Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes

Our aim was to review the data from the National Pregnancy in Diabetes (NPID) audit, and to identify the challenges and opportunities for improving pregnancy outcomes in women with diabetes. We reviewed three years of NPID data and relevant diabetes and obstetric literature, and found that there has been little change in pregnancy preparation or outcomes over the past 3 years, with substantial clinic-to clinic variations in care. Women with Type 2 diabetes remain less likely to take 5 mg preconception folic acid (22.8% vs. 41.8%; P < 0.05), and more likely to take potentially harmful medications (statin and/or ACE inhibitor 13.0% vs. 1.8%; P < 0.05) than women with Type 1 diabetes. However, women with Type 1 diabetes are less likely to achieve the recommended glucose control target of HbA_1c < 48 mmol/mol (6.5%) (14.9% vs. 38.1%; P < 0.05). The following opportunities for improvement were identified. First, the need to integrate reproductive health into the diabetes care plans of all women with diabetes aged 15-50 years. Second, to develop more innovative approaches to improve uptake of pre-pregnancy care in women with Type 2 diabetes in primary care settings. Third, to integrate insulin pump, continuous glucose monitoring and automated insulin delivery technologies into the pre-pregnancy and antenatal care of women with Type 1 diabetes. Fourth, to improve postnatal care with personalized approaches targeting women with previous pregnancy loss, congenital anomaly and perinatal mortality. A nationwide commitment to delivering integrated reproductive and diabetes healthcare interventions is needed to improve the health outcomes of women with diabetes.

Prevalence and disease associations in feline thrombocytopenia: a retrospective study of 194 cases

OBJECTIVES

To assess the prevalence of thrombocytopenia in a referral population of cats in the UK, to identify disease processes associated with thrombocytopenia and to assess the proportion of thrombocytopenic cats that tested positive for feline leukaemia virus or feline immunodeficiency virus.

MATERIALS AND METHODS

Retrospective analysis of medical records at a UK referral hospital. Cats were grouped by mechanism of thrombocytopenia and disease process (where known).

RESULTS

Prevalence of thrombocytopenia was 5·9%. The most common disease processes associated with thrombocytopenia were haematological or infectious disease and neoplasia; 11% of thrombocytopenic cats tested were positive for feline leukaemia virus, which is lower than reported previously. Cats presenting with unexplained haemorrhage had significantly lower platelet counts than other thrombocytopenic cats. Primary immune-mediated thrombocytopenia was less commonly diagnosed than in dogs and associated with the most severe platelet depletion in this study.

CLINICAL SIGNIFICANCE

Thrombocytopenia in cats may be more prevalent than previously reported and severe thrombocytopenia may be associated with spontaneous haemorrhage. Severe thrombocytopenia in cats appears less commonly immune-mediated than in dogs. Thrombocytopenia did not appear to be associated with retroviral infections.

Reproductive hormone analyses and effects of adjuvant zoledronic acid in early breast cancer - An AZURE (BIG 01/04) sub-study

PURPOSE

Adjuvant bisphosphonates have been shown to improve disease outcomes in early breast cancer in women who are postmenopausal at the start of treatment. We explored the influence of pretreatment serum levels of reproductive hormones in the hypothalamic-pituitary-gonadal (HPG) axis from a subset of patients included in the AZURE trial to investigate their impact on disease recurrence and whether reproductive hormone measurements are of value in selecting patients for treatment with adjuvant zoledronic acid.Patients and methods; The AZURE trial is an academic, multi-centre, international phase III trial that randomised patients to standard adjuvant therapy (chemotherapy and/or endocrine therapy)±intravenous zoledronic acid, 4 mg for 5 years. Serum from 865 patients taken at randomisation was stored at -80 °C prior to central batch analysis for inhibin A, oestradiol and follicle stimulating hormone (FSH). We assessed the clinical value of pretreatment hormone levels for predicting invasive disease free survival (IDFS), skeletal recurrence and distant recurrence and response to treatment with zoledronic acid.

