Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery

BACKGROUND

Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added.

OBJECTIVES

Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness.

SECONDARY OBJECTIVE

to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses.

SEARCH METHODS

We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022.

SELECTION CRITERIA

We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis.

AUTHORS' CONCLUSIONS

A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.

Redo aortic valve replacement versus valve-in-valve trans-catheter aortic valve implantation: a UK propensity-matched analysis

This study sought to compare the morbidity and mortality of redo aortic valve replacement (redo-AVR) versus valve-in-valve trans-catheter aortic valve implantation (valve-in-valve TAVI) for patients with a failing bioprosthetic valve. A multicenter UK retrospective study of redo-AVR or valve-in-valve TAVI for patients referred for redo aortic valve intervention due to a degenerated aortic bioprosthesis. Propensity score matching was performed for confounding factors. From July 2005 to April 2021, 911 patients underwent redo-AVR and 411 patients underwent valve-in-valve TAVI. There were 125 pairs for analysis after propensity score matching. The mean age was 75.2±8.5 years. In-hospital mortality was 7.2% (n=9) for redo-AVR versus 0 for valve-in-valve TAVI, p=0.002. Surgical patients suffered more post-operative complications, including intra-aortic balloon pump support (p=0.02), early re-operation (p<0.001), arrhythmias (p<0.001), respiratory and neurological complications (p=0.02 and p=0.03) and multi-organ failure (p=0.01). The valve-in-valve TAVI group had a shorter intensive care unit and hospital stay (p<0.001 for both). However, moderate aortic regurgitation at discharge and higher post-procedural gradients were more common after valve-in-valve TAVI (p<0.001 for both). Survival probabilities in patients who were successfully discharged from the hospital were similar after valve-in-valve TAVI and redo-AVR over the 6-year follow-up (log-rank p=0.26). In elderly patients with a degenerated aortic bioprosthesis, valve-in-valve TAVI provides better early outcomes as opposed to redo-AVR, although there was no difference in mid-term survival in patients successfully discharged from the hospital.

Core training and surgical opportunities: A UK-based analysis

BACKGROUND AND AIM

The COVID-19 pandemic, the new Intercollegiate Surgical Curriculum Programme curriculum and the European Work Time Directive significantly reduced surgical exposure for trainees. This study analyzed the operative experience of Phase 1 trainees (CT1/ST1 vs. CT2/ST2) against the Annual Review of Competence Progression (ARCP) criterion of 120 procedures yearly.

METHODS

National survey research in October 2021. Study end-point was the completion of >4 weekly procedures, equivalent to 120 cases per year. Chi-square test and multivariate regression analysis were performed.

RESULTS

205 participants from 5 Deaneries were included, 48.3% were CT1/ST1 and 51.7% were CT2/ST2. About 54.5% of year-1 and 50% of year-2 trainees were 28 30 years old, 55.6% and 50.9% were male, and 39.4% and 38.7% were White British. About 39.4% of CT1/ST1 and 22.6% of CT2/ST2 performed <4 weekly procedures (P = 0.01), with no difference in the "Observed" (P = 0.6) or "Assisted" (P = 0.3) number of cases. CT2/ST2 recorded more "ST-S" (p 0.04), "S-TU" (P = 0.03), and "Performed" (P = 0.02) operations. For CT1/ST1, older age (HR 2.4, 95% CI [1.1; 5.3], P = 0.02) and southern deaneries (HR 1.7, 95% CI [1.2; 2.4], P = 0.004) were independent factor for <4 weekly procedures. For CT2/ST2, northern regions were associated with more favorable training (HR 1.4, 95% CI [1.1; 1.7], P = 0.01).

CONCLUSION

Over one third of Phase 1 trainees do not meet the ARCP requirement of >120 procedures annually. Age and region of training are independent factors in the number of logbook cases.

RELEVANCE FOR PATIENTS

This research focuses on training opportunities for junior surgical residents across the United Kingdom. The degree and type of exposure to the operating theatre have a significant impact on the development of surgical competencies. These are undoubtedly related to patient outcomes, as the quality of care delivered to patients and relatives greatly relies on the training background of future consultant surgeons.

Permanent pacemaker post-valve surgery: Do valve type and position matter? A propensity score matching study

BACKGROUND AND AIM

This study evaluates whether aortic valve replacement (AVR) or mitral valve replacement (MVR) with biological versus mechanical prostheses is independent risk factors for permanent pacemaker (PPM) post-cardiac surgery, alongside traditionally accepted determinants.

METHODS

This study focused on single-centre retrospective analysis of 10 years of activity. Case-control 1-to-9 matching was performed for 7 pre-operative and 2 intraoperative confounding factors.

