

Anatomical characterisation of the cricothyroid membrane in females of childbearing age using computed tomography

BACKGROUND

In the event of failure to secure the airway by conventional means, it may be necessary to perform invasive airway access via the cricothyroid membrane. No studies have addressed anatomy of this structure in the obstetric population. We aimed to review the anatomical variation of this structure in a population of childbearing age.

METHODS

We searched the radiology database for computed tomography studies of the neck performed in a 13-month period in consecutive patients aged 15-55 years. Studies on 18 females and 22 males were reviewed. Male patients were included for comparison. Data were reconstructed using a high spatial frequency algorithm to optimise spatial resolution. Five parameters were measured: distance from the skin to the membrane, maximum midline height of the membrane in the vertical plane, maximum transverse diameter of the membrane, neck diameter and cartilaginous calcification.

RESULTS

The distance (mean range) from skin to the membrane was similar in females and males (16.2 [3-33] vs. 13.9 [3-37] mm, P = 0.42). The vertical height (9.9 [7-17] vs. 11.4 [8-15] mm, P = 0.04) and maximum width of the membrane (14.5 [10-17] mm vs. 12.5 [10-15] mm, P < 0.01) were greater in males. Cartilaginous calcification was low and did not differ between genders.

CONCLUSIONS

The cricothyroid membrane is not necessarily a superficial structure and consequently may be difficult to palpate. The smallest dimensions of the membrane indicate that smaller than recommended cricothyroidotomy devices may be required in some patients as the external diameter of commercial trocar devices and tracheal tubes may exceed 7 mm.

Could standardizing "commercial off-the-shelf" (COTS) monitors to the DICOM part 14: GSDF improve the presentation of dental images? A visual grading characteristics analysis

OBJECTIVES

To investigate whether standardizing commercial off-the-shelf (COTS) display devices to the digital imaging and communications in medicine part 14: greyscale standard display function (DICOM part 14: GSDF) would affect the presentation of dental images.

METHODS

Two COTS display devices from the radiology department of a dental teaching hospital and a laptop computer monitor for reference were calibrated to conform to DICOM part 14: GSDF. Four dental surgeons and two final-year students undertook a relative visual grading analysis of the two devices before and after calibration, under control of the viewing environment.

RESULTS

Calibrating COTS display devices to conform to the DICOM part 14: GSDF and viewing under reduced ambient light result in a consistent, perceived visual sensation for the presented radiological image. The area under the visual grading characteristics curve (AUCVGC) before calibration is 0.62 CI (0.56, 0.68) and AUCVGC after calibration is 0.51 CI (0.45, 0.57).

CONCLUSIONS

Standardizing COTS display devices to the DICOM part 14: GSDF can improve image presentation.

InVERT molding for scalable control of tissue microarchitecture

Complex tissues contain multiple cell types that are hierarchically organized within morphologically and functionally distinct compartments. Construction of engineered tissues with optimized tissue architecture has been limited by tissue fabrication techniques, which do not enable versatile microscale organization of multiple cell types in tissues of size adequate for physiological studies and tissue therapies. Here we present an 'Intaglio-Void/Embed-Relief Topographic molding' method for microscale organization of many cell types, including induced pluripotent stem cell-derived progeny, within a variety of synthetic and natural extracellular matrices and across tissues of sizes appropriate for in vitro, pre-clinical, and clinical studies. We demonstrate that compartmental placement of non-parenchymal cells relative to primary or induced pluripotent stem cell-derived hepatocytes, compartment microstructure, and cellular composition modulate hepatic functions. Configurations found to sustain physiological function in vitro also result in survival and function in mice for at least 4 weeks, demonstrating the importance of architectural optimization before implantation.

Comparison of empirical continuous positive airway pressure (CPAP) treatment versus initial portable sleep monitoring followed by CPAP treatment for patients with suspected obstructive sleep apnoea

BACKGROUND

Polysomnography is labour-intensive for diagnosing obstructive sleep apnoea (OSA). We compared two algorithms for initiating continuous positive airway pressure (CPAP) treatment for patients with suspected OSA.

METHODS

Symptomatic OSA patients were randomised into either algorithm I or II. Algorithm I consisted of an empirical CPAP trial whereas algorithm II utilised an Apnea Risk Evaluation System, a wireless device applied on the forehead, for establishing a diagnosis before a CPAP trial for 3 weeks. Primary outcome was success of CPAP trial, defined as CPAP usage > 4 h/night and willingness to continue CPAP. Subjective usefulness of CPAP, accuracy of Apnea Risk Evaluation System versus polysomnography and CPAP adherence at 6 months were secondary end-points.

RESULTS

Altogether 138 patients in algorithm I and 110 patients in algorithm II completed the CPAP trial. There were no significant differences between these algorithms with respect to the primary end-point. The sensitivity and specificity of algorithm I versus II as a diagnostic test for OSA were 0.3, 0.8 versus 0.31, 1.00 respectively. In predicting CPAP adherence at 6 months, the likelihood ratio positive for algorithms I and II was 2.7 and 5.27 respectively. The mean (SE) time taken from the first consultation to the end of CPAP trial in algorithm I and algorithm II was 60 (2) and 98 (5) days, respectively, P < 0.01.

CONCLUSION

An ambulatory approach with portable sleep monitoring for diagnosing OSA before a CPAP trial can identify more patients who would adhere to CPAP at 6 months than empirical CPAP treatment alone.

Activation of thio-tepa cytotoxicity toward human breast-cancer cells by hepatic cytochrome-p450

The anti-tumor alkylating agent thio-TEPA is metabolized by hepatic cytochrome P450 to yield an oxo derivative. TEPA, plus one or more reactive metabolites. The contribution of this metabolism to the parent drug's cytotoxicity was evaluated in cell culture using the human breast carcinoma cell line MCF-7 as a model. Incubation of thio-TEPA in the presence of NADPH + an Aroclor 1254-induced rat liver 9000. x - supernatant fraction (S9 fraction) resulted in a dramatic increase in drug cytotoxicity, as measured using a clonogenic assay for cell survival. This increase in cytotoxicity was not evident when thio-TEPA was incubated with an uninduced rat liver homogenate, indicating that one or more Aroclor-inducible liver enzymes contribute to drug activation in this system. Metyrapone, a selective inhibitor of the Aroclor-inducible cytochrome P450 2B1, completely blocked liver S9-dependent cytotoxicity, as did an inhibitory antibody directed against P450 2B1, demonstrating that P450 2B1 is the S9 catalyst of thio-TEPA activation. Although TEPA is the major thio-TEPA metabolite formed by P450 2B 1, neither TEPA nor a TEPA metabolite is the cytotoxic species generated by the liver S9 fraction, as evidenced by the moderate cytotoxicity of TEPA in this cellular system, by the failure of S9 to activate TEPA appreciably, and by the lack of synergism between TEPA and thio-TEPA. While glutathione had little or no effect on the cytotoxicity of thio-TEPA or TEPA, low levels of extracellular glutathione (0.25-0.5 mM) fully blocked S9-dependent thio-TEPA activation, suggesting a cell surface site of action of the S9-generated cytotoxic metabolites. These metabolites may also act intracellulary, since depletion of intracellular glutathione by treatment with buthionine sulfoximine enhanced the cytotoxicity of thio-TEPA to a V79 cell transformant that stably expresses P450 2B1, but not to the parental V79 line or to MCF-7 cells. These studies establish a role for cytochrome P450 2B1 in the activation of thio-TEPA to cytotoxic metabolites that are distinct from TEPA, and furthermore suggest a mechanism of action that includes the cell surface as a novel target of this cancer chemotherapeutic agent.