RESULTS

Oestradiol in the postmenopausal range (<50 pmol/l) was associated with a significantly shorter IDFS (HR 1.36 95%CI: 1.05-1.78 p=0.022), predominantly due to distant recurrence (HR 1.33 95%CI: 0.98-1.81 p=0.065), compared to oestradiol ≥50pmol/l. In contrast, FSH in the postmenopausal range (>26 IU/l) was associated with a longer time to bone as first recurrence (HR 0.66 95%CI: 0.41-1.04 p=0.072) compared to an FSH ≤26 IU/l. When all 3 hormone levels were within the assay specified postmenopausal range, a trend to improved IDFS was seen with addition of zoledronic acid in biochemically postmenopausal women only (postmenopausal HR=0.81; 95%CI: 0.54-1.22, non-postmenopausal HR=0.99; 95%CI: 0.69-1.39) with risk reductions that mirrored the results of the main AZURE study, although the interaction between menopausal status and treatment effect was not statistically significant (p=0.47).

CONCLUSION

Oestradiol and FSH may influence the pattern of disease recurrence with postmenopausal levels possibly creating a less conducive environment for the formation of bone metastases, therefore disseminated tumour cells could seek alternative niches outside of bone. Biochemical evaluation of a panel of reproductive hormones may be helpful to assist selection of patients for adjuvant zoledronic acid when menopausal status is unknown.

Effect of MAF amplification on treatment outcomes with adjuvant zoledronic acid in early breast cancer: a secondary analysis of the international, open-label, randomised, controlled, phase 3 AZURE (BIG 01/04) trial

BACKGROUND

Adjuvant use of bisphosphonates can reduce the incidence of bone metastases in early breast cancer. Recurrence and survival seem to be improved only in postmenopausal patients, but the underlying mechanisms remain unclear. We investigated whether MAF amplification (a biomarker for bone metastasis) in primary tumours could predict the treatment outcomes of adjuvant zoledronic acid.

METHODS

The study population included patients enrolled in the international, open-label, randomised, controlled, phase 3 AZURE trial at eligible UK sites who had stage II or III breast cancer and who gave consent for use of their primary tumour samples. Patients were randomly assigned (1:1) to receive standard adjuvant systemic therapy alone (control group) or with zoledronic acid every 3-4 weeks for six doses, then every 3-6 months until the end of 5 years. Minimisation took into account the number of involved axillary lymph nodes, clinical tumour stage, oestrogen-receptor status, type and timing of systemic therapy, menopausal status, statin use, and treating centre. The primary endpoint was disease-free survival; the secondary endpoint, invasive-disease-free survival, was the primary disease endpoint for the analysis in this report. MAF amplification was assessed by fluorescence in-situ hybridisation of two cores of breast tumour tissue in a microarray, done in a central laboratory by technicians unaware of treatment assignment. We used multivariate analyses to assess disease outcomes by intention to treat. We also assessed interactions between MAF-positive status and menopausal status on efficacy of zoledronic acid. The AZURE trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN79831382.

FINDINGS

1739 AZURE patients contributed primary tumour samples, of whom 865 (50%) had two assessable cores (445 in the control groups and 420 in the zoledronic acid group). 184 (21%) tumours were MAF positive (85 in the control groups and 99 in the zoledronic acid group) and the remaining tumours were MAF negative. At a median follow-up of 84·6 months (IQR 72·0-95·8), MAF status was not prognostic for invasive-disease-free survival in the control group (MAF-positive vs MAF-negative: hazard ratio [HR] 0·92, 95% CI 0·59-1·41), but was in the zoledronic acid group (0·52, 0·36-0·75). In patients with MAF-negative tumours, zoledronic acid was associated with higher invasive-disease-free survival than was control treatment (HR 0·74, 95% CI 0·56-0·98), but not in patients who had MAF-positive tumours. Additionally, among 121 patients not postmenopausal at randomisation with MAF-positive tumours, zoledronic acid was associated with lower invasive-disease-free survival (HR 2·47, 95% CI 1·23-4·97) and overall survival (2·27, 95% CI 1·04-4·93) than control treatment.

INTERPRETATION

MAF status can predict likelihood of benefit from adjuvant zoledronic acid and merits further investigation as a potential companion diagnostic.

FUNDING

Novartis Global and Inbiomotion.

