Indirect Comparisons of Efficacy between Combination Approaches in Metastatic Hormone-sensitive Prostate Cancer: A Systematic Review and Network Meta-analysis

CONTEXT

There have been substantial changes in the management of men with metastatic hormone-sensitive prostate cancer (mHSPC) over the past 5 yr, with upfront combination therapies replacing androgen-deprivation therapy (ADT) alone. A range of therapies have entered the space with no clear answer regarding their comparative efficacy.

OBJECTIVE

To perform a systematic review and network meta-analysis to characterise the comparative efficacy of combination approaches in men with mHSPC.

EVIDENCE ACQUISITION

We searched multiple databases and abstracts of major meetings up to June 2019 for randomised trials of patients receiving first-line therapy for metastatic disease, a combination of ADT and one (or more) of taxane-based chemotherapy, and androgen receptor-targeted therapies. The primary endpoint was overall survival (OS) and we evaluated progression-free survival as a secondary outcome. We performed subgroup analysis based on the volume of disease.

EVIDENCE SYNTHESIS

We found seven trials that met our eligibility criteria using either docetaxel, abiraterone acetate, enzalutamide, or apalutamide in combination with ADT. All agents in combination with ADT were shown to be superior to ADT alone; enzalutamide + ADT had the lowest absolute hazard ratio compared with ADT only (hazards ratio 0.53, 95% confidence interval 0.37-0.75), and an estimated 76.9% probability that it is the preferred treatment to prolong OS compared with other combination treatments, or with ADT alone. Enzalutamide appeared to have better OS compared with docetaxel in men with low-volume disease, but there was no difference in other comparisons.

CONCLUSIONS

Combination therapy with any of docetaxel, abiraterone acetate, enzalutamide, or apalutamide provides a significant OS benefit when compared with ADT alone. We did not identify significant differences in OS between different combination therapies. Subtle differences between these options provide clinicians considerable flexibility when selecting options for individual patients.

PATIENT SUMMARY

Many men with metastatic, hormone-sensitive prostate cancer should be managed with upfront combination therapy instead of androgen-deprivation therapy alone. Clinicians may consider many factors during the decision-making process, and thus management should be tailored for patients individually.

Ambulance-delivered transdermal glyceryl trinitrate versus sham for ultra-acute stroke: Rationale, design and protocol for the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) trial (ISRCTN26986053)

RATIONALE

Vascular nitric oxide levels are low in acute stroke and donors such as glyceryl trinitrate have shown promise when administered very early after stroke. Potential mechanisms of action include augmentation of cerebral reperfusion, thrombolysis and thrombectomy, lowering blood pressure, and cytoprotection.

AIM

To test the safety and efficacy of four days of transdermal glyceryl trinitrate (5 mg/day) versus sham in patients with ultra-acute presumed stroke who are recruited by paramedics prior to hospital presentation.

SAMPLE SIZE ESTIMATES

The sample size of 850 patients will allow a shift in the modified Rankin Scale with odds ratio 0.70 (glyceryl trinitrate versus sham, ordinal logistic regression) to be detected with 90% power at 5% significance (two-sided).

DESIGN

The Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) is a multicentre UK prospective randomized sham-controlled outcome-blinded parallel-group trial in 850 patients with ultra-acute (≤4 h of onset) FAST-positive presumed stroke and systolic blood pressure ≥120 mmHg who present to the ambulance service following a 999 emergency call. Data collection is performed via a secure internet site with real-time data validation.

STUDY OUTCOMES

The primary outcome is the modified Rankin Scale measured centrally by telephone at 90 days and masked to treatment. Secondary outcomes include: blood pressure, impairment, recurrence, dysphagia, neuroimaging markers of the acute lesion including vessel patency, discharge disposition, length of stay, death, cognition, quality of life, and mood. Neuroimaging and serious adverse events are adjudicated blinded to treatment.

DISCUSSION

RIGHT-2 has recruited more than 500 participants from seven UK ambulance services.

STATUS

Trial is ongoing.

FUNDING

British Heart Foundation.

REGISTRATION

ISRCTN26986053.

