Crizotinib versus chemotherapy in advanced ALK-positive lung cancer

BACKGROUND: In single-group studies, chromosomal rearrangements of the anaplastic lymphoma kinase gene (ALK ) have been associated with marked clinical responses to crizotinib, an oral tyrosine kinase inhibitor targeting ALK. Whether crizotinib is superior to standard chemotherapy with respect to efficacy is unknown. METHODS: We conducted a phase 3, open-label trial comparing crizotinib with chemotherapy in 347 patients with locally advanced or metastatic ALK-positive lung cancer who had received one prior platinum-based regimen. Patients were randomly assigned to receive oral treatment with crizotinib (250 mg) twice daily or intravenous chemotherapy with either pemetrexed (500 mg per square meter of body-surface area) or docetaxel (75 mg per square meter) every 3 weeks. Patients in the chemotherapy group who had disease progression were permitted to cross over to crizotinib as part of a separate study. The primary end point was progression-free survival. RESULTS: The median progression-free survival was 7.7 months in the crizotinib group and 3.0 months in the chemotherapy group (hazard ratio for progression or death with crizotinib, 0.49; 95% confidence interval [CI], 0.37 to 0.64; P<0.001). The response rates were 65% (95% CI, 58 to 72) with crizotinib, as compared with 20% (95% CI, 14 to 26) with chemotherapy (P<0.001). An interim analysis of overall survival showed no significant improvement with crizotinib as compared with chemotherapy (hazard ratio for death in the crizotinib group, 1.02; 95% CI, 0.68 to 1.54; P=0.54). Common adverse events associated with crizotinib were visual disorder, gastrointestinal side effects, and elevated liver aminotransferase levels, whereas common adverse events with chemotherapy were fatigue, alopecia, and dyspnea. Patients reported greater reductions in symptoms of lung cancer and greater improvement in global quality of life with crizotinib than with chemotherapy. CONCLUSIONS: Crizotinib is superior to standard chemotherapy in patients with previously treated, advanced non-small-cell lung cancer with ALK rearrangement. (Funded by Pfizer; ClinicalTrials.gov number, NCT00932893.) Copyright © 2013 Massachusetts Medical Society.

Treatment rationale study design for the MetLung trial : a randomized, double-blind phase III study of onartuzumab (MetMAb) in combination with erlotinib versus erlotinib alone in patients who have received standard chemotherapy for stage IIIB or IV met-positive non-small-cell lung cancer

We present the treatment rationale and study design of the MetLung phase III study. This study will investigate onartuzumab (MetMAb) in combination with erlotinib compared with erlotinib alone, as second- or third-line treatment, in patients with advanced non-small-cell lung cancer (NSCLC) who are Met-positive by immunohistochemistry. Approximately 490 patients (245 per treatment arm) will receive erlotinib (150 mg oral daily) plus onartuzumab or placebo (15 mg/kg intravenous every 3 weeks) until disease progression, unacceptable toxicity, patient or physician decision to discontinue, or death. The efficacy objectives of this study are to compare overall survival (OS) (primary endpoint), progression-free survival, and response rates between the 2 treatment arms. In addition, safety, quality of life, pharmacokinetics, and translational research will be investigated across treatment arms. If the primary objective (OS) is achieved, this study will provide robust results toward an alternative treatment option for patients with Met-positive second- or third-line NSCLC. © 2012 Elsevier Inc. All Rights Reserved.

Development of empirical equations for irradiance profile of a standard parabolic trough collector using Monte Carlo ray tracing technique

Irradiance profile around the receiver tube (RT) of a parabolic trough collector (PTC) is a key effect of optical performance that affects the overall energy performance of the collector. Thermal performance evaluation of the RT relies on the appropriate determination of the irradiance profile. This article explains a technique in which empirical equations were developed to calculate the local irradiance as a function of angular location of the RT of a standard PTC using a vigorously verified Monte Carlo ray tracing model. A large range of test conditions including daily normal insolation, spectral selective coatings and glass envelop conditions were selected from the published data by Dudley et al. [1] for the job. The R2 values of the equations are excellent that vary in between 0.9857 and 0.9999. Therefore, these equations can be used confidently to produce realistic non-uniform boundary heat flux profile around the RT at normal incidence for conjugate heat transfer analyses of the collector. Required values in the equations are daily normal insolation, and the spectral selective properties of the collector components. Since the equations are polynomial functions, data processing software can be employed to calculate the flux profile very easily and quickly. The ultimate goal of this research is to make the concentrating solar power technology cost competitive with conventional energy technology facilitating its ongoing research.