RESULTS

After matching, 617 patients were included for analysis: AVR (79.4% n=490) and MVR (20.6% n=127). PPM was implanted in 3.7% (n=18) and 3.1% (n=4), P=0.8, respectively. A further analysis for PPM rate in biological versus mechanical prostheses did not provide any significant result (P=0.6 AVR and P=0.8 MVR). Post-operative complications in AVR and MVR groups were as follows: Reopening (4.5% vs. 6.3%, P=0.4), myocardial infarction (0.8% vs. 3.2%, P=0.04), pulmonary (32.9% vs. 38.6%, P=0.3), neurological (9.2% vs. 11.8%, P=0.4), renal (9.8% vs. 7.9%, P=0.5), wound (1.4% vs. 2.4%, P=0.5), infective (5.5% vs. 8.7%, P=0.2), and multiple organ failure (4.9% vs. 5.5%, P=0.6). The length of intensive care unit (hours) and hospital stay (days) was 71±163.8 versus 106.5±243.7 (P=0.5) and 14.7±14.7 versus 18.9±20.8 (P=0.01). In-hospital mortality resulted in 4.1% for AVR and 3.9% for MVR, P=0.9.

CONCLUSION

Valve position and valve type do not affect the likelihood of requiring permanent pacing in patients undergoing isolated aortic and MVR.

RELEVANCE FOR PATIENTS

A significant proportion of patients undergoing cardiac surgery develop arrhythmias and conduction disturbances postoperatively, often requiring the implantation of a PPM. Determining factors associated with an increase likelihood of permanent pacing would allow the optimization of per- and intra-operative care, with the aim of reducing the incidence of patients requiring post-operative PPM insertion.

28 Diagnosed vs Undiagnosed Chronic Obstructive Pulmonary Disease: Short and Long-term Impact on Coronary Artery Bypass Surgery

Introduction

This study sought to compare clinical outcomes among non-COPD, diagnosed COPD, and undiagnosed COPD patients, in CABG surgery.

Method

A single-centred retrospective study, from January 2010 to December 2019. Primary outcomes were post-operative complications, lenght of ITU admission and in-hospital staying. Secondary outcomes were re-intervention rate, in-hospital and long-term mortality.

Results

4020 patients were divided into: non-COPD – Group A (74.55% n = 2997), diagnosed COPD – Group B (14.78% n = 594), and undiagnosed COPD – Group C (10.67% n = 429). The rate of respiratory complications was noted in this order: Group B &gt; Group C &gt; Group A (p 0.00000002). Perioperative Acute Kidney Injury, wound complications, and in-hospital staying were higher in Group B (p 0.0004, p 0.03, and p 0.0009, respectively). Long-term mortality resulted greater in Group B and C (p 0.0004). No difference in long-term mortality was noted in relation to the expected FEV1% in Group B (p 0.29) and Group C (p 0.82).

Conclusions

In CABG surgery, patients with diagnosed COPD carry a prolonged in-hospital staying and greater peri-operative complications. Both diagnosed and undiagnosed COPD predispose to respiratory complications and higher long-term mortality rate. Consequently, undiagnosed COPD should be included in the EuroSCORE. Finally, the expected FEV1% appears not to correlate with long-term survival.

Short-term and long-term impact of diagnosed and undiagnosed chronic obstructive pulmonary disease on coronary artery bypass grafting surgery

OBJECTIVES

This study sought to compare clinical outcomes between three categories of patients: non-chronic obstructive pulmonary disease (COPD), diagnosed COPD and undiagnosed COPD in coronary artery bypass grafting surgery.

METHODS

A single-centred retrospective study from January 2010 to December 2019. Primary outcomes were postoperative complications, length of ITU admission and in-hospital staying. Secondary outcomes were reintervention rate, in-hospital and long-term mortality.

RESULTS

A total of 4020 patients were analysed and divided into three cohorts: non-COPD (group A) (74.55%, n=2997), diagnosed COPD (group B) (14.78%, n=594) and undiagnosed COPD (group C) (10.67%, n=429). The rate of respiratory complications was noted in this order: group B>group C>group A (p 0.00000002). Periooperative acute kidney injury and wound complications were higher in group B (p 0.0004 and p 0.03, respectively). Prolonged in-hospital staying (days) resulted in group B (p 0.0009). Finally, long-term mortality was statistically higher in group B and C compared with group A (p 0.0004). No difference in long-term mortality was noted in relation to the expected FEV1% in group B (p 0.29) and group C (p 0.82).

CONCLUSIONS

In CABG surgery, COPD is a well-known independent risk factor for morbidity. Patients with preoperative spirometry results indicative of COPD result in the same outcomes of known patients with COPD. As a result of that, greater value should be given to the preoperative spirometry in the EuroSCORE. Finally, the expected FEV1% appears not be a predictor for long-term survival.

Acute Kidney Injury Associated with Cardiac Surgery: a Comprehensive Literature Review

Objective

To comprehensively understand cardiac surgeryassociated acute kidney injury (CSA-AKI) and methods of prevention of such complication in cardiac surgery patients.

Methods

A comprehensive literature search was performed using the electronic database to identify articles describing acute kidney injury (AKI) in patients that undergone cardiac surgery. There was neither time limit nor language limit on the search. The results were narratively summarized.