Abstract TP69: Baseline Characteristics and Outcomes of Stroke Mimics in The Rapid Intervention With Glyceryl Trinitrate In Hypertensive Stroke Trial-2 (RIGHT-2): An Interim Analysis

Introduction: The ongoing Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial (RIGHT-2) is testing the safety and efficacy of paramedic-delivered transdermal glyceryl trinitrate (GTN) in patients with ultra-acute stroke. We sought to assess whether stroke mimics have a benign outcome in comparison to stroke patients.

Methods: RIGHT-2 is an ongoing prospective randomised single-blind blinded-endpoint parallel group trial enrolling 1050 previously independently patients with suspected stroke (Face Arm Speech Test score ≥2/3) within 4 hours of onset. Consenting patients are randomised to receive GTN or sham patch in the pre-hospital setting. The primary outcome is the modified Rankin scale (mRS) assessed at day 90. Data are number (%) or mean (standard deviation).

Results: As of July 2017, 600 patients had been recruited of which 146 (24.3%) were stroke mimics. Mimics were younger, age 65.1 (18.1) years; had a lower NIHSS 5.6 (6.3) vs 11.4 (7.4); and higher Glasgow coma scale, 14.3 (1.8) vs 13.6 (2.3) than stroke participants. The most common diagnoses were: seizure (16%), migraine/headache (16%) and functional (10%). Of those who have completed day 90 follow-up compared with stroke, mimics had significantly better functional outcome, mRS 2.6 (2.0) vs 3.9 (1.8), p<0.0001, and quality of life, and lower disability and depression scores, and a lower death rate, 11 (12.1%) vs 73 (26.4%), p=0.0047.

Conclusion: Although their outcome is better than stroke participants, mimics do not necessarily have benign outcomes. Pragmatic pre-hospital trials with safety data on mimics may ultimately ease implementation of interventions into clinical practice.

A randomised phase II trial and feasibility study of palliative chemotherapy in frail or elderly patients with advanced gastroesophageal cancer (321GO)

BACKGROUND

Elderly patients are commonly under-represented in cancer clinical trials. The 321GO was undertaken in preparation for a definitive phase three trial assessing different chemotherapy regimens in a frail and/or elderly population with advanced gastroesophageal (GO) cancer.

METHODS

Patients with advanced GO cancer considered unfit for conventional dose chemotherapy were randomly assigned in a 1 : 1 : 1 ratio to: epirubicin, oxaliplatin and capecitabine (EOX); oxaliplatin and capecitabine (OX); and capecitabine alone (X) (all 80% of full dose and unblinded). The primary end point was patient recruitment over an 18-month period. A registration study recorded treatment choice for all patients with advanced GO cancer at trial centres.

RESULTS

A total of 313 patients were considered for palliative chemotherapy for GO cancer over the 18-month period: 115 received full dose treatment, 89 less than standard treatment or entered 321GO and 111 no treatment. Within 321GO, 55 patients were randomly assigned (19 to OX and X; 17 to EOX). Progression-free survival (PFS) for all patients was 4.4 months and by arm 5.4, 5.6 and 3.0 months for EOX, OX and X, respectively. The number of patients with a good overall treatment utility (OTU), a novel patient-centred endpoint, at 12 weeks was 3 (18%), 6 (32%) and 1 (6%) for EOX, OX and X, respectively. At 6 weeks, 22 patients (41%) had experienced a non-haematologic toxicity ⩾grade 3, most commonly lethargy or diarrhoea. The OTU was prognostic for overall survival in patients alive at week 12 (logrank test P=0.0001).

CONCLUSIONS

It is feasible to recruit elderly and/or frail patients with advanced GO cancer to a randomised clinical trial. The OX is the preferred regimen for further study. Overall treatment utility shows promise as a comparator between treatment regimens for feasibility and randomised trials in the elderly and/or frail GO cancer population.