A pilot study comparing the effect of orally administered esomeprazole and omeprazole on gastric fluid pH in horses

AIMS To compare the efficacy of an enteric coated esomeprazole paste with an enteric coated omeprazole paste to increase gastric pH after oral administration in horses. METHODS Nine adult Standardbred horses were randomly assigned to three groups, each containing three horses, for a study comprising three phases of 10 days, with an 18-day washout period between each phase. In each phase, three horses received either 0.5 mg/kg esomeprazole, 1 mg/kg omeprazole or a placebo, as an oral paste, once daily for 10 days (Days 0-9). Over the course of study all horses received all three treatments. Gastric fluid samples were collected using a gastroscope on Days 1, 3, 5, 8 and 10, with food and water withheld for 16 hours prior to collection of samples. The pH of all samples was measured immediately after collection. RESULTS Mean pH (3.38; SD 1.75) of the gastric fluid samples in the horses that received the placebo was lower than in the horses that received esomeprazole (6.28; SD 1.75) or omeprazole (6.13; SD 1.75) (p<0.001). There was no difference in the mean pH between horses receiving esomeprazole and those receiving omeprazole (p=0.56). CONCLUSIONS AND CLINICAL RELEVANCE Under these study conditions, esomeprazole paste was equally as effective as omeprazole paste in increasing gastric pH in horses. Enteric coated esomeprazole, may be a therapeutic alternative to omeprazole for the prevention of gastric ulcers in horses.

Using the Repertory Grid Technique to Examine Trainee Clinical Psychologists' Construal of Their Personal and Professional Development

The repertory grid technique was used to explore how 26 third-year trainee clinical psychologists construed their personal and professional selves over the course of training and into the future. Each trainee completed a demographic questionnaire and a repertory grid with 10 elements: four 'personal self' elements, four 'professional self' elements and two 'qualified clinical psychologist' elements. They then rated the 10 elements on 10 bipolar constructs of their choosing. Trainees' personal and professional selves were construed to be similar to each other. Trainees had low self-esteem and reported currently feeling anxious, stressed, unsettled and lacking an appropriate work-life balance. These difficulties were attributed to the demands of training and were expected to resolve once training was completed with future selves being construed as similar to ideal selves. Suggestions for future research with improved methodology are made, and the implications of the findings for trainees, training providers and employers of newly qualified clinical psychologists are given. The overall implication being that stress in training is normative and the profession has a duty to normalize this and ensure that self-care and personal development are recognized as core competencies of the clinical psychologist for the benefit of its members and their clients. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Clinical psychology trainees experience training as demanding and stressful, which negatively impacts on their personal and professional self-image and self-esteem. However, they are optimistic that they will become more like their ideal self in the future. Stress in clinical training (and beyond) is normative, and thus, personal development and self-care should be recognized as clinical psychologist's core competencies.

Final efficacy and updated safety results of the randomized phase III BEATRICE trial evaluating adjuvant bevacizumab-containing therapy in triple-negative early breast cancer

Background

The purpose of this analysis was to assess the long-term impact of adding bevacizumab to adjuvant chemotherapy for early triple-negative breast cancer (TNBC).

Methods

Patients eligible for the open-label randomized phase III BEATRICE trial had centrally confirmed triple-negative operable primary invasive breast cancer (pT1a-pT3). Investigators selected anthracycline- and/or taxane-based chemotherapy for each patient. After definitive surgery, patients were randomized 1:1 to receive ≥4 cycles of chemotherapy alone or with 1 year of bevacizumab (5 mg/kg/week equivalent). Stratification factors were nodal status, selected chemotherapy, hormone receptor status, and type of surgery. The primary end point was invasive disease-free survival (IDFS; previously reported). Secondary outcome measures included overall survival (OS) and safety.

Results

After 56 months' median follow-up, 293 of 2591 randomized patients had died. There was no statistically significant difference in OS between treatment arms in either the total population (hazard ratio 0.93, 95% confidence interval [CI] 0.74-1.17; P = 0.52) or pre-specified subgroups. The 5-year OS rate was 88% (95% CI 86-90%) in both treatment arms. Updated IDFS results were consistent with the primary IDFS analysis. Five-year IDFS rates were 77% (95% CI 75-79%) with chemotherapy alone versus 80% (95% CI 77-82%) with bevacizumab. From 18 months after first study dose to study end, new grade ≥3 adverse events occurred in 4.6% and 4.5% of patients in the two arms, respectively.