Key-private proxy re-encryption under LWE

Proxy re-encryption (PRE) is a highly useful cryptographic primitive whereby Alice and Bob can endow a proxy with the capacity to change ciphertext recipients from Alice to Bob, without the proxy itself being able to decrypt, thereby providing delegation of decryption authority. Key-private PRE (KP-PRE) specifies an additional level of confidentiality, requiring pseudo-random proxy keys that leak no information on the identity of the delegators and delegatees. In this paper, we propose a CPA-secure PK-PRE scheme in the standard model (which we then transform into a CCA-secure scheme in the random oracle model). Both schemes enjoy highly desirable properties such as uni-directionality and multi-hop delegation. Unlike (the few) prior constructions of PRE and KP-PRE that typically rely on bilinear maps under ad hoc assumptions, security of our construction is based on the hardness of the standard Learning-With-Errors (LWE) problem, itself reducible from worst-case lattice hard problems that are conjectured immune to quantum cryptanalysis, or “post-quantum”. Of independent interest, we further examine the practical hardness of the LWE assumption, using Kannan’s exhaustive search algorithm coupling with pruning techniques. This leads to state-of-the-art parameters not only for our scheme, but also for a number of other primitives based on LWE published the literature.

Efficient selective identity-based encryption without random oracles

We construct two efficient Identity-Based Encryption (IBE) systems that admit selective-identity security reductions without random oracles in groups equipped with a bilinear map. Selective-identity secure IBE is a slightly weaker security model than the standard security model for IBE. In this model the adversary must commit ahead of time to the identity that it intends to attack, whereas in an adaptive-identity attack the adversary is allowed to choose this identity adaptively. Our first system—BB1—is based on the well studied decisional bilinear Diffie–Hellman assumption, and extends naturally to systems with hierarchical identities, or HIBE. Our second system—BB2—is based on a stronger assumption which we call the Bilinear Diffie–Hellman Inversion assumption and provides another approach to building IBE systems. Our first system, BB1, is very versatile and well suited for practical applications: the basic hierarchical construction can be efficiently secured against chosen-ciphertext attacks, and further extended to support efficient non-interactive threshold decryption, among others, all without using random oracles. Both systems, BB1 and BB2, can be modified generically to provide “full” IBE security (i.e., against adaptive-identity attacks), either using random oracles, or in the standard model at the expense of a non-polynomial but easy-to-compensate security reduction.

Efficient lattice (H)IBE in the standard model

We construct an efficient identity based encryption system based on the standard learning with errors (LWE) problem. Our security proof holds in the standard model. The key step in the construction is a family of lattices for which there are two distinct trapdoors for finding short vectors. One trapdoor enables the real system to generate short vectors in all lattices in the family. The other trapdoor enables the simulator to generate short vectors for all lattices in the family except for one. We extend this basic technique to an adaptively-secure IBE and a Hierarchical IBE.

NTRUCCA : how to strengthen NTRUEncrypt to chosen-ciphertext security in the standard model

NTRUEncrypt is a fast and practical lattice-based public-key encryption scheme, which has been standardized by IEEE, but until recently, its security analysis relied only on heuristic arguments. Recently, Stehlé and Steinfeld showed that a slight variant (that we call pNE) could be proven to be secure under chosen-plaintext attack (IND-CPA), assuming the hardness of worst-case problems in ideal lattices. We present a variant of pNE called NTRUCCA, that is IND-CCA2 secure in the standard model assuming the hardness of worst-case problems in ideal lattices, and only incurs a constant factor overhead in ciphertext and key length over the pNE scheme. To our knowledge, our result gives the first IND-CCA2 secure variant of NTRUEncrypt in the standard model, based on standard cryptographic assumptions. As an intermediate step, we present a construction for an All-But-One (ABO) lossy trapdoor function from pNE, which may be of independent interest. Our scheme uses the lossy trapdoor function framework of Peikert and Waters, which we generalize to the case of (k − 1)-of-k-correlated input distributions.

