A Repurposing Programme Evaluating Transdermal Oestradiol Patches for the Treatment of Prostate Cancer Within the PATCH and STAMPEDE Trials: Current Results and Adapting Trial Design

AIMS

Androgen deprivation therapy (ADT), usually achieved with luteinising hormone releasing hormone analogues (LHRHa), is central to prostate cancer management. LHRHa reduce both testosterone and oestrogen and are associated with significant long-term toxicity. Previous use of oral oestrogens as ADT was curtailed because of cardiovascular toxicity. Transdermal oestrogen (tE2) patches are a potential alternative ADT, supressing testosterone without the associated oestrogen-depletion toxicities (osteoporosis, hot flushes, metabolic abnormalities) and avoiding cardiovascular toxicity, and we here describe their evaluation in men with prostate cancer.

MATERIALS AND METHODS

The PATCH (NCT00303784) adaptive trials programme (incorporating recruitment through the STAMPEDE [NCT00268476] platform) is evaluating the safety and efficacy of tE2 patches as ADT for men with prostate cancer. An initial randomised (LHRHa versus tE2) phase II study (n = 251) with cardiovascular toxicity as the primary outcome measure has expanded into a phase III evaluation. Those with locally advanced (M0) or metastatic (M1) prostate cancer are eligible. To reflect changes in both management and prognosis, the PATCH programme is now evaluating these cohorts separately.

RESULTS

Recruitment is complete, with 1362 and 1128 in the M0 and M1 cohorts, respectively. Rates of androgen suppression with tE2 were equivalent to LHRHa, with improved metabolic parameters, quality of life and bone health indices (mean absolute change in lumbar spine bone mineral density of -3.0% for LHRHa and +7.9% for tE2 with an estimated difference between arms of 9.3% (95% confidence interval 5.3-13.4). Importantly, rates of cardiovascular events were not significantly different between the two arms and the time to first cardiovascular event did not differ between treatment groups (hazard ratio 1.11, 95% confidence interval 0.80-1.53; P = 0.54). Oncological outcomes are awaited.

FUTURE

Efficacy results for the M0 cohort (primary outcome measure metastases-free survival) are expected in the final quarter of 2023. For M1 patients (primary outcome measure - overall survival), analysis using restricted mean survival time is being explored. Allied translational work on longitudinal samples is underway.

New horizons in subdural haematoma

Subdural haematoma (SDH) is a common injury sustained by older people living with frailty and multimorbidity, and typically following falls from a standing height. Anticoagulant and antiplatelet use are commonly indicated in older people with SDH, but few data inform decision-making surrounding these agents in the context of intracranial bleeding. Opposing risks of rebleeding and thrombosis must therefore be weighed judiciously. Decision-making can be complex and requires detailed awareness of the epidemiology to ensure the safest course of action is selected for each patient. Outcomes of surgical decompression in acute SDH are very poor in older people. However, burr hole drainage can be safe and effective in older adults with symptomatic chronic SDH (cSDH). Such patients need careful assessment to ensure symptoms arise from cSDH and not from coexisting medical pathology. Furthermore, the emerging treatment of middle meningeal artery embolisation offers a well-tolerated, minimally invasive intervention which may reduce the risks of rebleeding in older adults. Nonetheless, UK SDH management is heterogenous, and no accepted UK or European guidelines exist at present. Further randomised trial evidence is required to move away from clinical practice based on historic observational data.

Exploring options to strengthen rural health care: comparing the United States of America and United Kingdom

INTRODUCTION

The USA has long wrestled with the challenges of delivering high quality care to rural areas and has developed an extensive set of policy interventions to support rural providers. The release of the results of a Parliamentary inquiry into rural health and care in the UK provides an opportunity to compare US and UK efforts to support rural health and share lessons learned from the USA.

METHODS

This presentation reviews the results of a study of US federal and state policy efforts to support rural providers dating back to the early 1970s. The lessons learned from these efforts can inform the work of the UK as it addresses the recommendations discussed in the February 2022 report from the Parliamentary inquiry. The presentation will review the major recommendations identified in the report and compare US efforts to address similar challenges.

RESULTS

The results of the inquiry indicate that the USA and UK share common challenges and inequalities in rural healthcare access. The Inquiry Panel made 12 recommendations for change under four broad headings:Build understanding of the distinctive needs of rural areas;Deliver services suited to the specific needs of rural places;Develop a structural and regulatory framework that fosters adaption and innovation; andDevelop integrated services that provide holistic, person-centered care.

DISCUSSION

This presentation will be of interest to policymakers in the USA, the UK, and other countries working to improve rural healthcare systems.

P-187 Post-thaw embryo quality is not predictive of live birth rates in frozen embryo transfer cycles: a retrospective cohort study

Study question

To determine whether post-thaw change in embryo quality is associated with live birth outcomes.

Summary answer

Post-thaw embryo morphology is not predictive of live birth rates in single frozen embryo transfer cycles.

What is known already

Embryo quality is typically evaluated via morphological assessment of embryos based on the Gardner criteria. For medical or elective reasons, embryos are commonly frozen for future use through the vitrification process. Research has shown that embryo quality pre-vitrification correlates highly with freeze-thaw survival, implantation, pregnancy, and subsequent live birth rates. Good-quality embryos are therefore more likely to be selected for vitrification. However, it is not unusual to find a decline in the quality of these vitrified embryos upon thawing them for embryo transfer.