Results

All the relevant articles have been extracted; results have been summarized in each related section. CSA-AKI is a serious postoperative complication and it can contribute to a significant increase in perioperative morbidity and mortality rates. Optimization of factors that can reduce CSA-AKI, therefore, contributes to a better postoperative outcome.

Conclusion

Several factors can significantly increase the rate of AKI; identification and minimization of such factors can lead to lower rates of CSA-AKI and lower perioperative morbidity and mortality rates.

Bone-targeted agent treatment patterns and the impact of bone metastases on patients with advanced breast cancer in the United States

OBJECTIVE

Bone metastases are common among patients with advanced breast cancer, putting patients at increased risk of skeletal-related events (SREs). This study described impact of bone metastases, utilization of bone-targeted agents (BTAs) and physicians' decision processes for BTA use in advanced breast cancer.

METHODS

Data were collected using the Adelphi Breast Cancer Disease-Specific Programme in the United States. Physicians completed a detailed record for eligible patients (women ≥18 years, with stage IIIB-IV breast cancer).

RESULTS

Data available from 1276 patients with advanced breast cancer included 485 (38%) with bone metastases. Most (80%) reported pain at bone metastasis diagnosis; of those reporting pain, 55% reported moderate to severe pain. Among patients with bone metastasis, 69% received a BTA. Reasons for initiating BTAs were bone pain (32%) and an estimated high risk of SREs (25%). Reasons for not treating with BTAs were very recent diagnosis (37%), poor Karnofsky performance status (14%), perceived low risk of SREs (11%) and short life expectancy (11%). Zoledronic acid (48%) and denosumab (42%) were commonly used BTAs; the main reasons for initiating BTA treatment were long-term safety (28% and 32%, respectively) and efficacy in delaying SREs (15% and 31%, respectively). The analysis was not adjusted for age or other possible confounders.

CONCLUSION

Bone pain is a common and sometimes severe symptom of bone metastases in advanced breast cancer and a common reason for initiating BTA treatment. Safety and efficacy were the main factors considered by physicians when selecting BTAs.

Physicians' preferences for bone metastases treatments in France, Germany and the United Kingdom

BACKGROUND

Several bone-targeted agents (BTAs) are available for preventing skeletal-related events (SREs), but they vary in terms of efficacy, safety and mode of administration. This study assessed data on European physicians' treatment preferences for preventing SREs in patients with bone metastases from solid tumours.

METHODS

Physicians completed a web-based discrete-choice experiment survey of 10 choices between pairs of profiles of hypothetical BTAs for a putative patient. Each profile included five attributes within a pre-defined range (primarily based on existing BTAs' prescribing information): time (months) until the first SRE; time (months) until worsening of pain; annual risk of osteonecrosis of the jaw (ONJ); annual risk of renal impairment; and mode of administration. Choice questions were developed using an experimental design with known statistical properties. A separate main-effects random parameters logit model was estimated for each country and provided the relative preference for the treatment attributes in the study.

RESULTS

A total of 191 physicians in France, 192 physicians in Germany, and 197 physicians in the United Kingdom completed the survey. In France and the United Kingdom, time until the first SRE and risk of renal impairment were the most important attributes; in Germany, time until the first SRE and delay in worsening of pain were the most important. In all countries, a 120-min infusion every 4 weeks was the least preferred mode of administration (p < 0.05) and the annual risk of ONJ was judged to be the least important attribute.

CONCLUSIONS

When making treatment decisions regarding the choice of BTA, delaying the onset of SREs/worsening of pain and reducing the risk of renal impairment are the primary objectives for physicians.

Bone-targeted agent treatment patterns and the impact of bone metastases on patients with advanced breast cancer in real-world practice in six European countries

BACKGROUND

Bone metastases (BMs) are common in patients with breast cancer and can lead to skeletal-related events (SREs), which are associated with increased pain and reduced quality of life (QoL). Bone-targeted agents (BTAs), like zoledronic acid and denosumab, reduce the incidence of SREs and delay progression of bone pain.

MATERIALS AND METHODS

We evaluated the management of BMs and pain in six European countries (Belgium, France, Germany, Italy, Spain, and UK) using the Adelphi Breast Cancer Disease Specific Programme, which included a physician survey and patient-reported outcomes (PROs) to assess the impact of BMs on pain and QoL.

RESULTS

301 physicians completed patient record forms for 2984 patients with advanced breast cancer; 1408 with BMs and 1136 with metastases at sites other than bone (non-BMs). Most patients with BMs (88%) received a BTA, with 81% receiving treatment during 3 months following BM diagnosis. For those who did not receive a BTA, the main reasons given were: very recent BM diagnosis, perceived low risk of bone complications, and short life expectancy. Most patients with BMs (68%) were experiencing bone pain and, of these, 97% were taking analgesics (including 28% receiving strong opioids). Despite this, moderate to severe pain was reported in 20% of patients who were experiencing pain. PROs were assessed in 766 patients with advanced breast cancer (392 with BMs, 374 with non-BMs). Overall, patients with BMs reported worse pain and QoL outcomes than those with non-BMs, those not receiving a BTA reported worse pain.