Lattice-based completely non-malleable PKE in the standard model

This paper presents ongoing work toward constructing efficient completely non-malleable public-key encryption scheme based on lattices in the standard (common reference string) model. An encryption scheme is completely non-malleable if it requires attackers to have negligible advantage, even if they are allowed to transform the public key under which the related message is encrypted. Ventre and Visconti proposed two inefficient constructions of completely non-malleable schemes, one in the common reference string model using non-interactive zero-knowledge proofs, and another using interactive encryption schemes. Recently, two efficient public-key encryption schemes have been proposed, both of them are based on pairing identity-based encryption.

Parallel authentication and public-key encryption

A parallel authentication and public-key encryption is introduced and exemplified on joint encryption and signing which compares favorably with sequential Encrypt-then-Sign (ɛtS) or Sign-then-Encrypt (Stɛ) schemes as far as both efficiency and security are concerned. A security model for signcryption, and thus joint encryption and signing, has been recently defined which considers possible attacks and security goals. Such a scheme is considered secure if the encryption part guarantees indistinguishability and the signature part prevents existential forgeries, for outsider but also insider adversaries. We propose two schemes of parallel signcryption, which are efficient alternative to Commit-then-Sign-and- Encrypt (Ct&G3&S). They are both provably secure in the random oracle model. The first one, called generic parallel encrypt and sign, is secure if the encryption scheme is semantically secure against chosen-ciphertext attacks and the signature scheme prevents existential forgeries against random-message attacks. The second scheme, called optimal parallel encrypt. and sign, applies random oracles similar to the OAEP technique in order to achieve security using encryption and signature components with very weak security requirements — encryption is expected to be one-way under chosen-plaintext attacks while signature needs to be secure against universal forgeries under random-plaintext attack, that is actually the case for both the plain-RSA encryption and signature under the usual RSA assumption. Both proposals are generic in the sense that any suitable encryption and signature schemes (i.e. which simply achieve required security) can be used. Furthermore they allow both parallel encryption and signing, as well as parallel decryption and verification. Properties of parallel encrypt and sign schemes are considered and a new security standard for parallel signcryption is proposed.

MITIE C-Arm - Advanced innovation in education

Aim: In 2013 QUT introduced the Medical Imaging Training Immersive Environment (MITIE) as a virtual reality (VR) platform that allowed students to practice general radiography. The system software has been expanded to now include C-Arm. The aim of this project was to investigate the use of this technology in the pedagogy of undergraduate medical imaging students who have limited to no experience in the use of the C-Arm clinically. Method: The Medical Imaging Training Immersive Environment (MITIE) application provides students with realistic and fully interactive 3D models of C-Arm equipment. As with VR initiatives in other health disciplines (1–2) the software mimics clinical practice as much as possible and uses 3D technology to enhance 3D spatial awareness and realism. The application allows students to set up and expose a virtual patient in a 3D environment as well as creating the resultant “image” for comparison with a gold standard. Automated feedback highlights ways for the student to improve their patient positioning, equipment setup or exposure factors. The students' equipment knowledge was tested using an on line assessment quiz and surveys provided information on the students' pre-clinical confidence scale, with post-clinical data comparisons. Ethical approval for the project was provided by the university ethics panel. Results: This study is currently under way and this paper will present analysis of initial student feedback relating to the perceived value of the application for confidence in a high risk environment (i.e. operating theatre) and related clinical skills development. Further in-depth evaluation is ongoing with full results to be presented. Conclusion: MITIE C-Arm has a development role to play in the pre-clinical skills training for Medical Radiation Science students. It will augment their theoretical understanding prior to their clinical experience. References 1. Bridge P, Appleyard R, Ward J, Phillips R, Beavis A. The development and evaluation of a virtual radiotherapy treatment machine using an immersive visualisation environment. Computers and Education 2007; 49(2): 481–494. 2. Gunn T, Berry C, Bridge P et al. 3D Virtual Radiography: Development and Initial Feedback. Paper presented at the 10th Annual Scientific Meeting of Medical Imaging and Radiation Therapy, March 2013 Hobart, Tasmania.