Study design, size, duration

We retrospectively identified a patient cohort based out of the Ottawa Fertility Centre in Ottawa, Ontario, Canada, between 2016 and 2020.

Participants/materials, setting, methods

Frozen single embryo transfer (FET) cycles involving good-quality expanded blastocysts deriving from autologous oocytes were selected for inclusion. We compared FET cycles involving good post-thaw embryo quality to those with worsened/poor post-thaw embryo quality. The primary outcome was live birth after FET. Secondary outcomes included rates of positive serum human chorionic gonadotropin, clinical intrauterine pregnancy, miscarriage, and ectopic pregnancy. We fit a multivariate logistic regression model, adjusting for patient and cycle characteristics.

Main results and the role of chance

A total of 962 single FET cycles were analyzed. There were 826 embryos that preserved their pre-vitrification quality post-thaw and 136 embryos that exhibited poorer quality on post-thaw assessment. Baseline characteristics were mostly comparable between the two groups under study. In the multivariate regression model, the adjusted odds of live birth was not significantly different in the group with good post-thaw embryo quality compared to that in the group with worse/poor post-thaw embryo quality (odds ratio [OR] 1.30, 95% confidence interval [CI] 0.86-1.96, p = 0.21). Similarly, no significant associations were found between post-thaw embryo quality and the secondary outcomes of positive BhCG (OR 1.19, 95% CI 0.81-1.75), clinical intrauterine pregnancy (OR 1.29, 95% CI 0.87-1.87), miscarriage (OR 0.97, 95% CI 0.53-1.77), and ectopic pregnancy rates (OR 0.41, 95% CI 0.14-1.24).

Limitations, reasons for caution

Although a multivariate regression model was used to adjust for clinically relevant confounders, there remains the possibility for residual confounding given the observational nature of our study.

Wider implications of the findings

The results of our study suggest that, after adjusting for patient and cycle characteristics, post-thaw embryo quality does not impact live birth outcomes.

Trial registration number

Not applicable

P-428 Fertility outcomes following treatment of chronic endometritis: a systematic review and meta-analysis

Study question

To determine if treatment of chronic endometritis (CE) impacts fertility outcomes

Summary answer

Treatment of CE in women with infertility, recurrent pregnancy loss, or recurrent implantation failure, improves live birth outcomes

What is known already

Chronic endometritis is an inflammatory condition that involves plasma cells invading the endometrial stroma. Prevalence of CE is high among patients with recurrent pregnancy loss (RPL), recurrent implantation failure (RIF), and infertility. Proposed treatment strategies include oral antibiotics, intrauterine antibiotic infusion, platelet-rich plasma, and hysteroscopic surgery, among others. Although treatment-associated CE cure rates have been high, few studies have reported on fertility outcomes following treatment of CE. Previously published systematic reviews have also yielded widely conflicting outcomes regarding the impact of CE treatment on fertility outcomes.

Study design, size, duration

We conducted a systematic search of the literature until late December 2021 across the Cochrane, EMBASE, and Medline databases. We used a DerSimonian and Laird random-effects meta-analysis model for the quantitative analysis.

Participants/materials, setting, methods

Clinical trials, prospective and retrospective observational studies that examined the treatment outcomes of CE were included. Study eligibility assessment, data extraction, and risk of bias assessment were independently performed by two reviewers. Comparisons were made between the groups of treated versus untreated CE, treated versus persistent CE, and between specific treatment strategies. Pooled risk ratios (RR) for the impact of CE treatment on outcomes such as live birth, clinical pregnancy, and miscarriage rates were assessed

Main results and the role of chance

Twelve studies totalling 1,539 women were included in our systematic review (3 randomized controlled trials and 9 observational studies), and 5 studies were included in the quantitative meta-analysis. Patients all had confirmed CE and a history of infertility, RPL, or RIF. Cure rates ranged between 37.2-91.8%. Live birth rate in the treated CE group ranged from 27.1-84.6%, from 16.4-44.4% in the non-treated CE group, and from 6.7-30.8% in the persistent CE group. Clinical pregnancy rate in the treated CE group ranged from 29.3-76.3%, from 11.1-30% in the non-treated CE group, and from 20-42.3% in the persistent CE group. Miscarriage rate in the treated CE group ranged from 6.7-23.8%, from 35.7-55.6% in the non-treated CE group, and from 27.3-66.7% in the persistent CE group. Risk ratio for the pooled effect of successful CE treatment compared to persistent CE on live birth was 2.98 (95% confidence ratio [CI] 1.51-5.91, I2=36.8%), on clinical pregnancy rate was 2.25 (95% CI 1.59-3.18, I2=40.1%), and on miscarriage rate was 0.55 (95% CI 0.28-1.10, I2=0.0%). Insufficient studies compared specific treatment subtypes to allow for any substantive qualitative or quantitative analysis.

Limitations, reasons for caution

Our results are limited by significant between-study heterogeneity in the study design, patient population, and comparisons used. Subgroup analysis by categories of comparisons mitigates some of this heterogeneity

Wider implications of the findings

Adequate treatment of CE significantly improves live birth rates in patients with RPL, RIF, and infertility. Assessment for CE should become part of routine fertility investigations, and resolution of CE must be confirmed prior to initiating fertility treatments.