CONCLUSION

Despite the large proportion of patients receiving BTAs in this study, some patients with BMs are still not receiving early treatment to prevent SREs or to manage pain. Improving physicians' understanding of the role of BTAs and the importance of early treatment following BM diagnosis has the potential to improve patient care.

Physician preferences for bone metastasis drug therapy in Canada

BACKGROUND

Currently in Canada, several bone-targeted agents (btas) with varying characteristics are available for the prevention of skeletal-related events (sres) in patients with bone metastasis secondary to solid tumours. In the present study, we evaluated the preferences of physicians in Canada for the various attributes of the available btas.

METHODS

Physicians treating patients with bone metastasis from solid tumours were invited to complete an online discrete-choice experiment. Respondents were asked to choose between pairs of hypothetical medications for virtual patients. Each hypothetical medication was described based on predefined key attributes: time until first sre, time until worsening of pain, medication-related annual risk of osteonecrosis of the jaw (onj), medication-related annual risk of renal impairment, and mode of administration. A random-parameters logit model was used to analyze the choices between hypothetical medications and thus infer physician preferences for medication attributes.

RESULTS

Responses from the 200 physicians who completed the discrete-choice experiment suggested that months until first sre, risk of renal impairment, and months until worsening of pain were considered the most important attributes affecting choice of bta. The annual risk of onj was considered the least important attribute.

CONCLUSIONS

When making treatment decisions about the choice of bta for patients with bone metastasis from solid tumours, delaying sres and worsening of pain, and reducing the risk of renal impairment are primary considerations for physicians in Canada.

Bone targeting agent treatment patterns and the impact of bone metastases on patients with advanced breast cancer in the US

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Background: Bone is the most common site of distant metastasis in patients with advanced breast cancer. Bone metastases (BMs) often lead to skeletal-related events (SREs) and may result in debilitating bone pain which impacts a patient’s quality of life. Bone targeting agents (BTAs) reduce the incidence of SREs and progression of pain due to BMs. This study aims to understand real world patients’ experience of bone pain and to assess BTAs treatment patterns. Methods: Data were extracted from the Adelphi Breast Cancer Disease-Specific Programme (DSP), a cross-sectional survey of 98 US oncologists conducted from February to May 2015 in the USA. Each physician completed comprehensive record forms capturing the following information about the next 12 patients being treated for advanced breast cancer: Presence of BMs, patient’s pain state at diagnosis of BMs, current pain state, time since diagnosis of BMs, current analgesic use and reasons for prescribing BTAs. Results: Bone pain was more prevalent (p < 0.001) in patients with BMs (67% of 485) than those without BM (7% of 791). Mean time for pain assessment was 6.2 months after BM diagnosis. Among breast cancer patients with BMs and bone pain (n = 323), 98% required analgesic medications to manage the pain, including 40% (n = 130) who were treated with strong opioids (e.g., morphine, oxycodone, hydromorphone, or methadone). Of these patients, 100 (77%) had moderate/severe bone pain. Of the patients with BMs, 69% (n = 337) were treated with a BTA and treatment was initiated within 3 months of BMs diagnosis in 91% (n = 306) of them. The reasons for prescribing a BTA within 3 months of BM diagnosis were “bone pain” (32%), “high risk of bone complications” (25%), “prior history of bone complications”(18%), “number of BMs” (11%) and “location of BMs” (4%). Conclusions: Advanced breast cancer patients with BMs are more likely to experience bone pain, and three-fourths of the patients treated with strong opioids experienced moderate/severe bone pain.The majority of patients with BMs receive a BTA prescription for the reduction of bone pain and risk of bone complications.

Physicians' preferences for bone metastases drug therapy in the United States

OBJECTIVE

Several characteristics of bone-targeted agents are considered when making treatment decisions. This study evaluated physicians' therapy preferences for preventing skeletal-related events (SREs) in patients with bone metastases secondary to solid tumors.

METHODS

A Web-enabled, discrete-choice experiment online survey was conducted among physicians who treated patients with bone metastases and solid tumors in the United States. Respondents chose between pairs of hypothetical medications defined by combinations of six attributes at varying levels for two hypothetical patients. Preference weights for attribute levels were estimated using a random-parameters logit model.

RESULTS

In total, 200 physicians completed the survey. Their mean age was 52 years, 57% were in practice for more than 15 years, 37% were oncologists, and 65% treated 10 or fewer patients with bone metastases weekly. Out-of-pocket cost to patients was the most important attribute overall. Among clinical outcomes, time to first SRE and risk of renal impairment were the most important attributes. Statistically significant preferences were observed for all attribute levels for time to first SRE, risk of renal impairment, and mode of administration. Predicted choice probability analysis showed that physicians preferred a hypothetical medication with attributes similar to those of denosumab over one with attributes similar to those of zoledronic acid.

