Enzalutamide is an oral androgen-receptor inhibitor that prolongs survival in men with metastatic castration-resistant prostate cancer in whom the disease has progressed after chemotherapy. New ...treatment options are needed for patients with metastatic prostate cancer who have not received chemotherapy, in whom the disease has progressed despite androgen-deprivation therapy.
In this double-blind, phase 3 study, we randomly assigned 1717 patients to receive either enzalutamide (at a dose of 160 mg) or placebo once daily. The coprimary end points were radiographic progression-free survival and overall survival.
The study was stopped after a planned interim analysis, conducted when 540 deaths had been reported, showed a benefit of the active treatment. The rate of radiographic progression-free survival at 12 months was 65% among patients treated with enzalutamide, as compared with 14% among patients receiving placebo (81% risk reduction; hazard ratio in the enzalutamide group, 0.19; 95% confidence interval CI, 0.15 to 0.23; P<0.001). A total of 626 patients (72%) in the enzalutamide group, as compared with 532 patients (63%) in the placebo group, were alive at the data-cutoff date (29% reduction in the risk of death; hazard ratio, 0.71; 95% CI, 0.60 to 0.84; P<0.001). The benefit of enzalutamide was shown with respect to all secondary end points, including the time until the initiation of cytotoxic chemotherapy (hazard ratio, 0.35), the time until the first skeletal-related event (hazard ratio, 0.72), a complete or partial soft-tissue response (59% vs. 5%), the time until prostate-specific antigen (PSA) progression (hazard ratio, 0.17), and a rate of decline of at least 50% in PSA (78% vs. 3%) (P<0.001 for all comparisons). Fatigue and hypertension were the most common clinically relevant adverse events associated with enzalutamide treatment.
Enzalutamide significantly decreased the risk of radiographic progression and death and delayed the initiation of chemotherapy in men with metastatic prostate cancer. (Funded by Medivation and Astellas Pharma; PREVAIL ClinicalTrials.gov number, NCT01212991.).
Summary In anticipation of a future pandemic potentially arising from H5N1, H7N9 avian influenza or Middle East Respiratory Syndrome, and in large part in response to severe acute respiratory ...syndrome (SARS) in 2003, the city of Taipei, Taiwan, has developed extensive new strategies to manage pandemics. These strategies were tested during the 2009 H1N1 outbreak. This article assesses pandemic preparedness in Taipei in the wake of recent pandemic experiences in order to draw lessons relevant to the broader international public health community. Drawing on Taiwan and Taipei Centers for Disease Control data on pandemic response and control, we evaluated the effectiveness of the changes in pandemic response policies developed by these governments over time, emphasizing hospital and medical interventions with particular attention paid to Traffic Control Bundling. SARS and H1N1 2009 catalysed the Taiwan and Taipei CDCs to continuously improve and adjust their strategies for a future pandemic. These new strategies for pandemic response and control have been largely effective at providing interim pandemic containment and control, while development and implementation of an effective vaccination programme is underway. As Taipei's experiences with these cases illustrate, in mitigating moderate or severe pandemic influenza, a graduated process including Traffic Control Bundles accompanied by hospital and medical interventions, as well as school- and community-focused interventions, provides an effective interim response while awaiting vaccine development. Once a vaccine is developed, to maximize pandemic control effectiveness, it should be allocated with priority given to vulnerable groups, healthcare workers and school children.
Summary
Background
Non‐alcoholic fatty liver disease has reached epidemic proportions in type 2 diabetes (T2D). Glucagon‐like peptide‐1 analogues are licensed in T2D, yet little data exist on ...efficacy and safety in liver injury.
Aim
To assess the safety and efficacy of 26‐week liraglutide on liver parameters in comparison with active‐placebo.
Methods
Individual patient data meta‐analysis was performed using patient‐level data combined from six 26‐week, phase‐III, randomised controlled T2D trials, which comprise the ‘Liraglutide Effect and Action in Diabetes’ (LEAD) program. The LEAD‐2 sub‐study was analysed to assess the effect on CT‐measured hepatic steatosis.
Results
Of 4442 patients analysed, 2241 (50.8%) patients had an abnormal ALT at baseline mean ALT 33.8(14.9) IU/L in females; 47.3(18.3) IU/L in males. Liraglutide 1.8 mg reduced ALT in these patients vs. placebo (−8.20 vs. −5.01 IU/L; P = 0.003), and was dose‐dependent (no significant differences vs. placebo with liraglutide 0.6 or 1.2 mg). This effect was lost after adjusting for liraglutide's reduction in weight (mean ALT difference vs. placebo −1.41 IU/L, P = 0.21) and HbA1c (+0.57 IU/L, P = 0.63). Adverse effects with 1.8 mg liraglutide were similar between patients with and without baseline abnormal ALT. In LEAD‐2 sub‐study, liraglutide 1.8 mg showed a trend towards improving hepatic steatosis vs. placebo (liver‐to‐spleen attenuation ratio +0.10 vs. 0.00; P = 0.07). This difference was reduced when correcting for changes in weight (+0.06, P = 0.25) and HbA1c (0.00, P = 0.93).