A novel protein isoform of the RON tyrosine kinase receptor transforms human pancreatic duct epithelial cells

The MST1R gene is overexpressed in pancreatic cancer producing elevated levels of the RON tyrosine kinase receptor protein. While mutations in MST1R are rare, alternative splice variants have been previously reported in epithelial cancers. We report the discovery of a novel RON isoform discovered in human pancreatic cancer. Partial splicing of exons 5 and 6 (P5P6) produces a RON isoform that lacks the first extracellular immunoglobulin-plexin-transcription domain. The splice variant is detected in 73% of xenografts derived from pancreatic adenocarcinoma patients and 71% of pancreatic cancer cell lines. Peptides specific to RON P5P6 detected in human pancreatic cancer specimens by mass spectrometry confirm translation of the protein isoform. The P5P6 isoform is found to be constitutively phosphorylated, present in the cytoplasm, and it traffics to the plasma membrane. Expression of P5P6 in immortalized human pancreatic duct epithelial (HPDE) cells activates downstream AKT, and in human pancreatic epithelial nestin-expressing cells, activates both the AKT and MAPK pathways. Inhibiting RON P5P6 in HPDE cells using a small molecule inhibitor BMS-777607 blocked constitutive activation and decreased AKT signaling. P5P6 transforms NIH3T3 cells and induces tumorigenicity in HPDE cells. Resultant HPDE-P5P6 tumors develop a dense stromal compartment similar to that seen in pancreatic cancer. In summary, we have identified a novel and constitutively active isoform of the RON tyrosine kinase receptor that has transforming activity and is expressed in human pancreatic cancer. These findings provide additional insight into the biology of the RON receptor in pancreatic cancer and are clinically relevant to the study of RON as a potential therapeutic target.

Aspen shaving versus chip bedding: effects on breeding and behavior

The choice of laboratory cage bedding material is often based on both practical and husbandry issues, whereas behavioral outcomes rarely appear to be considered. It has been noted that a breeding success difference appears to be associated with the differential use of aspen chip and aspen shaving bedding in our facility; therefore, we sought to analyze breeding records maintained over a 20-month period. In fact, in all four mouse strains analyzed, shaving bedding was associated with a significant increase in average weanlings per litter relative to chip bedding. To determine whether these bedding types also resulted in differences in behaviors associated with wellbeing, we examined nest building, anxiety-like, depressive-like (or helpless-like), and social behavior in mice housed on chip versus shaving bedding. We found differences in the nests built, but no overall effect of bedding type on the other behaviors examined. Therefore, we argue that breeding success, perhaps especially in more challenging strains, is improved on shaving bedding and this is likely due to improved nest-building potential. For standard laboratory practices, however, these bedding types appear equivalent.

Relative efficiency of chlamydia screening in non-clinical settings in two California counties

We examined the relative efficiency of non-clinical sites to screen for chlamydia in youth and young adults. Chlamydia screening targeting youth (under 30 years of age) was performed at non-clinical sites in high-morbidity neighbourhoods of two California counties. Venues were subdivided into community outreach, schools, parenting centres and drug treatment/correctional facilities. Relative efficiency was estimated with multivariate Poisson regression using incidence of chlamydia per person-hours labour adjusting for strategy and county. Among the 1514 youths screened, the overall prevalence of chlamydia was 5.5%. By venue, the highest prevalence was in drug treatment/correction facilities at 11.1% followed by parenting centres at 6.3%, community outreach at 4.9% and schools at 4.6%. Drug treatment/correctional facilities were the most labour time efficient at 9.9 person-hours per chlamydia case. Schools and parenting centres had the lowest cost per screen at 0.9 person-hours per screen. Adjusted relative labour time efficiency (chlamydia cases per paid person-hour) was significantly higher in schools, 2.0 (95% confidence interval [CI] 1.0-4.2), parenting centres, 3.2 (95% CI 1.6-6.6) and drug treatment/correctional facilities, 2.9 (95% CI 1.0-7.8), compared with community outreach. In conclusion, parenting centres and drug treatment centres and correctional facilities are the most efficient venues for chlamydia screening.