Trial registration number

not applicable

P-748 Cesarean scar defect does not predict embryo transfer outcomes: A retrospective cohort study

Study question

Is the presence of a cesarean scar defect associated with live birth outcomes at the time of embryo transfer?

Summary answer

The presence of a cesarean scar defect is not predictive of live birth rates at the time of embryo transfer.

What is known already

Cesarean delivery is associated with subsequent impaired fertility, with lower pregnancy and live birth rates and longer inter-pregnancy intervals, compared to patients who delivered vaginally. Studies exploring pregnancy rates after IVF and embryo transfer also suggest lower pregnancy rates among patients with prior cesarean delivery. A postulated mechanism by which a prior cesarean delivery may impact fertility is the cesarean scar defect, and prior studies have shown a possible association between a scar defect and suboptimal outcomes.

Study design, size, duration

We retrospectively identified a patient cohort based out of the Ottawa Fertility Centre in Ottawa, Ontario, Canada, between 2013 and 2019.

Participants/materials, setting, methods

This retrospective cohort study included 317 patients with a prior cesarean delivery. Embryo transfer outcomes compared between the two groups based on the finding of a cesarean scar defect. The primary outcome was live birth rate, secondary outcomes of positive hCG, clinical intrauterine pregnancy, miscarriage rate. We fit a multivariate log binomial regression model with a priori variables for the primary and secondary outcomes, adjusting for patient and cycle characteristics.

Main results and the role of chance

There was no statistically significant difference in live birth rate among patients with a cesarean scar defect compared to those without, 28.0% vs 29.5% respectively (adjusted RR 0.95, 95% CI 0.68-1.35). There was no statistically significant difference in any of the secondary outcomes. Area of the defect and subgroup analysis of fresh vs frozen embryo transfer did not demonstrate any difference. Secondary analysis of patients with retroverted uterus had significantly lower live birth rates compared to those with an anteverted uterus, 17.7% vs 32.4%, respectively (adjusted RR 0.56, 95% CI 0.34-0.91).

Limitations, reasons for caution

Although a multivariate log binomial model was used to adjust for clinically relevant confounders, there remains the possibility for residual confounding given the observational nature of our study.

Wider implications of the findings

The results of our study suggest that, after adjusting for patient and cycle characteristics, the presence of a cesarean scar defect may not impact live birth outcomes and secondary analysis of the impact of uterine retroversion requires more study.

Trial registration number

Not applicable

Opioid Use Among Rural Medicare Beneficiaries

This study examines differences in opioid prescribing rates among a nationally representative sample of Medicare beneficiaries across rural and urban areas, as well as among beneficiaries with chronic overlapping pain conditions (COPCs). We assess whether prescribing patterns exceed the Centers for Disease Control and Prevention guidelines for dose and duration, and identify socioeconomic and health risk factors associated with opioid prescribing using logistic regression analyses. Data were from the 2010-2017 Medicare Current Beneficiary Survey files. Rural-Urban Commuting Area codes were used to identify patients’ residential location. The Area Health Resource Files were used to identify market characteristics such as primary care and mental health shortage areas. With the exception of 2010, over years 2011-2017, higher percentages of community-dwelling rural beneficiaries received opioid prescriptions (21.8-25.4%) compared to their urban counterparts (19.1-23.7%). During the same time period, facility-dwelling rural beneficiaries were more likely to receive opioid prescriptions (39.8-47.2%) compared to their urban counterparts (28.8-35.0%). Higher percentages (18.8%) of the community dwelling population in rural had COPCs compared to urban (15.2%), and a higher percentage of rural beneficiaries with COPCs (31.4%) received an opioid prescription than their urban counterparts (22.2%). Previous research points to other factors contributing to a lack of alternatives to opioids for pain management in rural areas, including greater reliance on primary care providers, lack of access to chronic pain specialists and alternative therapies, and travel barriers. Improving the capacity of rural primary care to deal with COPCs and expanding access to specialists via telehealth warrants further attention from policymakers.

Addition of docetaxel to hormonal therapy in low- and high-burden metastatic hormone sensitive prostate cancer: long-term survival results from the STAMPEDE trial

BACKGROUND

STAMPEDE has previously reported that the use of upfront docetaxel improved overall survival (OS) for metastatic hormone naïve prostate cancer patients starting long-term androgen deprivation therapy. We report on long-term outcomes stratified by metastatic burden for M1 patients.

METHODS

We randomly allocated patients in 2 : 1 ratio to standard-of-care (SOC; control group) or SOC + docetaxel. Metastatic disease burden was categorised using retrospectively-collected baseline staging scans where available. Analysis used Cox regression models, adjusted for stratification factors, with emphasis on restricted mean survival time where hazards were non-proportional.

RESULTS

Between 05 October 2005 and 31 March 2013, 1086 M1 patients were randomised to receive SOC (n = 724) or SOC + docetaxel (n = 362). Metastatic burden was assessable for 830/1086 (76%) patients; 362 (44%) had low and 468 (56%) high metastatic burden. Median follow-up was 78.2 months. There were 494 deaths on SOC (41% more than the previous report). There was good evidence of benefit of docetaxel over SOC on OS (HR = 0.81, 95% CI 0.69-0.95, P = 0.009) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P = 0.827). Analysis of other outcomes found evidence of benefit for docetaxel over SOC in failure-free survival (HR = 0.66, 95% CI 0.57-0.76, P < 0.001) and progression-free survival (HR = 0.69, 95% CI 0.59-0.81, P < 0.001) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P > 0.5 in each case). There was no evidence that docetaxel resulted in late toxicity compared with SOC: after 1 year, G3-5 toxicity was reported for 28% SOC and 27% docetaxel (in patients still on follow-up at 1 year without prior progression).