Understanding advanced and extended professional practice

The Advanced Pharmacy Practice Framework Steering Committee (now replaced by the Pharmacy Practitioner Development Committee) undertook work to develop an advanced pharmacy practice recognition model. As part of that work, and to assure clarity and consistency in the terminology it uses, the Committee collated the definitions used in literature sources consulted. Most recently, this involved a review of the meaning attributed to the terms ‘advanced’ and ‘extended’ when used in the context of describing aspects of professional practice. Both terms encompass the acquisition of additional expertise. While ‘advanced’ practice involves the acquisition of additional expertise to achieve a higher performance level, ‘extended’ practice relates specifically to scope of practice and involves the acquisition of additional expertise sufficient to provide services or perform tasks that are outside the usual scope of practice of the profession. Performance level operates independently of scope of practice but both must be elucidated to fully describe the professional practice of an individual practitioner.

A method for matching patients to advanced prostate cancer clinical trials

Objective: To illustrate a new method for simplifying patient recruitment for advanced prostate cancer clinical trials using natural language processing techniques. Background: The identification of eligible participants for clinical trials is a critical factor to increase patient recruitment rates and an important issue for discovery of new treatment interventions. The current practice of identifying eligible participants is highly constrained due to manual processing of disparate sources of unstructured patient data. Informatics-based approaches can simplify the complex task of evaluating patient’s eligibility for clinical trials. We show that an ontology-based approach can address the challenge of matching patients to suitable clinical trials. Methods: The free-text descriptions of clinical trial criteria as well as patient data were analysed. A set of common inclusion and exclusion criteria was identified through consultations with expert clinical trial coordinators. A research prototype was developed using Unstructured Information Management Architecture (UIMA) that identified SNOMED CT concepts in the patient data and clinical trial description. The SNOMED CT concepts model the standard clinical terminology that can be used to represent and evaluate patient’s inclusion/exclusion criteria for the clinical trial. Results: Our experimental research prototype describes a semi-automated method for filtering patient records using common clinical trial criteria. Our method simplified the patient recruitment process. The discussion with clinical trial coordinators showed that the efficiency in patient recruitment process measured in terms of information processing time could be improved by 25%. Conclusion: An UIMA-based approach can resolve complexities in patient recruitment for advanced prostate cancer clinical trials.

A randomized controlled trial protocol testing a decision support intervention for older patients with advanced kidney disease

Aim To assess the effectiveness of a decision support intervention using a pragmatic single blind Randomized Controlled Trial. Background Worldwide the proportion of older people (aged 65 years and over) is rising. This population is known to have a higher prevalence of chronic diseases including chronic kidney disease. The resultant effect of the changing health landscape is seen in the increase in older patients (aged ≥65 years) commencing on dialysis. Emerging evidence suggests that for some older patients dialysis may provide minimal benefit. In a majority of renal units non-dialysis management is offered as an alternative to undertaking dialysis. Research regarding decision-making support that is required to assist this population in choosing between dialysis or non-dialysis management is limited. Design. A multisite single blinded pragmatic randomized controlled trial is proposed. Methods Patients will be recruited from four Queensland public hospitals and randomizd into either the control or intervention group. The decision support intervention is multimodal and includes counselling provided by a trained nurse. The comparator is standard decision-making support. The primary outcomes are decisional regret and decisional conflict. Secondary outcomes are improved knowledge and quality of life. Ethics approval obtained November 2014. Conclusion This is one of the first randomized controlled trials assessing a decision support intervention in older people with advance chronic kidney disease. The results may provide guidance for clinicians in future approaches to assist this population in decision-making to ensure reduced decisional regret and decisional conflict.

Neoadjuvant crizotinib in advanced inflammatory myofibroblastic tumour with ALK gene rearrangement

Background Inflammatory myofibroblastic tumours (IMTs) are rare sarcomas that were first described in the lung. They are composed of myofibroblastic mesenchymal spindle cells accompanied by an inflammatory infiltrate of plasma cells. Complete resection is the treatment of choice. There is currently no standard treatment for inoperable or recurrent disease. Expression of ALK protein triggered by ALK gene rearrangement at chromosome 2p23 has been found in 36%-60% of IMTs. Case report We report a rapid early response to crizotinib as neoadjuvant therapy, enabling surgical excision of a large ALK-translocated IMT, which resulted in complete disease clearance. To the best of our knowledge, this is the first case in the literature of a patient with IMT in whom crizotinib was used successfully in the neoadjuvant or curative setting.