Conclusion

Final OS results showed no significant benefit from bevacizumab therapy for early TNBC. Late-onset toxicities were rare in both groups. Five-year OS and IDFS rates suggest that the prognosis for patients with TNBC is better than previously thought.

ClinicalTrials.gov

NCT00528567.

11 years' follow-up of trastuzumab after adjuvant chemotherapy in HER2-positive early breast cancer: final analysis of the HERceptin Adjuvant (HERA) trial

BACKGROUND

Clinical trials have shown that trastuzumab, a recombinant monoclonal antibody against HER2 receptor, significantly improves overall survival and disease-free survival in women with HER2-positive early breast cancer, but long-term follow-up data are needed. We report the results of comparing observation with two durations of trastuzumab treatment at a median follow-up of 11 years, for patients enrolled in the HERA (HERceptin Adjuvant) trial.

METHODS

HERA (BIG 1-01) is an international, multicentre, open-label, phase 3 randomised trial of 5102 women with HER2-positive early breast cancer, who were enrolled from hospitals in 39 countries between Dec 7, 2001, and June 20, 2005. After completion of all primary therapy (including, surgery, chemotherapy, and radiotherapy as indicated), patients were randomly assigned (1:1:1) to receive trastuzumab for 1 year (once at 8 mg/kg of bodyweight intravenously, then 6 mg/kg once every 3 weeks) or for 2 years (with the same dose schedule), or to the observation group. Primary endpoint is disease-free survival, and analyses are in the intention-to-treat population. Hazard ratios (HRs) were estimated from Cox models, and survival curves were estimated by the Kaplan-Meier method. Comparison of 2 years versus 1 year of trastuzumab is based on 366-day landmark analyses. This study is registered with ClinicalTrials.gov (NCT00045032).

FINDINGS

Of the 5102 women randomly assigned in the HERA trial, three patients had no evidence of having provided written informed consent to participate. We followed up the intention-to-treat population of 5099 patients (1697 in observation, 1702 in 1-year trastuzumab, and 1700 in 2-years trastuzumab groups). After a median follow-up of 11 years (IQR 10·09-11·53), random assignment to 1 year of trastuzumab significantly reduced the risk of a disease-free survival event (HR 0·76, 95% CI 0·68-0·86) and death (0·74, 0·64-0·86) compared with observation. 2 years of adjuvant trastuzumab did not improve disease free-survival outcomes compared with 1 year of this drug (HR 1·02, 95% CI 0·89-1·17). Estimates of 10-year disease-free survival were 63% for observation, 69% for 1 year of trastuzumab, and 69% for 2 years of trastuzumab. 884 (52%) patients assigned to the observation group selectively crossed over to receive trastuzumab. Cardiac toxicity remained low in all groups and occurred mostly during the treatment phase. The incidence of secondary cardiac endpoints was 122 (7·3%) in the 2-years trastuzumab group, 74 (4·4%) in the 1-year trastuzumab group, and 15 (0·9%) in the observation group.

INTERPRETATION

1 year of adjuvant trastuzumab after chemotherapy for patients with HER2-positive early breast cancer significantly improves long-term disease-free survival, compared with observation. 2 years of trastuzumab had no additional benefit.

FUNDING

F Hoffmann-La Roche (Roche).

Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery

BACKGROUND

Increasing numbers of older patients are undergoing vascular surgery. Inadequate preoperative assessment and optimization may contribute to increased postoperative morbidity and mortality.

METHODS

Patients aged at least 65 years scheduled for elective aortic aneurysm repair or lower-limb arterial surgery were enrolled in an RCT of standard preoperative assessment or preoperative comprehensive geriatric assessment and optimization. Randomization was stratified by sex and surgical site (aorta/lower limb). Primary outcome was length of hospital stay. Secondary outcome measures included new medical co-morbidities, postoperative medical or surgical complications, discharge to a higher level of dependency and 30-day readmission rate.

RESULTS

A total of 176 patients were included in the final analysis (control 91, intervention 85). Geometric mean length of stay was 5·53 days in the control group and 3·32 days in the intervention group (ratio of geometric means 0·60, 95 per cent c.i. 0·46 to 0·79; P < 0·001). There was a lower incidence of delirium (11 versus 24 per cent; P = 0·018), cardiac complications (8 versus 27 per cent; P = 0·001) and bladder/bowel complications (33 versus 55 per cent; P = 0·003) in the intervention group compared with the control group. Patients in the intervention group were less likely to require discharge to a higher level of dependency (4 of 85 versus 12 of 91; P = 0·051).