Restriction map of a YAC and cosmid contig encompassing the oculopharyngeal muscular dystrophy candidate region on chromosome 14q11.2-q13

As part of our effort to clone positionally the oculopharyngeal muscular dystrophy (OPMD) gene, we constructed a YAC contig, a cosmid contig, and an EcoRI restriction map of the OPMD candidate region. The YAC contig spans more than 2 Mb and encompasses the loci D14S283 and D14S990 and the cardiac alpha and beta myosin heavy chain genes (MYH6 and MYH7). A 700-kb cosmid contig containing the D14S990 and the myosin genes and a long-range restriction map covering the region between D14S990 and the MYH6 and MYH7 gene cluster were established. A detailed EcoRI restriction map of the cosmid contig was determined, and five putative CpG islands were identified. Based on these data, the four loci were mapped within an approximately 600-kb region with the following centromere to telomere order: D14S283, D14S990, MYH6, and MYH7. The YAC and cosmid contigs will facilitate the identification of genes lying within the OPMD candidate interval.

Consequences for fetus and neonate of maternal red cell allo-immunisation

AIMS

To study the distribution of clinically important red cell antibodies in pregnancy, and the associated fetal and neonatal morbidity and mortality.

METHODS

The case notes of women with clinically important red cell antibodies identified in their serum during pregnancy were reviewed.

RESULTS

During a 12 month period 22,264 women were referred for antenatal screening. Clinically important red cell antibodies were detected in 244 (1%). Of these, 100 were anti-D and 144 were non-RhD antibodies. There were three intrauterine deaths, three fetuses required intrauterine transfusion, 10 neonates were transfused, 27 others had phototherapy, and 27 with a positive direct antiglobulin test received no treatment. Early fetal losses occurred in the presence of both high and low levels of anti-D.

CONCLUSIONS

Anti-D remains the most common clinically important antibody in pregnancy, and accounts for the greatest fetal and neonatal morbidity and mortality. Of the other antibodies detected, anti-c was associated with most neonatal morbidity. The production of many of the non-D antibodies detected could be avoided by the use of selected red cells when transfusing pre-menopausal women.

Metabolism and excretion of the novel antipsychotic drug ziprasidone in rats after oral administration of a mixture of 14C- and 3H-labeled ziprasidone

The metabolism and excretion of ziprasidone (5-[2-[4-(1,2-benzisothiazol-3-yl)piperazin-1-yl]ethyl]-6-++ +chloroindolin-2-one hydrochloride hydrate) were studied in Long Evans rats after oral administration of a single dose of a mixture of 14C- and 3H-labeled ziprasidone. The radioactive dose was quantitatively recovered over 7 days in both male and female rats. The percentage of the dose excreted in urine, bile, and feces of rats was 21.6, 19.2, and 55.6%, respectively. The total excretion in urine and bile suggested that at least 41% of the drug was absorbed. Absorption of ziprasidone was rapid, and the mean plasma concentrations of the unchanged drug and metabolites were slightly higher in the female rats than in the males. The maximal plasma concentrations for ziprasidone and metabolites were reached at 1 hr in both male and female rats. Based on AUC (0-12 hr) values, approximately 59 and 52% of the circulating radioactivity (average of 14C and 3H) was attributable to metabolites in male and female rats, respectively. Ziprasidone was extensively metabolized in rats, and only a small amount of ziprasidone was excreted as unchanged drug. Twelve metabolites were identified by ion spray LC/MS, using a combination of parent ion and product ion scanning techniques. The structures of eight metabolites were unambiguously confirmed by coelution on HPLC with synthetic standards, and four additional metabolites were partially identified. There was a gender-related difference in the excretion of urinary metabolites in Long Evans rats. The major route of metabolism in male rats involved N-dealkylation. In female rats the major metabolites were due to oxidation at the benzisothiazole ring. Based on the structures of these metabolites, four major and two minor routes of metabolism of ziprasidone were identified. The major routes included 1) N-dealkylation of the ethyl side chain attached to the piperazinyl nitrogen, 2) oxidation at the sulfur, resulting in the formation of sulfoxide and sulfone, 3) oxidation on the benzisothiazole moiety (other than sulfur), and 4) hydration of the C==N bond and subsequent oxidation at the sulfur of the benzisothiazole moiety. The minor routes involved N-oxidation on the piperazine ring and hydrolysis of the oxindole moiety.

