Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial

BACKGROUND: Long-term hormone therapy has been the standard of care for advanced prostate cancer since the 1940s. STAMPEDE is a randomised controlled trial using a multiarm, multistage platform design. It recruits men with high-risk, locally advanced, metastatic or recurrent prostate cancer who are starting first-line long-term hormone therapy. We report primary survival results for three research comparisons testing the addition of zoledronic acid, docetaxel, or their combination to standard of care versus standard of care alone.

METHODS: Standard of care was hormone therapy for at least 2 years; radiotherapy was encouraged for men with N0M0 disease to November, 2011, then mandated; radiotherapy was optional for men with node-positive non-metastatic (N+M0) disease. Stratified randomisation (via minimisation) allocated men 2:1:1:1 to standard of care only (SOC-only; control), standard of care plus zoledronic acid (SOC + ZA), standard of care plus docetaxel (SOC + Doc), or standard of care with both zoledronic acid and docetaxel (SOC + ZA + Doc). Zoledronic acid (4 mg) was given for six 3-weekly cycles, then 4-weekly until 2 years, and docetaxel (75 mg/m(2)) for six 3-weekly cycles with prednisolone 10 mg daily. There was no blinding to treatment allocation. The primary outcome measure was overall survival. Pairwise comparisons of research versus control had 90% power at 2·5% one-sided α for hazard ratio (HR) 0·75, requiring roughly 400 control arm deaths. Statistical analyses were undertaken with standard log-rank-type methods for time-to-event data, with hazard ratios (HRs) and 95% CIs derived from adjusted Cox models. This trial is registered at ClinicalTrials.gov (NCT00268476) and ControlledTrials.com (ISRCTN78818544).

FINDINGS: 2962 men were randomly assigned to four groups between Oct 5, 2005, and March 31, 2013. Median age was 65 years (IQR 60-71). 1817 (61%) men had M+ disease, 448 (15%) had N+/X M0, and 697 (24%) had N0M0. 165 (6%) men were previously treated with local therapy, and median prostate-specific antigen was 65 ng/mL (IQR 23-184). Median follow-up was 43 months (IQR 30-60). There were 415 deaths in the control group (347 [84%] prostate cancer). Median overall survival was 71 months (IQR 32 to not reached) for SOC-only, not reached (32 to not reached) for SOC + ZA (HR 0·94, 95% CI 0·79-1·11; p=0·450), 81 months (41 to not reached) for SOC + Doc (0·78, 0·66-0·93; p=0·006), and 76 months (39 to not reached) for SOC + ZA + Doc (0·82, 0·69-0·97; p=0·022). There was no evidence of heterogeneity in treatment effect (for any of the treatments) across prespecified subsets. Grade 3-5 adverse events were reported for 399 (32%) patients receiving SOC, 197 (32%) receiving SOC + ZA, 288 (52%) receiving SOC + Doc, and 269 (52%) receiving SOC + ZA + Doc.

INTERPRETATION: Zoledronic acid showed no evidence of survival improvement and should not be part of standard of care for this population. Docetaxel chemotherapy, given at the time of long-term hormone therapy initiation, showed evidence of improved survival accompanied by an increase in adverse events. Docetaxel treatment should become part of standard of care for adequately fit men commencing long-term hormone therapy.

FUNDING: Cancer Research UK, Medical Research Council, Novartis, Sanofi-Aventis, Pfizer, Janssen, Astellas, NIHR Clinical Research Network, Swiss Group for Clinical Cancer Research.

Famine and land in Ireland and India 1845-1880: James Caird and the political economy of hunger

The perception of Ireland and India as ‘zones of famine’ led many nineteenth-century observers to draw analogies between these two troublesome parts of the British empire. This article investigates this parallel through the career of James Caird (1816–92), and specifically his interventions in the latter stages of both the Great Irish Famine of 1845–50, and the Indian famines of 1876–9. Caird is best remembered as the joint author of the controversial dissenting minute in the Indian famine commission report of 1880; this article locates the roots of his stance in his previous engagements with Irish policy. Caird's interventions are used to track the trajectory of an evolving ‘Peelite’ position on famine relief, agricultural reconstruction, and land reform between the 1840s and 1880s. Despite some divergences, strong continuities exist between the two interventions – not least concern for the promotion of agricultural entrepreneurship, for actively assisting economic development in ‘backward’ economies, and an acknowledgement of state responsibility for preserving life as an end in itself. Above all in both cases it involved a critique of a laissez-faire dogmatism – whether manifest in the ‘Trevelyanism’ of 1846–50 or the Lytton–Temple system of 1876–9.