Conclusions
Twenty‐six weeks' liraglutide 1.8 mg is safe, well tolerated and improves liver enzymes in patients with type 2 diabetes. This effect appears to be mediated by its action on weight loss and glycaemic control.
Since the start of the Wide-angle Search for Planets (WASP) program, more than 160 transiting exoplanets have been discovered in the WASP data. In the past, possible transit-like events identified by ...the WASP pipeline have been vetted by human inspection to eliminate false alarms and obvious false positives. The goal of this paper is to assess the effectiveness of machine learning as a fast, automated, and reliable means of performing the same functions on ground-based wide-field transit-survey data without human intervention. To this end, we have created training and test data sets made up of stellar light curves showing a variety of signal types including planetary transits, eclipsing binaries, variable stars, and non-periodic signals. We use a combination of machine-learning methods including Random Forest Classifiers (RFCs) and convolutional neural networks (CNNs) to distinguish between the different types of signals. The final algorithms correctly identify planets in the test data ∼90 per cent of the time, although each method on its own has a significant fraction of false positives. We find that in practice, a combination of different methods offers the best approach to identifying the most promising exoplanet transit candidates in data from WASP, and by extension similar transit surveys.
Microdeletions within chromosome 15q13.3 are associated both with a recently recognised syndrome of mental retardation, seizures, and dysmorphic features, and with schizophrenia.
Based on routine ...diagnostic testing of approximately 8200 samples using array comparative genomic hybridisation, we identified 20 individuals (14 children and six parents in 12 families) with microdeletions of 15q13.3. Phenotypes in the children included developmental delay, mental retardation, or borderline IQ in most and autistic spectrum disorder (6/14), speech delay, aggressiveness, attention deficit hyperactivity disorder, and other behavioural problems. Both parents were available in seven families, and the deletion was de novo in one, inherited from an apparently normal parent in four, and inherited from a parent with learning disability and bipolar disorder in two families. Of the 14 children, six in five families were adopted, and DNA was available for only one of these 10 biological parents; the deletion was very likely inherited for one of these families with two affected children. Among the unavailable parents, two mothers were described as having mental retardation, another mother as having "mental illness", and one father as having schizophrenia. We hypothesise that some of the unavailable parents have the deletion.
The occurrence of increased adoption, frequent autism, bipolar disorder, and lack of penetrance are noteworthy findings in individuals with deletion 15q13.3. A high rate of adoption may be related to the presence of the deletion in biological parents. Unconfirmed histories of antisocial behaviours in unavailable biological parents raise the concern that future research may show that deletion 15q13.3 is associated with such behaviours.
The detection of low-mass transiting exoplanets in multiple systems brings new constraints to planetary formation and evolution processes and challenges the current planet formation theories. ...Nevertheless, only a mere fraction of the small planets detected by Kepler and K2 have precise mass measurements, which are mandatory to constrain their composition. We aim to characterise the planets that orbit the relatively bright star K2-138. This system is dynamically particular as it presents the longest chain known to date of planets close to the 3:2 resonance. We obtained 215 HARPS spectra from which we derived the radial-velocity variations of K2-138. Via a joint Bayesian analysis of both the K2 photometry and HARPS radial-velocities (RVs), we constrained the parameters of the six planets in orbit. The masses of the four inner planets, from b to e, are 3.1, 6.3, 7.9, and 13.0 M⊕ with a precision of 34, 20, 18, and 15%, respectively. The bulk densities are 4.9, 2.8, 3.2, and 1.8 g cm−3, ranging from Earth to Neptune-like values. For planets f and g, we report upper limits. Finally, we predict transit timing variations of the order two to six minutes from the masses derived. Given its peculiar dynamics, K2-138 is an ideal target for transit timing variation (TTV) measurements from space with the upcoming CHaracterizing ExOPlanet Satellite (CHEOPS) to study this highly-packed system and compare TTV and RV masses.
To compare the Osteoarthritis Research Society International (OARSI) and Articular Cartilage Structure (ACS) grading schemes applied to multiple and single sections, along with additional histologic ...measures, in two mouse models of Osteoarthritis (OA).
Six coronal histologic stifle joint sections were collected from 40 C57BL/6J mice, including aged mice with spontaneous OA (approximately 18 months of age; n = 15) and young (12-week-old) mice that either underwent destabilization of the medial meniscus (DMM) surgery (n = 15) or sham surgery (n = 10). Sections were evaluated with the standard OARSI (0–6) scheme, a modified OARSI scheme, the ACS (0–12) scheme, histomorphometry of cartilage and bone, and scoring of osteophytes (0–3) and synovial hyperplasia (0–3). Principal components analysis (PCA) was used to determine the features explaining the greatest variability among the sections.
The grading schemes performed similarly when applied to a single mid-coronal section or six total coronal sections per joint. OARSI grading produced similar results when applied to hematoxylin and eosin or toluidine blue-stained sections. Aged mice had higher severity scores in the LTP than DMM mice (mid-coronal OARSI grade aged = 2.3 and DMM = 1.1, p = 0.0006; ACS grade aged = 4.1 and DMM = 1.6, p = 0.0024). PCA resulted in retention of four factors that accounted for 78.4% of the total variance. Factor 1 (36.4%) included the OARSI grade, ACS grade, Toluidine blue grade, articular cartilage area and thickness and the osteophyte grade.