CONCLUSIONS

Physicians indicated that clinical attributes are important when considering bone-targeting therapy for bone metastases, but consistent with the current health care landscape, patient out-of-pocket cost was the most important. With health care costs being increasingly shifted to patients, physicians require accurate information about co-pays and assistance programs to avoid patients receiving less costly, yet potentially inferior, treatment.

Patient preferences for treatments to delay bone metastases

BACKGROUND

Most patients with advanced prostate cancer (PCa) develop bone metastases (BM) and present with bone complications like fracture. Bone-targeted agents that prevent metastasis-induced bone complications can cause adverse events. Understanding how patients view treatment options may optimize care. This study aimed to quantify how PCa patients value a hypothetical treatment that delays BM but can cause osteonecrosis of the jaw (ONJ). The study also assessed the value patients place on avoiding metastasis-induced bone complications versus increased survival.

METHODS

PCa patients from the United Kingdom (n = 201) and Sweden (n = 200) on androgen-deprivation therapy or hormone therapy for ≥ 3 years completed a 10-question discrete-choice-experiment survey examining whether patients would accept a BM-delaying treatment. Two time-tradeoff questions assessed patients' willingness to tradeoff between survival and bone complications. Percentages of patients choosing treatment were summarized by levels of treatment efficacy and ONJ risk. Odds ratios from a logit model were used to evaluate how patient and medication characteristics affected treatment choice. Proportions of patients choosing each tradeoff scenario were calculated.

RESULTS

A majority of patients accepted treatment at the lowest benefit level (5-month BM delay) and highest risk level (9% ONJ risk). PCa symptoms and prior treatment affected patient preferences. Nearly 80% of patients would tradeoff at least 3 months of survival to avoid bone complications.

CONCLUSIONS

PCa patients in the U.K and Sweden may value a medication that delays BM, despite the risk of ONJ. Furthermore, patients were willing to tradeoff up to 5 months of survival for prevention of bone complications.

Patients' preferences for bone metastases treatments in France, Germany and the United Kingdom

Purpose

The aim of this study was to assess patients’ preferences for efficacy, safety, and mode of administration in relation to available bone-targeted agents (BTA) for the prevention of skeletal-related events (SREs) associated with bone metastases in Europe.

Methods

Adults in France (n = 159), Germany (n = 166), and the United Kingdom (UK; n = 159) with a self-reported physician diagnosis of bone metastases secondary to a solid tumour completed an online discrete- choice experiment survey of ten questions, choosing between pairs of hypothetical BTA profiles. Profiles were defined by five treatment attributes: delay of first SRE, delay of worsening of pain, annual risk of osteonecrosis of the jaw (ONJ), annual risk of renal impairment, and mode of administration. Profiles were generated using an experimental design with known statistical properties. A main-effects random parameters logit (RPL) model was applied to relate participants’ choices to the characteristics of the BTA profiles.

Results

The most important treatment attributes for patients across all three countries were time until first SRE, annual risk of renal complications and time until pain worsening. For these attributes, better levels of outcomes were significantly preferred to worse levels (p < 0.05). A 120-minutes infusion every 4 weeks was the least preferred mode of administration. Risk of ONJ was judged by patients in the UK and Germany to be the least important attribute.

Conclusions

Patients consider delaying SREs, avoiding renal impairment and delaying pain worsening as the most important goals to consider when selecting treatment to prevent the bone complications commonly associated with bone metastases.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-014-2309-x) contains supplementary material, which is available to authorized users.

Preferences for treatment to delay bone metastases (BM) in patients with castration-resistant prostate cancer (CRPC) at high risk of developing BM

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Background: Limited treatments are available for patients with non-metastatic CRPC. Prophylactic treatment may be associated with adverse events (AE). We evaluated patient preferences for a medication delaying bone metastases (BM) with a risk of AE.Methods: UK and Swedish adults with CRPC at high risk for BM (on androgen-deprivation or hormone therapy for ≥ 3 yrs) completed an online discrete-choice experiment with 10 choice questions. Patients were asked if they would prefer to receive a hypothetical prophylactic medication (HPM) with a risk of osteonecrosis of the jaw (ONJ) to prevent BM or to decline HPM thus not receiving any treatment benefit or risk. HPMs were defined by delay in BM (0-23 months) and risk of ONJ (0-9%). The proportion of patients who chose HPM with different combinations of BM delay and ONJ risk was calculated. To further evaluate the impact of BM to patients, time tradeoff was used to assess patients’ willingness to trade off between life years with and without bone complications (i.e., skeletal-related events, including spinal cord compression, surgery or radiation to bone, and pathologic fracture).Results: A total of 201 UK patients and 200 Swedish patients completed the survey. As shown in the table, even a HPM with the lowest level of BM delay (5 months) and the highest level of ONJ risk (9%) was acceptable to the majority of patients in both countries. Furthermore, when asked about the tradeoff between life years with and without bone complications, 52% of UK patients and 26% of Swedish patients were willing to trade off 5 months of survival to avoid bone complications; nearly three-quarters of the patients were willing to trade off 3 months of survival to avoid bone complications. Conclusions: A majority of patients in the UK and Sweden were willing to take HPMs to delay BM, despite a treatment-related risk of ONJ and were willing to trade off 3 to 5 months of survival to avoid bone complications. [Table: see text]