Pathogenicity of rotavirus in rabbits

The role of rotavirus in diarrheal disease of rabbits was investigated, and a model for human rotavirus infection was established. Orogastric inoculation of 8- and 12-week-old New Zealand White rabbits with a rabbit strain of rotavirus (L:ALA:84) resulted in fecal shedding of virus for 6 to 8 days from 2 to 5 days after inoculation. Most rabbits exhibited diarrhea, coincident with the onset of viral shedding, which persisted for 2 to 4 days. Diarrhea was characterized by soft or fluid stools and fecal staining of the perineum. Inoculation of 3-week-old rabbits resulted in a briefer period of viral shedding and diarrhea of a milder nature. Histopathologic examination during the period of viral shedding revealed a mild, nonsuppurative enteritis. Inoculated rabbits exhibited antibodies in serum to rotavirus by enzyme-linked immunosorbent assay. Sham-inoculated or uninoculated rabbits maintained in the same cage or the same room with inoculated rabbits acquired rotavirus infection. The mild diarrheal disease which resulted with a rotavirus isolate from severe field cases suggests that cofactors were involved.

Epidemiology and etiology of diarrhea in colony-born Macaca nemestrina

The epidemiology of diarrhea in colony-born M. nemestrina was studied in 205 neonates and infants in an Infant Primate Research Laboratory (IPRL), and in 248 neonates, juveniles and adolescents up to 4 years of age at a separate breeding and holding facility (Primate Field Station, PFS). Computerized medical records of individual animals over a 5-year period were analyzed to determine the incidence of diarrhea; age, duration and number of episodes; mortality and etiology. The incidence of diarrhea at the IPRL was highest in infants at less than 1 month of age (18.6 cases per 1000 animal days) and at 1-6 months olds (2.0 cases per 1000 animals days). Many infants had multiple episodes. All episodes were less than 10 days in duration. Mortality was low. At the PFS, the highest incidence occurred in infants at 6-12 months of age (1.36 cases per 1000 animal days). Multiple episodes were less common. Duration was variable. The infectious agents diagnosed at both facilities were Shigella, Campylobacter and Cryptosporidium. No pathogens were identified in many episodes. Shigella was more common at PFS than at the IPRL. Chronic diarrhea occurred in approximately 10% of animals at PFS. Intestinal amyloidosis and retroperitoneal fibromatosis were found in 13 animals with chronic diarrhea. Further studies are needed to determine the pathogenesis of chronic diarrhea, the etiologic significance of Campylobacter, and the causes of diarrhea when no pathogens are isolated.

Comparison of a slow-release trimethoprim with co-trimoxazole: efficacy and selection of resistance in the Enterobacteriaceae

One hundred and fifty one patients with symptoms of urinary tract infection were treated randomly in a double blind study with a slow release form of trimethoprim or with co-trimoxazole. Similar cure rates were seen. There was no difference between the proportions of patients in the two groups who acquired trimethoprim-resistant Enterobacteriaceae. Further clinical trials with slow release trimethoprim should be performed.

THE ELECTRONIC STATES OF CIS- AND TRANS-ACETYLENE

The electronic energy levels of cis- and trans-bent planar centrosymmetric acetylene molecules, with [Formula: see text] and r cc = 1.383 Å, have been calculated by the LCAO/ASMO/CI procedure. The lowest energy state that can spectroscopically combine with the linear ground state is found to be of symmetry class Au belonging to the trans-bent molecule and to lie at 4.58 ev above the ground state. This compares favorably with the experimentally observed electronic transition of lowest energy which is of type (1Au−1∑g+) and at 5.24 ev. The lowest-energy allowed transition to a cis-bent state of these dimensions is at 9.39 ev, and hence this may not form part of the unanalyzed system of bands in the 2000–1500 Å region, as has been suggested. However, a transition to a trans-bent state of type (1Bu−1∑g+) is predicted to fall in this region. The energies of other electronic states are discussed in relation to the observed absorption systems of acetylene.

A Case Showing Multiple Congenital Abnormalities of the Eye; the Origin of the Vitreous Indicated by One of Them

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