CONCLUSION

In this study of patients aged 65 years or older undergoing vascular surgery, preoperative comprehensive geriatric assessment was associated with a shorter length of hospital stay. Patients undergoing assessment and optimization had a lower incidence of complications and were less likely to be discharged to a higher level of dependency. Registration number: ISRCTN23142588 (http://www.controlled-trials.com).

Abstract P6-17-01: Adjuvant treatment with zoledronic acid (ZOL) in stage II/III breast cancer. The AZURE trial (BIG 01/04) 10 year follow-up

This abstract was not presented at the symposium.

Abstract P1-09-01: Impact of MAF gene amplification on disease recurrence and effects of adjuvant zoledronic acid in early breast cancer

Background: Meta-analysis of clinical trials has shown that adjuvant bisphosphonates reduce bone metastases and improve survival in postmenopausal (PM) pts1. However, we are unable to select pts most likely to benefit. To address this, the recently identified early breast cancer bone relapse biomarker, 16q23(MAF) gain (MAF+)2, was tested retrospectively in the large prospectively randomized AZURE trial3 of standard adjuvant therapy +/- zoledronic acid (ZOL) to determine the prognostic value of MAF and its potential to predict the effects of ZOL on disease outcomes.

Materials and methods: All analyses were performed with ethics approval and consent. The biomarker analysis was completed on TMAs from primary tumors. Quadruplicate cores of breast tumor tissue were arrayed across replicate TMAs. MAF+ was detected using a validated (MAF/D16Z3) FISH test (Inbiomotion SL, Barcelona, Spain). A central laboratory (Targos, Kassel, Germany) validated the assay for analytic and diagnostic performance, established acceptance criteria, included appropriate quality controls for each assay, and performed the analyses in a blinded fashion. A copy number cut-off ≥2.5 was preset for MAF+. Invasive disease free (IDFS), overall (OS) survival and time to bone metastases multivariate analyses were performed in control and ZOL pts separately. Subsequently, interactions between MAF+ and effects of ZOL on disease outcomes by menopausal status were evaluated.

Results: 1769 of the 3360 AZURE pts donated primary tumor samples. Median follow-up was 84 months. 865 pts (49%) had 2 FISH evaluable cores and were included in the analysis of which 184 (21%) had MAF+ tumors. Tumors that were MAF+ were more likely to be of higher grade, ER-ve and Her2+.

In control pts, MAF was not prognostic for IDFS or OS although there were differences in IDFS by menopause (HR for MAF-/MAF+ in PM=0.47 [95%CI 0.25-0.88]; HR in non-PM=1.58 [0.82-3.03], test for interaction (TFI) by menopause P=0.007). In ZOL pts, MAF was prognostic for IDFS (HR=0.52 [0.36-0.75] and OS (HR=0.48 [0.31-0.75]). There were insufficient bone events (19 MAF+, 73 MAF-) in this sample set to reliably assess the impact of MAF+ on relapse in bone.

In pts with MAF- tumors, ZOL was associated with improved IDFS (HR=0.74 [0.56-0.98]) and OS (HR=0.78 [0.55-1.10]). However, the effects of ZOL in MAF+ were profoundly influenced by menopausal status with possibly better outcomes in PM women (HR for IDFS=0.74 [0.35-1.58]) but clearly worse IDFS and OS outcomes in ZOL treated MAF+ pts who were non-PM (HR for IDFS 2.46 [1.23-4.92], TFI by treatment P=0.002 and HR for OS=2.27 [1.04-4.93], TFI by treatment P=0.032). The interactions between disease outcomes, ZOL use and menopause were driven largely by an association between MAF+ and an increased risk of extra-skeletal recurrence with the use of ZOL in women who were not PM.

Conclusions: Absence of MAF amplification is associated with improved disease outcomes with adjuvant ZOL. However, the use of adjuvant ZOL in women with MAF+ tumors who are not PM at the start of treatment is associated with extraskeletal spread and worse DFS and OS.