Grading of a single mid-coronal section using either the OARSI or ACS schemes combined with osteophyte and histomorphometric measures can consistently define OA severity in mice.
Background: Eosinophilic oesophagitis is a rarely diagnosed condition involving eosinophil infiltration of the oesophageal mucosa and creating significant symptoms of dysphagia. Failure to diagnose ...this disorder relates to reluctance to biopsy an apparently normal oesophagus. This is essential for histological diagnosis. To date, treatment success has been achieved only with corticosteroids. We describe here the use of an eosinophil stabilising agent Montelukast for the symptomatic relief of these patients. Patients and methods: Twelve patients have been identified with this condition in our unit since 1995, after thorough investigation of their dysphagia. We commenced eight of these patients on the leukotriene receptor antagonist Montelukast to symptomatically improve their swallowing while avoiding the use of long term corticosteroids. Results: Many of these patients had been previously misdiagnosed, and therefore inappropriately and unsuccessfully treated for an extensive period prior to referral to our unit. All patients were unresponsive to acid suppression therapy alone but showed improvement in their swallowing on Montelukast. Six of eight reported complete subjective improvement, five patients remaining completely asymptomatic on a maintenance regimen. Conclusions: Eosinophilic oesophagitis is a disease that is often misdiagnosed due to lack of awareness and reluctance of clinicians to biopsy an apparently normal oesophagus in dysphagic patients, and therefore obtain a histological diagnosis. Investigation of these patients adds further evidence to this condition being a separate pathological state from gastro-oesophageal reflux and eosinophilic enteritis. Montelukast has been found to be of significant help in the symptomatic control of these patients while avoiding long term corticosteroids use.
Prognostic models are needed that reflect contemporary practice for men with metastatic castration-resistant prostate cancer (mCRPC). We sought to identify predictive and prognostic variables for ...overall survival (OS) in chemotherapy-naïve men with mCRPC treated with enzalutamide.
Patients from the PREVAIL trial database (enzalutamide versus placebo) were randomly split 2 : 1 into training (n = 1159) and testing (n = 550) sets. Using the training set, 23 predefined variables were analyzed and a multivariable model predicting OS was developed and validated in an independent testing set.
Patient characteristics and outcomes were well balanced between training and testing sets; median OS was 32.7 months in each. The final validated multivariable model included 11 independent prognostic variables. Median OS for low-, intermediate-, and high-risk groups (testing set) defined by prognostic risk tertiles were not yet reached (NYR) (95% CI NYR–NYR), 34.2 months (31.5–NYR), and 21.1 months (17.5–25.0), respectively. Hazard ratios (95% CI) for OS in the low- and intermediate-risk groups versus high-risk group were 0.20 (0.14–0.29) and 0.40 (0.30–0.53), respectively. Secondary outcomes of response and progression differed widely in model-defined risk groups. Enzalutamide improved outcomes in all prognostic risk groups.
Our validated prognostic model incorporates variables routinely collected in chemotherapy-naïve men with mCRPC treated with enzalutamide, identifying subsets of patients with widely differing survival outcomes that provide useful information for external validation, patient care, and clinical trial design.
ClinicalTrials.gov: NCT01212991.
To determine if the quantitative MRI techniques T2 and T1ρ mapping are sensitive to ischemic injury to epiphyseal cartilage in vivo in a piglet model of Legg-Calvé-Perthes disease using a clinical 3T ...MRI scanner. We hypothesized that T2 and T1ρ relaxation times would be increased in the epiphyseal cartilage of operated vs contralateral-control femoral heads 1 week following onset of ischemia.
Unilateral femoral head ischemia was surgically induced in eight piglets. Piglets were imaged 1 week post-operatively in vivo at 3T MRI using a magnetization-prepared 3D fast spin echo sequence for T2 and T1ρ mapping and a 3D gradient echo sequence for cartilage segmentation. Ischemia was confirmed in all piglets using gadolinium contrast-enhanced MRI. Median T2 and T1ρ relaxation times were measured in the epiphyseal cartilage of the ischemic and control femoral heads and compared using paired t-tests. Histological assessment was performed on a subset of five piglets.
T2 and T1ρ relaxation times were significantly increased in the epiphyseal cartilage of the operated vs control femoral heads (ΔT2 = 11.9 ± 3.7 ms, 95% CI = 8.8, 15.0 ms, P < 0.0001; ΔT1ρ = 12.8 ± 4.1 ms, 95% CI = 9.4, 16.2 ms, P < 0.0001). Histological assessment identified chondronecrosis in the hypertrophic and deep proliferative zones within ischemic epiphyseal cartilage.
T2 and T1ρ mapping are sensitive to ischemic injury to the epiphyseal cartilage in vivo at clinical 3T MRI. These techniques may be clinically useful to assess injury and repair to the epiphyseal cartilage to better stage the extent of ischemic damage in Legg-Calvé-Perthes disease.
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