Effects of GYKI 52466 and some 2,3-benzodiazepine derivatives on hippocampal in vitro basal neuronal excitability and 4-aminopyridine epileptic activity

In order to determine whether the anticonvulsant effect of 2, 3-benzodiazepines is also displayed in a model of in vitro epilepsy, such as the "epileptiform" hippocampal slice, we studied the effects of 2,3-benzodiazepine 1-(4-aminophenyl)-4-methyl-7, 8-methylenedioxe-5H 2,3-benzodiazepine hydrochloride (GYKI 52466) and some new 2,3-benzodiazepine derivatives on CA1 basal neuronal excitability and on CA1 epileptiform burst activity produced by 4-aminopyridine in rat hippocampal slices. The results showed that GYKI 52466 affected basal neuronal excitability as evidenced by its influence on the magnitude of the CA1 orthodromic-evoked field potentials. 2,3-Benzodiazepines showed their antiepileptic effect also in an in vitro model of experimental epilepsy. The effects of the new 2,3-benzodiazepine derivatives suggest that the methylenedioxidation in positions 7 and 8 of the 2,3-benzodiazepine ring is the main structural modification for the antiepileptic effect of 2,3-benzodiazepines to take place.

Effects of the novel acetylcholinesterase inhibitor N-octyl-1,2,3, 4-tetrahydro-9-aminoacridine on locomotor activity and avoidance learning in mice

The acetylcholinesterase reversible inhibitor N-octyl-1,2,3, 4-tetrahydro-9-aminoacridine (THA-C8) is a new synthesized derivative of tacrine (THA) characterized by an alkyl chain in the molecular structure which ameliorates the penetrability of the compound into the central nervous system. THA-C8 (0.1-5 mg/kg) significantly reduced spontaneous locomotor activity in CD1 mice at a dose of 3 mg/kg. Moreover, THA-C8 (0.2-2 mg/kg) significantly improved shuttle-box avoidance acquisition at doses (0.25, 0.3, 1 mg/kg) not affecting locomotion and that are much lower than the doses reported to be effective for THA in animal models. From the data reported it seems that the new compound could be interesting for therapeutic purposes.

Studies on a new series of THA analogues: effects of the aromatic residues that line the gorge of AChE

A series of N-monoalkylsubstituted 1,2,3,4-tetrahydro-9-aminoacridines have been prepared after modelling simulation of the AChE-inhibitor complex. Molecular modelling has predicted a number of hydrophobic residues to be involved in the catalytic mechanism of this interaction between the binding sites of AChE and this series of aminoacridines. In these compounds the acridine moiety becomes sandwiched between the rings of PHE330 and TRP84. In particular, the alkyl chain shows the important role of aromatic groups as binding sites. Their in vitro inhibitory properties (enzyme from Electrophorus electricus) confirm the aromatic groups as a general and significant characteristic of the mechanism of AChE inhibition.

Synthesis and cholinesterase inhibitory activity of 6-, 7-methoxy-(and hydroxy-) tacrine derivatives

Some 6- and 7-methoxy-(and hydroxy-) tacrine derivatives were synthesized and evaluated for their in vitro acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) inhibitory activities. The most potent analogue in our series was the 9-heptylamino-6-methoxytacrine 3af which, in comparison with tacrine (THA), displayed an almost identical inhibitory effect, slightly lower acute toxicity and higher selectivity profile towards AchE when compared with THA.

Effects of the new A2 adenosine receptor antagonist 8FB-PTP, an 8 substituted pyrazolo-triazolo-pyrimidine, on in vitro functional models