1EBCTCG Lancet 2015;386:1353–1361; 2Pavlovic M et al JNCI 2015;107(12):djv256; 3Coleman RE et al Lancet Oncol 2014;15:997-1006.

Citation Format: Coleman R, Hall A, Bell R, Cameron D, Marshall H, Jean-Mairet J, Tercero J, Rojo F, Albanell J, Gomis R. Impact of MAF gene amplification on disease recurrence and effects of adjuvant zoledronic acid in early breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-01.

The Impact of Advancing Age on Recurrence and Survival Following Major Hepatectomy for Colorectal Liver Metastases

INTRODUCTION

This study analysed the effect of age on survival in patients undergoing major hepatectomy (MH) for colorectal liver metastases (CRLM). The effect of adjuvant chemotherapy (AC) with age was also assessed.

METHOD

Patients undergoing MH for CRLM between 1996 and 2011 were reviewed. Patients aged <75 or ≥75 were compared for disease-free (DFS) and overall survival (OS) as well as impact of AC on survival.

RESULTS

Seven hundred twenty-seven patients underwent MH of which 105 (14 %) were aged ≥75. Morbidity was greater in the ≥75 group (25 versus 34 %, p = 0.048). No difference was noted in mortality. There was no difference in DFS between the two groups at 5 years (16.8 vs 18.9 months (p = 0.570). OS was longer in the <75 group (38.6 vs 32.0 months (p = 0.001). DFS was better in groups receiving AC than those not (<75 24.2 vs 12.2 months (p = <0.001) and ≥75 24 vs 12.1 months (p = 0.007)). OS in the ≥75 group was improved in the group receiving AC compared to the ≥75 group not (41.1 vs 16.6 months, p = 0.005). Age ≥75 was not an independent risk factor for reduced DFS on multivariate analysis.

CONCLUSION

Well-selected patients aged ≥75 should be considered for MH followed by adjuvant chemotherapy.

Meta-analysis and cost effective analysis of portal-superior mesenteric vein resection during pancreatoduodenectomy: Impact on margin status and survival

INTRODUCTION

The benefit of portal-superior mesenteric vein resection (PSMVR) with pancreatoduodenectomy (PD) remains controversial. This study assesses the impact of PSMVR on resection margin status and survival.

METHOD

An electronic search was performed to identify relevant articles. Pooled odds ratios were calculated for outcomes using the fixed or random-effects models for meta-analysis. A decision analytical model was developed for estimating cost effectiveness.

RESULTS

Sixteen studies with 4145 patients who underwent pancreatoduodenectomy were included: 1207 patients had PSMVR and 2938 patients had no PSMVR. The R1 resection rate and post-operative mortality was significantly higher in PSMVR group (OR1.59[1.35, 1.86] p=<0.0001, and OR1.72 [1.02,2.92] p = 0.04 respectively). The overall survival at 5-years was worse in the PSMVR group (HR0.20 [0.07,0.55] P = 0.020). Tumour size (p = 0.030) and perineural invasion (P = 0.009) were higher in the PSMVR group. Not performing PSMVR yielded cost savings of $1617 per additional month alive without reduction in overall outcome.

CONCLUSION

On the basis of retrospective data this study shows that PD with PSMVR is associated with a higher R1 rate, lower 5-year survival and is not cost-effective. It appears that PD with PSMVR can only be justified if R0 resection can be achieved. The continuing challenge is accurate selection of these patients.

Dynamic Behaviour of Plain Slideways

The friction characteristics resulting from the motion of one surface over another form a very important facet of the behaviour of many physical systems. This statement is particularly valid when considering the behaviour of machine tool slideways. Most slideway elements consist of two plain surfaces whose friction characteristic is modified by the addition of a lubricant. In many cases the complete slideway consists of many mating surfaces and the choice of slideway material, slideway machining and lubricant is often influenced by the long term problem of wear. The aim of this paper is to present results of experiments on a test rig designed to be representative of machine tool slideway conditions; the experiments were wholly concerned with the behaviour of the bearing under dynamic conditions. The major emphasis is on results obtained with a polar additive lubricant which appears to exclude the possibility of ‘stick-slip’ oscillations. A parallel series of tests are reported where a normal hydraulic oil was used as lubricant. The use of this second lubricant allowed some study of the ‘stick-slip’ process. The dynamic friction characteristics, cyclic friction characteristics and damping capacity of several slideway surface combinations have been obtained and are discussed in the context of earlier work in the field and the role of slideways in machine tool behaviour.