CONCLUSIONS

The clinically significant benefit in survival for upfront docetaxel persists at longer follow-up, with no evidence that benefit differed by metastatic burden. We advocate that upfront docetaxel is considered for metastatic hormone naïve prostate cancer patients regardless of metastatic burden.

Improved identification and differentiation from epileptiform activity of human hippocampal sharp wave ripples during NREM sleep

In rodents, pyramidal cell firing patterns from waking may be replayed in nonrapid eye movement sleep (NREM) sleep during hippocampal sharp wave ripples (HC-SWR). In humans, HC-SWR have only been recorded with electrodes implanted to localize epileptogenicity. Here, we characterize human HC-SWR with rigorous rejection of epileptiform activity, requiring multiple oscillations and coordinated sharp waves. We demonstrated typical SWR in those rare HC recordings which lack interictal epileptiform spikes (IIS) and with no or minimal seizure involvement. These HC-SWR have a similar rate (~12 min^-1 on average, variable across NREM stages and anterior/posterior HC) and apparent intra-HC topography (ripple maximum in putative stratum pyramidale, slow wave in radiatum) as rodents, though with lower frequency (~85 Hz compared to ~140 Hz in rodents). Similar SWR are found in HC with IIS, but no significant seizure involvement. These SWR were modulated by behavior, being largely absent (<2 min^-1 ) except during NREM sleep in both Stage 2 (~9 min^-1 ) and Stage 3 (~15 min^-1 ), distinguishing them from IIS. This study quantifies the basic characteristics of a strictly selected sample of SWR recorded in relatively healthy human hippocampi.

Tuberculosis due to Mycobacterium bovis in pet cats associated with feeding a commercial raw food diet

OBJECTIVES

Mycobacterium bovis, a member of the Mycobacterium tuberculosis complex, can infect cats and has proven zoonotic risks for owners. Infected cats typically present with a history of outdoor lifestyle and hunting behaviour, and cutaneous granulomas are most commonly observed. The aim of this study is to describe an outbreak of tuberculous disease commencing with six young cats, living exclusively indoors in five different households across England, being presented to separate veterinarians across the UK with a variety of clinical signs.

METHODS

Investigations into the pyogranulomatous lesions, lymphadenopathy and/or pulmonary disease of these cases consistently identified infection with M bovis. Infection was confirmed by PCR, where possible, or was indicated with a positive interferon-gamma release assay (IGRA), where material for PCR was unavailable. In-contact, cohabiting cats were screened by IGRA and follow-up testing was undertaken/advised where results were positive. A lifestyle investigation was undertaken to identify the source of infection.

RESULTS

Six clinically sick cats and seven in-contact cats were identified with evidence of M bovis infection. Five clinical cases were either too sick to treat or deteriorated despite therapy, giving a mortality rate of 83%. Lifestyle investigations revealed the common factors between clusters to be that affected cats had mycobacterial infections speciated to M bovis, were exclusively indoor cats and were fed a commercially available raw food product produced by a single manufacturer. The Food Standards Agency, Animal & Plant Health Agency, Public Health England and the food manufacturer concerned have been notified/informed. Other possible sources of exposure for these cats to M bovis were explored and were excluded, including wildlife contact, access to raw milk, the presence of rodent populations inside the buildings in which the cats lived and exposure to known infectious humans.

CONCLUSIONS AND RELEVANCE

Upon investigations, our results provide compelling, if circumstantial, evidence of an association between the commercial raw diet of these cats and their M bovis infections.

Monitoring cognitive change in multiple sclerosis using a computerized cognitive battery

Background

Cognitive monitoring that can detect short-term change in multiple sclerosis is challenging. Computerized cognitive batteries such as the CogState Brief Battery can rapidly assess commonly affected cognitive domains.

Objectives

The purpose of this study was to establish the acceptability and sensitivity of the CogState Brief Battery in multiple sclerosis patients compared to controls. We compared the sensitivity of the CogState Brief Battery to that of the Paced Auditory Serial Addition Test over 12 months.

Methods

Demographics, Expanded Disability Status Scale scores, depression and anxiety scores were compared with CogState Brief Battery and Paced Auditory Serial Addition Test performances of 51 patients with relapsing-remitting multiple sclerosis, 19 with secondary progressive multiple sclerosis and 40 healthy controls. Longitudinal data in 37 relapsing-remitting multiple sclerosis patients were evaluated using linear mixed models.

Results

Both the CogState Brief Battery and the Paced Auditory Serial Addition Test discriminated between multiple sclerosis and healthy controls at baseline (p<0.001). CogState Brief Battery tasks were more acceptable and caused less anxiety than the Paced Auditory Serial Addition Test (p<0.001). In relapsing-remitting multiple sclerosis patients, reaction time slowed over 12 months (p<0.001) for the CogState Brief Battery Detection (mean change -34.23 ms) and Identification (-25.31 ms) tasks. Paced Auditory Serial Addition Test scores did not change over this time.