1. We have characterized the in vitro pharmacological profile of putative A2 adenosine antagonists, two non-xanthine compounds, 5-amino-8-(4-fluorobenzyl)-2-(2-furyl)-pyrazolo [4,3-e]-1,2,4-triazolo[1,5-c] pyrimidine (8FB-PTP) and 5-amino-9-chloro-2-(2-furyl 1,2,4-triazolo [1,5-c] quinazoline (CGS 15943), and the xanthine derivative (E)7-methyl-8-(3,4-dimethoxystyryl)-1,3-dipropyl- xanthine (KF 17837). 2. In binding studies on bovine brain, 8FB-PTP was the most potent (Ki = 0.074 nM) and selective (28 fold) drug on A2 receptors, whereas CGS 15943 and KF 17837 exhibited affinity in the low and high nanomolar range, respectively, and showed little selectivity. 3. In functional studies, 8FB-PTP antagonized 5'-N-ethyl-carboxamidoadenosine (NECA)-induced vasorelaxation of bovine coronary artery (pA2 = 7.98) and NECA-induced inhibition of rabbit platelet aggregation (pA2 = 8.20). CGS 15943 showed weak activity in the platelet aggregation model (pA2 = 7.43) and failed to antagonize NECA-induced vasodilatation. KF 17837 was ineffective in both models up to micromolar concentrations. 4. Antagonism of A1-mediated responses was tested versus 2-chloro-N6-cyclopentyladenosine (CCPA) in rat atria. 8FB-PTP and CGS 15943 also antagonized competitively the negative chronotropic response induced by CCPA. Conversely, KF 17837 was unable to reverse A1-mediated responses. 5. 8FB-PTP is a potent and competitive antagonist of responses mediated by A2 adenosine receptors. The data provided a basis to reduce, by further chemical modifications, the affinity at A1 receptor and therefore enhance A2 receptor selectivity.

Physostigmine analogs anticholinesterases: effects of the lengthening of the N-carbamic chain on the inhibition kinetics

Data are presented about the inhibitor power of new carbamates against acetylcholinesterase. The study was carried out on two series of physostigmine analogs, N-alkyl and N-methyl,N-alkylphysostigmines. For these inhibitors, the second-order rate constants for inhibition, ki, and the first-order rate constants of reactivation, k3, have been determined. From the reported results, electronic, hydrophobic and steric effects, due to the enhancement of the alkyl chain, may have influenced all kinetics parameters discussed. In comparison to physostigmine, both the new N-methyl,N-alkylphysostigmines and the N-alkylphysostigmines showed a non-linear decrease in the values of ki and k3. This study presents the hydrophobic interactions as an important factor not only in determining carbamylation but also decarbamylation rates constants.

Synthesis and antileishmanial activity of some 1- or 2-(dihydroxyalkyl) and 3-(dihydroxyalkoxy)pyrazolo [3,4-d] pyrimidines

Several new derivatives of 4-amino-, 4,6-diamino- and 4-hydrazino-[3,4-d]pyrimidine dihydroxyalkyl substituted in the 1 or 2 positions, or dihydroxyalkoxy substituted in the 3 position have been synthesized. Some of these compounds were evaluated for their activity against Leishmania infantum in mice. The highest degree of antileishmanial activity was displayed by the 4-amino-1-(dihydroxyalkyl) derivatives which yielded parasite inhibition values nearly comparable with that of glucantime in a standard 5-day test.

Neuropharmacology of several beta-carboline derivatives and their 9-acetylated esters. In vivo versus in vitro studies in the rabbit

The effects of 3-methoxycarbonyl- (beta-CCM, Ia), 3-ethoxycarbonyl- (beta-CCE, Ic), 3-propoxycarbonyl- (PrCC, Ie), 3-N-methylcarboxamido- (FG-7142, Ig) beta-carboline and 2-acetyl-3-methoxycarbonyl-1,2-dihydro-beta-carboline (IIa) as well as of their corresponding 9-acetyl derivatives (Ib, Id, If, Ih and IIb) have been studied in rabbits. In addition, the effects of 6,7-dimethoxy-4-ethyl-3-methoxycarbonyl-beta-carboline (DMCM) have also been studied. In in vitro studies, these drugs compete with 3H-diazepam to benzodiazepine (BDZ) receptor in membrane preparations from brain cortex. The values of IC50 are in the nanomolar range without significant differences between the acetyl derivatives and their congeners only compound If shows a 10-fold decrease of the binding capacity in respect to its congener Ie. In the presence of 10(-5) M GABA, a decrease in the binding capacity for DMCM, Ia, Ic and Ig and an increase for If are observed. In vivo studies show that DMCM, Ia, Ib, IIa and IIb elicit three dose-dependent stages of electrocortical changes (trains of slow waves, trains of spike-and-wave complexes and "grand-mal" seizures). Compounds Ic, Id and Ig elicit only the first two stages. Compound Ih elicits only the first stage. While compound Ie does not affect the EEG pattern, its 9-acetyl derivative If induces changes (cortical spindles and disruption of the hippocampal theta waves) characteristic of agonist ligands of BDZ receptor. These findings confirm that the efficacy of compounds DMCM, Ia, Ic, Id, Ig and Ih as inverse agonists of BDZ receptor in the EEG paradigm parallels the reduction of their apparent binding affinity in the presence of GABA. The 9-acetylated compounds may be more inverse agonist in vivo than predicted from the in vitro findings, due to hydrolysis in the plasma.

Chronic venous insufficiency--clinical and therapeutic approach

Chronic venous insufficiency is defined as a state of venous hypertension that is shown by two big syndromes: the edematous and the indurating hypodermitis. The common characteristic of this pathology is the claudication of the valve function; the most frequent cases being in descending order, are the following: Post-traumatic syndrome, Essential insufficiency, Artenovenous fistula, Angioplasies.