Hormone receptor positive, HER2 negative metastatic breast cancer: A systematic review of the current treatment landscape

Endocrine therapy for the treatment of hormone receptor positive, HER2 negative, metastatic breast cancer is continually evolving. We systematically reviewed phase 2 and 3 randomized controlled trials (RCTs) of agents used in this setting to assess the effectiveness and safety of these agents for postmenopausal women. Across the 32 studies in more than 10,000 patients, the greatest improvement in progression-free survival (PFS) was seen with the addition of a cyclin-dependent kinase (CDK)4/6 inhibitor to standard endocrine therapy. Treatment with a mammalian target of rapamycin (mTOR) inhibitor, phosphoinositol-3-kinase (Pi3K) inhibitor, vascular endothelial growth factor (VEGF) inhibitor and with a selective estrogen receptor degrader (SERD) also showed benefit in PFS for selected trials. Overall survival (OS) improved with the use of mTOR inhibitors and a SERD; however, studies were not powered for an OS endpoint. Encouraging results from early studies of histone deacetylase (HDAC) and B-cell lymphoma (BCL2) inhibitors are yet to be confirmed in phase III clinical trials. Study discontinuation rates and toxicity-related deaths were highest with VEGF inhibitors in combination with endocrine therapy, limiting their use in hormone receptor positive breast cancer. CDK4/6 inhibitors and mTOR inhibitors appeared to have activity in both first and second line settings, but required additional monitoring for common toxicities. The activity of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors was limited to the first-line setting and treatment discontinuation rates were higher than with mTOR inhibitors and SERDs. Overall, PFS benefit appears to be greatest when agents acting on CDK4/6, mTOR and Pi3K pathways, and SERDs are added to standard endocrine therapy. If these early results persist in further studies, these data are likely to change the way we treat hormone receptor positive, HER2 negative metastatic breast cancer. In the follow-up article to this review, we will consider the potential future treatment options for these patients.

Lymphatic imaging to assess rheumatoid flare: mechanistic insights and biomarker potential

Proliferation of draining lymphatic vessels coupled with dynamic changes in lymph node volume and flow are characteristic features in rheumatoid arthritis (RA). Furthermore, impaired lymph egress from inflamed synovium is associated with joint flare in murine models of inflammatory-erosive arthritis. Unfortunately, advances towards a greater understanding of lymphatic changes in RA pathogenesis have been slow due to the absence of outcome measures to quantify lymphatic function in vivo. While lymphoscintigraphy is the current standard to assess lymphedema and sentinel lymph nodes in cancer patients, its sensitivity and specificity are inadequate to study lymphatics in RA. The emergence of high-resolution MRI, power Doppler ultrasound, and near-infrared imaging that permits real-time quantification of lymphatic function in animal models has been a major advance, and these techniques have produced a new paradigm of altered lymphatic function that underlies both acute arthritic flare and chronic inflammation. In acute flare, lymphatic drainage increases several fold, whereas no lymphatic contractions are detected in lymph vessels draining chronic arthritic joints. Moreover, these outcomes are now being adapted to study lymphatics in RA towards the development of novel biomarkers of arthritic flare and the discovery of new therapeutic targets. In particular, interventions that directly increase lymphatic egress from diseased joints by opening collateral lymphatic vessels, and that restore lymphatic vessel contractions, provide novel therapeutic approaches with potential for minimal toxicity and immunosuppression. To summarize the origins of this field, recent advances, and future directions, we herein review: current knowledge of lymphatics in RA based on classic literature; new in-vivo imaging modalities that have elucidated how lymphatics modulate acute versus chronic joint inflammation in murine models; and how these preclinical outcome measures are being translated to study lymphatic function in RA inflammation and how effective RA therapies alter lymphatic flow and lymph nodes draining flaring joints.

Trial registration: ClinicalTrials.gov NCT02680067. Registered 7 December 2015; ClinicalTrials.gov NCT01098201. Registered 30 March 2010; and ClinicalTrials.gov NCT01083563. Registered 8 March 2010.