Conclusions

The CogState Brief Battery is highly acceptable and better able to detect cognitive change than the Paced Auditory Serial Addition Test. The CogState Brief Battery could potentially be used as a practical cognitive monitoring tool in the multiple sclerosis clinic setting.

Techniques for placement of stereotactic electroencephalographic depth electrodes: Comparison of implantation and tracking accuracies in a cadaveric human study

OBJECTIVE

Stereotactic electroencephalography (SEEG) is used for the evaluation and identification of the epileptogenic zone (EZ) in patients suffering from medically refractory seizures and relies upon the accurate implantation of depth electrodes. Accurate implantation is critical for identification of the EZ. Multiple electrodes and implantation systems exist, but these have not previously been systematically evaluated for implantation accuracy. This study compares the accuracy of two SEEG electrode implantation methods.

METHODS

Thirteen "technique 1" electrodes (applying guiding bolts and external stylets) and 13 "technique 2" electrodes (without guiding bolts and external stylets) were implanted into four cadaver heads (52 total of each) according to each product's instructions for use using a stereotactic robot. Postimplantation computed tomography scans were compared to preimplantation computed tomography scans and to the previously defined targets. Electrode entry and final depth location were measured by Euclidean coordinates. The mean errors of each technique were compared using linear mixed effects models.

RESULTS

Primary analysis revealed that the mean error difference of the technique 1 and 2 electrodes at entry and target favored the technique 1 electrode implantation accuracy (P < 0.001). Secondary analysis demonstrated that orthogonal implantation trajectories were more accurate than oblique trajectories at entry for technique 1 electrodes (P = 0.002). Furthermore, deep implantations were significantly less accurate than shallow implantations for technique 2 electrodes (P = 0.005), but not for technique 1 electrodes (P = 0.50).

SIGNIFICANCE

Technique 1 displays greater accuracy following SEEG electrode implantation into human cadaver heads. Increased implantation accuracy may lead to increased success in identifying the EZ and increased seizure freedom rates following surgery.

Linear time-varying model characterizes invasive EEG signals generated from complex epileptic networks

Electrocorticography (ECoG) and stereotactic electroencephalography (SEEG) are popular tools for studying neural mechanisms governing behavior and neural disorders, such as epilepsy. In particular, clinicians are interested in identifying brain regions that start seizures, i.e., the epileptogenic zone (EZ) from such invasive recordings. Currently, they visually inspect signals from each electrode to locate abnormal activity, and are not informed by predictive models that can characterize such recordings and potentially increase accuracy in localizing the EZ. In this paper, we test whether a simple linear time varying (LTV) model is sufficient to characterize both ECoG and SEEG activity. Specifically, we construct linear time invariant models in consecutive time windows before, during and after seizure events creating an LTV model from data collected in one ECoG and one SEEG patient. We find that these LTV models accurately reconstruct both ECoG and SEEG time series measured suggesting that these LTV models can be used for EZ localization.

Adding abiraterone or docetaxel to long-term hormone therapy for prostate cancer: directly randomised data from the STAMPEDE multi-arm, multi-stage platform protocol

Background

Adding abiraterone acetate with prednisolone (AAP) or docetaxel with prednisolone (DocP) to standard-of-care (SOC) each improved survival in systemic therapy for advanced or metastatic prostate cancer: evaluation of drug efficacy: a multi-arm multi-stage platform randomised controlled protocol recruiting patients with high-risk locally advanced or metastatic PCa starting long-term androgen deprivation therapy (ADT). The protocol provides the only direct, randomised comparative data of SOC + AAP versus SOC + DocP.

Method

Recruitment to SOC + DocP and SOC + AAP overlapped November 2011 to March 2013. SOC was long-term ADT or, for most non-metastatic cases, ADT for ≥2 years and RT to the primary tumour. Stratified randomisation allocated pts 2 : 1 : 2 to SOC; SOC + docetaxel 75 mg/m2 3-weekly×6 + prednisolone 10 mg daily; or SOC + abiraterone acetate 1000 mg + prednisolone 5 mg daily. AAP duration depended on stage and intent to give radical RT. The primary outcome measure was death from any cause. Analyses used Cox proportional hazards and flexible parametric models, adjusted for stratification factors. This was not a formally powered comparison. A hazard ratio (HR) <1 favours SOC + AAP, and HR > 1 favours SOC + DocP.

Results

A total of 566 consenting patients were contemporaneously randomised: 189 SOC + DocP and 377 SOC + AAP. The patients, balanced by allocated treatment were: 342 (60%) M1; 429 (76%) Gleason 8-10; 449 (79%) WHO performance status 0; median age 66 years and median PSA 56 ng/ml. With median follow-up 4 years, 149 deaths were reported. For overall survival, HR = 1.16 (95% CI 0.82-1.65); failure-free survival HR = 0.51 (95% CI 0.39-0.67); progression-free survival HR = 0.65 (95% CI 0.48-0.88); metastasis-free survival HR = 0.77 (95% CI 0.57-1.03); prostate cancer-specific survival HR = 1.02 (0.70-1.49); and symptomatic skeletal events HR = 0.83 (95% CI 0.55-1.25). In the safety population, the proportion reporting ≥1 grade 3, 4 or 5 adverse events ever was 36%, 13% and 1% SOC + DocP, and 40%, 7% and 1% SOC + AAP; prevalence 11% at 1 and 2 years on both arms. Relapse treatment patterns varied by arm.