Long-lasting proconflict effect induced by chronic administration of the beta-carboline derivative FG 7142

In this study, the effect of the chronic administration of the benzodiazepine (BZD) receptor ligand FG 7142 on the rat conflict test was examined. Rats chronically treated with FG 7142 (15 mg/kg, i.p. twice a day for 10 days) had an enhanced sensitivity to punishment at 4 and 15 days after the last treatment. This 'proconflict' effect was prevented by the concurrent administration of the BZD antagonist Ro 15-1788. The hypothesis that the long-lasting proconflict effect of chronic FG 7142 administration is the consequence of a persistent down-regulation of the GABAergic transmission is discussed.

Supraspinal convulsions induced by inverse benzodiazepine agonists in rabbits

The electroencephalographic (EEG) effects of inverse benzodiazepine (BDZ) agonists have been studied in rabbits after i.v. administration. A dose-dependent progression of three different stages of EEG changes have been observed with inverse BDZ agonists. At first, trains of slow waves in the occipital cortex occur, followed by trains of spike-and-wave complexes in the sensorimotor cortex. These two stages are superimposed on a desynchronized cortical activity, accompanied by an enhancement of the hippocampal theta rhythm. These EEG changes parallel a state of alertness. The third stage is characterized by generalized grand-mal seizures made up of high voltage spikes in the cortical and subcortical brain areas accompanied by generalized tonico-clonic convulsions. No modification of electrical activity is observed at the level of the spinal cord. Methyl-beta-carboline-3-carboxylate (beta-CCM) (at doses higher than 0.2 mg/kg) and 6,7-dimethoxy-4-ethyl-beta-carboline-3-carboxylate (DMCM) (at doses higher than 0.4 mg/kg) elicit all three stages, whereas ethyl-beta-carboline-3-carboxylate (beta-CCE) (0.2-2 mg/kg) and N-methyl-beta-carboline-3-carboxamide (2-20 mg/kg) only elicit the first two, and finally CGS 8216 only the first. The extent of the EEG progression by inverse BDZ agonists may therefore be used as an index of the efficacy of each compound. The BDZ antagonists Ro 15-1788 and Ro 15-3505 (0.3 mg/kg or higher), which do not change the EEG pattern, block the effects of the convulsant and subconvulsant doses of the inverse BDZ agonists, giving rise to a desynchronized EEG pattern.(ABSTRACT TRUNCATED AT 250 WORDS)

[Isochroman-4-spiro-4'-piperidine: synthesis and analgesic properties]

The synthesis of some isochroman-4-spiro-4'-piperidines by intramolecular O-methylation of 4-aryl-4-hydroxymethylpiperidines with formaldehyde and their analgesic activity ("hot plate"test in mice) are reported. The introduction of the new ring led to compounds with weak analgesic activity.

[Synthesis of 1,4-benzodiazepine and 1,5-benzodiazocine through oxidative fission of the double bond of indole derivatives]

A simplified new synthesis of some 5-phenyl-1,4-benzodiazepines and 6-phenyl-1,5-benzodiazocines, in satisfactory yields, by oxidation with sodium periodate of 1-alkylamino-2-methyl-3-phenylindoles, is described.

[Pyrazino(1,2-a)- and 1,4-diazepino(1,2-a)- indoles. III. Synthesis of pyrrolo(2',1':3,4)pyrazino(1,2-a)indoles and pyrrolo(2',1':3,4)-1,4-diazepino(1,2-a) indoles; isoindolo(2',1':3,4)pyrazino(1,2-a)-indoles and isoindolo(2',1':3,4)-1,4-diazepino(1,2-a)indoles; pyrazino(3,2,1-jk)- carbazoles and 1,4-diazepino(3,2,1-jk) carbazoles]

Pyrrolo(2',1':3,4)pyrazino (or 1,4-diazepino) (1,2-a)indoles and isoindolo(2',1':3,4)pyrazino (or 1,4-diazepino) (1,2-a)indoles were synthesized by reaction of 1-(2-aminoethyl)indole or 1-(3-aminopropyl)indole with gamma-keto and o-acylbenzoic acids. In addition, a novel synthetic route for the preparation of pyrazino(3,2,1-jk)- and 1,4-diazepino(3,2,1-jk)carbazoles has been realized.

[Pyrazino (1,2-a)- and 1,4-diazepino(1,2-a)indoles. II. Synthesis of 1-substituted 10-phenyl-3,4-dihydropyrazino(1,2-a)indoles and of 11-phenyl-4,5-dihydro-4H-diazepino(1,2-a)indoles]

The AA. describe the synthesis of some 1-substituted 10-phenyl-3,4-dihydropyrazino(1,2-a)indoles and 11-phenyl-4,5-dihydro-3H-1,4-diazepino(1,2-a)indoles. Preliminary pharmacological tests indicate that these products, have lower sedative and antiadrenergic activity than the compounds reported in our previous paper.