Conclusions

This direct, randomised comparative analysis of two new treatment standards for hormone-naïve prostate cancer showed no evidence of a difference in overall or prostate cancer-specific survival, nor in other important outcomes such as symptomatic skeletal events. Worst toxicity grade over entire time on trial was similar but comprised different toxicities in line with the known properties of the drugs.

Trial registration

Clinicaltrials.gov: NCT00268476.

Report on the International Workshop on Drug Prevention and Treatment in Rural Settings Organized by United Nation Office on Drugs and Crime (UNODC) and World Health Organization (WHO)

Very little evidence has been reported in literature regarding the misuse of substances in rural areas. Despite the common perception of rural communities as a protective and risk-mitigating environment, the scientific literature demonstrated the existence of many risk factors in rural communities. The Drug Prevention and Health Branch (DHB) of the United Nations Office on Drugs and Crime (UNODC), and the World Health Organization (WHO), in June 2016, organized a meeting of experts in treatment and prevention of SUDs in rural settings. The content presented during the meeting and the related discussion have provided materials for the preparation of an outline document, which is the basis to create a technical tool on SUDs prevention and treatment in rural settings. The UNODC framework for interventions in rural settings is a technical tool aimed to assist policy makers and managers at the national level. This paper is a report on UNODC/WHO efforts to improve the clinical conditions of people affected by SUDs and living in rural areas. The purpose of this article is to draw attention on a severe clinical and social problem in a reality forgotten by everyone.

30-year trends in overweight, obesity and waist-to-height ratio by socioeconomic status in Australian children, 1985 to 2015

BACKGROUND/OBJECTIVE

To report 30-year (1985-2015) prevalence trends in overweight, obesity and abdominal obesity among children by school level and socioeconomic status (SES).

SUBJECTS/METHODS

Five cross-sectional, population child surveys (age 4-18 years; n=27 808) conducted in 1985-1997-2004-2010-2015 in New South Wales, Australia. Outcomes were prevalence of measured overweight, obesity and waist-to-height ratio (WHtR⩾0.5) by sex, school level (children (primary) and adolescents (high)) and SES tertile.

RESULTS

In 2015, the prevalences of overweight, obesity and WHtR⩾0.5 in children were 16.4%, 7.0% and 14.6%, respectively, and in adolescents 21.9%, 17.2% and 4.6%, respectively. Obesity prevalence has not significantly changed in children or adolescents since 1997, nor since 2010 (children, P=0.681; adolescents, P=0.21). Overweight has not significantly changed in children since 1997, but has in adolescents since 1985, with a relative increase of 16 percentage points (P<0.001) between 2010 and 2015. WHtR⩾0.5 prevalence has significantly changed since 1985, except in adolescent girls between 2010 and 2015. Between 2010 and 2015 the relative increase in WHtR⩾0.5 was 17 and 40 percentage points in children and adolescent boys, respectively. Significant disparities in prevalence rates between children and adolescents from low and high SES backgrounds began in 2010 for overweight, since 1997 for obesity and since 2004 for WHtR⩾0.5. Differences between SES groups have become larger over the past 18 years.

CONCLUSIONS

Since 1997, obesity has remained stable, and overweight has stabilized in children, not in adolescents. WHtR⩾0.5 significantly increased between 1985 and 2015, with prevalence rates at each survey around twice the obesity prevalence. Compared with high SES children and adolescents, the risk of overweight, obesity and WHtR⩾0.5 was significantly higher for low SES children and adolescents. The findings are highly relevant to policy makers involved in child obesity prevention interventions and highlight the need for better targeted interventions among children and adolescents from low SES backgrounds, and adolescents in particular.

Developing Program Performance Measures for Rural Emergency Medical Services

BACKGROUND

The development of measures to monitor and evaluate the performance and quality of emergency medical services (EMS) systems has been a focus of attention for many years. The Medicare Rural Hospital Flexibility Program (Flex Program), established by Congress in 1997, provides grants to states to implement initiatives to strengthen rural healthcare delivery systems, including better integration of EMS into those systems of care.

OBJECTIVE

Building on national efforts to develop EMS performance measures, we sought to identify measures relevant to the rural communities and hospitals supported by the Flex Program. The measures are intended for use in monitoring rural EMS performance at the community level as well as for use by State Flex Programs and the Federal Office of Rural Health Policy (FORHP) to demonstrate the impact of the Flex Program.

METHODS

To evaluate the performance of EMS in rural communities, we conducted a literature search, reviewed research on performance measures conducted by key EMS organizations, and recruited a panel of EMS experts to identify and rate rurally-relevant EMS performance measures as well as emergent protocols for episodes of trauma, ST Elevation Myocardial Infarction (STEMI), and stroke. The rated measures were assessed for inclusion in the final measure set.

RESULTS

The Expert Panel identified 17 program performance measures to support EMS services in rural communities. These measures monitor the capacity of local agencies to collect and report quality and financial data, use the data to improve agency performance, and train rural EMS employees in emergent protocols for all age groups.

CONCLUSION

The system of care approach on which this rural EMS measures set is based can support the FORHP's goal of better focusing State Flex Program activity to improve program impact on the performance of rural EMS services in the areas of financial viability, quality improvement, and local/regional health system performance.

Technique, Results, and Complications Related to Robot-Assisted Stereoelectroencephalography

BACKGROUND:

Robot-assisted stereoelectroencephalography (SEEG) may represent a simplified, precise, and safe alternative to the more traditional SEEG techniques.

OBJECTIVE:

To report our clinical experience with robotic SEEG implantation and to define its utility in the management of patients with medically refractory epilepsy.

METHODS:

The prospective observational analyses included all patients with medically refractory focal epilepsy who underwent robot-assisted stereotactic placement of depth electrodes for extraoperative brain monitoring between November 2009 and May 2013. Technical nuances of the robotic implantation technique are presented, as well as an analysis of demographics, time of planning and procedure, seizure outcome, in vivo accuracy, and procedure-related complications.

RESULTS:

One hundred patients underwent 101 robot-assisted SEEG procedures. Their mean age was 33.2 years. In total, 1245 depth electrodes were implanted. On average, 12.5 electrodes were implanted per patient. The time of implantation planning was 30 minutes on average (range, 15-60 minutes). The average operative time was 130 minutes (range, 45-160 minutes). In vivo accuracy (calculated in 500 trajectories) demonstrated a median entry point error of 1.2 mm (interquartile range, 0.78-1.83 mm) and a median target point error of 1.7 mm (interquartile range, 1.20-2.30 mm). Of the group of patients who underwent resective surgery (68 patients), 45 (66.2%) gained seizure freedom status. Mean follow-up was 18 months. The total complication rate was 4%.

CONCLUSION:

The robotic SEEG technique and method were demonstrated to be safe, accurate, and efficient in anatomically defining the epileptogenic zone and subsequently promoting sustained seizure freedom status in patients with difficult-to-localize seizures.

High frequency activity correlates of robust movement in humans

The neural circuitry underlying fast robust human motor control is not well understood. In this study we record neural activity from multiple stereotactic encephalograph (SEEG) depth electrodes in a human subject while he/she performs a center-out reaching task holding a robotic manipulandum that occasionally introduces an interfering force field. Collecting neural data from humans during motor tasks is rare, and SEEG provides an unusual opportunity to examine neural correlates of movement at a millisecond time scale in multiple brain regions. Time-frequency analysis shows that high frequency activity (50-150 Hz) increases significantly in the left precuneus and left hippocampus when the subject is compensating for a perturbation to their movement. These increases in activity occur with different durations indicating differing roles in the motor control process.

PET imaging demonstrates histone deacetylase target engagement and clarifies brain penetrance of known and novel small molecule inhibitors in rat

Histone deacetylase (HDAC) enzymes have been demonstrated as critical components in maintaining chromatin homeostasis, CNS development, and normal brain function. Evidence in mouse models links HDAC expression to learning, memory, and mood-related behaviors; small molecule HDAC inhibitor tool compounds have been used to demonstrate the importance of specific HDAC subtypes in modulating CNS-disease-related behaviors in rodents. So far, no direct evidence exists to understand the quantitative changes in HDAC target engagement that are necessary to alter biochemistry and behavior in a living animal. Understanding the relationship between target engagement and in vivo effect is essential in refining new ways to alleviate disease. We describe here, using positron emission tomography (PET) imaging of rat brain, the in vivo target engagement of a subset of class I/IIb HDAC enzymes implicated in CNS-disease (HDAC subtypes 1, 2, 3, and 6). We found marked differences in the brain penetrance of tool compounds from the hydroxamate and benzamide HDAC inhibitor classes and resolved a novel, highly brain penetrant benzamide, CN147, chronic treatment with which resulted in an antidepressant-like effect in a rat behavioral test. Our work highlights a new translational path for understanding the molecular and behavioral consequences of HDAC target engagement.

Oscillations in human orbitofrontal cortex during even chance gambling

Evaluating value and risk as well as comparing expected and actual outcomes is the crux of decision making and reinforcement based learning. In this study, we record from stereotactic electroencephalograph depth electrodes in a human subject in numerous areas in the brain. We focus on the lateral and medial orbitofrontal cortex while they perform a gambling task involving betting on a high card. Preliminary time-frequency analysis shows modulations in the 5-15 Hz band that is well synced to the different events of the task. These oscillations increase in both high betting scenarios as well as in losing scenarios though their effects cannot be decoupled. However, the activity between lateral and medial orbitofrontal cortex is a lot more homogenous than previously seen. Additionally, the timing of some of these oscillations occurs before even a response in the visual cortex. This evidence hints that these areas encode priors that influence our decision in future statistically ambiguous scenarios.

Phenotypic characterisation of canine epileptoid cramping syndrome in the Border terrier

OBJECTIVES

To characterise the phenotype of Border terriers suspected to be affected by canine epileptoid cramping syndrome and to identify possible contributing factors.

METHODS

Owners of Border terriers with suspected canine epileptoid cramping syndrome were invited to complete an online questionnaire. The results of these responses were collated and analysed.

RESULTS

Twenty-nine Border terriers were included. Most affected dogs had their first episode before 3 years of age (range: 0·2 to 7·0 years). The majority of episodes lasted between 2 and 30 minutes (range: 0·5 to 150 minutes). The most frequent observations during the episodes were difficulty in walking (27 of 29), mild tremor (21 of 29) and dystonia (22 of 29). Episodes most frequently affected all four limbs (25 of 29) and the head and neck (21 of 29). Borborygmi were reported during episodes in 11 of 29 dogs. Episodes of vomiting and diarrhoea occurred in 14 of 29, with 50% of these being immediately before or after episodes of canine epileptoid cramping syndrome (7 of 14). Most owners (26 of 29) had changed their dog's diet, with approximately 50% (14 of 26) reporting a subsequent reduction in the frequency of episodes.

CLINICAL SIGNIFICANCE

This study demonstrates similarities in the phenotype of canine epileptoid cramping syndrome to paroxysmal dystonic choreoathetosis, a paroxysmal dyskinesia reported in humans. This disorder appears to be associated with gastrointestinal signs in some dogs and appears at least partially responsive to dietary adjustments.

Brain state evolution during seizure and under anesthesia: a network-based analysis of stereotaxic eeg activity in drug-resistant epilepsy patients

Epilepsy is a neurological condition with a prevalence of 1%, and 14-34% have medically refractory epilepsy (MRE). Seizures in focal MRE are generated by a single epileptogenic zone (or focus), thus there is potentially a curative procedure - surgical resection. This procedure depends significantly on correct identification of the focus, which is often uncertain in clinical practice. In this study, we analyzed intracranial stereotaxic EEG (sEEG) data recorded in two human patients with drug-resistant epilepsy prior to undergoing resection surgery. We view the sEEG data as samples from the brain network and hypothesize that seizure foci can be identified based on their network connectivity during seizure. Specifically, we computed a time sequence of connectivity matrices from EEG recordings that represent network structure over time. For each patient, connectivity between electrodes was measured using the coherence in a given frequency band. Matrix structure was analyzed using singular value decomposition and the leading singular vector was used to estimate each electrode's time dependent centrality (importance to the network's connectivity). Our preliminary study suggests that seizure foci may be the most weakly connected regions in the brain during the beginning of a seizure and the most strongly connected regions towards the end of a seizure. Additionally, in one of the patients analyzed, the network connectivity under anesthesia highlights seizure foci. Ultimately, network centrality computed from sEEG activity may be used to develop an automated, reliable, and computationally efficient algorithm for identifying seizure foci.

Dexrazoxane efficacy for anthracycline extravasation: use in UK clinical practice

Extravasation is recognised as a major complication of administering intravenous chemotherapy treatment. Of the agents involved in extravasation, anthracyclines are associated with the greatest risk to patients because they are vesicant agents, having the potential to cause blistering and ulceration. If not identified and left untreated, anthracycline extravasation can lead to more serious complications such as tissue necrosis and functional impairment. Dexrazoxane (Savene(®) ) is the only licensed antidote for the treatment of anthracycline extravasation and clinical evidence has shown Savene(®) to be highly effective for preventing the need for surgery following anthracycline extravasation, allowing full recovery in the majority of patients. To date, there have been eight published studies reporting a total of 102 cases of Savene(®) use. Here, we review the published data on the efficacy of Savene(®) and present an analysis of 12 UK case studies. All UK oncology centres where Savene(®) has been used to manage anthracycline extravasation were contacted by SpePharm UK, who requested case studies for this publication. All of the cases received, including two from our own experience of using Savene(®) have been included in the analysis.

Multivariate analysis of SEEG signals during seizure

Epilepsy is a neurological disorder that affects tens of millions of people every year and is characterized by sudden-onset seizures which are often associated with physical convulsions. Effective treatment and management of epilepsy would be greatly improved if convulsions could be caught quickly through early seizure detection. However, this is still a largely open problem due to the challenge of finding a robust statistic from the neural measurements. This paper suggests a new multivariate statistic by combining spectral techniques with matrix theory. Specifically, stereoelectroencephalography (SEEG) data was used to generate a series of coherence connectivity matrices which were then examined using singular value decomposition. Tracking the relative angles of the first singular vectors generated from this data provides an effective way of defining the most dominant characteristics of the SEEG during the normal, the pre-ictal, and the ictal states. This paper indicates that the first singular vector has a characteristic direction indicative of the seizure state and illustrates a data analysis method that incorporates all neural data as opposed to a small selection of channels.

Community mental health nurses' perspectives of recovery-oriented practice

Recovery-oriented practice, an approach aligned towards the service user perspective, has dominated the mental health care arena. Numerous studies have explored service users' accounts of the purpose, meaning and importance of 'recovery'; however, far less is known about healthcare staff confidence in its application to care delivery. A self-efficacy questionnaire and content analysis of nursing course documents were used to investigate a cohort of community mental health nurses' recovery-oriented practice and to determine the extent to which the current continuing professional development curriculum met their educational needs in this regard. Twenty-three community mental health nurses completed a self-efficacy questionnaire and 28 course documents were analysed. The findings revealed high levels of nurses' confidence in their understanding and ability to apply the recovery model and low levels of confidence were found in areas of social inclusion. The content analysis found only one course document that used the whole term 'recovery model'. The findings suggest a gap in the nurses' perceived ability and confidence in recovery-oriented practice with what is taught academically. Hence, nursing education needs to be more explicitly focused on the recovery model and its application to care delivery.