The development and validation of liquid chromatography method for the simultaneous determination of metformin and glipizide, gliclazide, glibenclamide or glimperide in plasma

This article describes the development of SPE and HPLC methods for the simultaneous determination of metformin and glipizide, gliclazide, glibenclamide or glimperide in plasma. Several extraction and HPLC methods have been described previously for the determination of each of these analytes in plasma separately. The simultaneous determination of these analytes is important for the routine monitoring of diabetic patients who take combination medications and for studying the pharmacokinetics of the combined dosage forms. In addition this developed method can serve as a standard method for the plasma determination of these analytes therefore saving time, effort and money. The recoveries of the developed methods were found to be between 76.3% and 101.9%. The limits of quantification were between 5 and 22.5 ng/ml. The intraday and interday precision (measured by coefficient of variation, CV%) was always less than 9%. The accuracy (measured by relative error %) was always less than 12%. Stability analysis showed that all analytes are stable for at least 3 months when stored at -70degreesC. (C) 2004 Elsevier B.V. All rights reserved.

Electron impact excitation of Gd XXXVII and radiative rates for Ni-like ions with 60

Energy levels and radiative rates for transitions among the 107 finestructure levels belonging to the (1s(2)2s(2)2p(6)) 3s(2)3p(6)3d(10), 3s(2)3p(6)3d(9)4l, 3s(2)3p(5)3d(10)4l, and 3s3p(6)3d(10)4l configurations of Ni-like ions with 60 less than or equal to Z less than or equal to 90 have been calculated using the GRASP code. The collision strengths (Omega) have also been computed for transitions in Gd XXXVII at energies below 800 Ryd, using the DARC code. Resonances have been resolved in a fine energy mesh in the threshold region, and excitation rate coefficients have been calculated for transitions from the ground level to excited levels at temperatures below 2500 eV. These have been compared with those available in the literature, and enhancement in the values of rates, due to resonances, has been observed up to an order of magnitude for some of the transitions.

The roles of thymidylate synthase and p53 in regulating Fas-mediated apoptosis in response to antimetabolites

Fas (CD95/Apo-1) is a member of the tumor necrosis factor receptor family. Receptor binding results in activation of caspase 8, leading to activation of proapoptotic downstream molecules. We found that expression of Fas was up-regulated >10-fold in MCF-7 breast and HCT116 and RKO colon cancer cell lines after treatment with IC(60) doses of 5-fluorouracil (5-FU) and raltitrexed (RTX). Combined treatment with the agonistic Fas antibody CH-11 and either 5-FU or RTX resulted in a highly synergistic induction of apoptosis in these cell lines. Similar results were obtained for another antifolate, Alimta. Induction of thymidylate synthase expression inhibited Fas induction in response to RTX and Alimta, but not in response to 5-FU. Furthermore, thymidylate synthase induction abrogated the synergy between CH-11 and both antifolates but had no effect on the synergistic interaction between 5-FU and CH-11. Inactivation of p53 in MCF-7 and HCT116 cell lines blocked 5-FU- and antifolate-mediated up-regulation of Fas. Furthermore, Fas was not up-regulated in response to 5-FU or antifolates in the p53-mutant H630 colon cancer cell line. Lack of Fas up-regulation in the p53-null and -mutant lines abolished the synergistic interaction between 5-FU and CH-11. Interestingly, synergy was still observed between the antifolates and CH-11 in the p53-null HCT116 and p53-mutant H630 cell lines, although this was significantly reduced compared with the p53 wild-type cell lines. Our results indicate that Fas is an important mediator of apoptosis in response to both 5-FU and antifolates.

Ca(2+)-sparks constitute elementary building blocks for global Ca(2+)-signals in myocytes of retinal arterioles.

Spontaneous Ca2+-events were imaged in myocytes within intact retinal arterioles (diameter < 40 mu m) freshly isolated from rat eyes. Ca2+-sparks were often observed to spread across the width of these small cells, and could summate to produce prolonged Ca2+-oscillations and contraction. Application of cyclopiazonic acid (20 mu M) transiently increased spark frequency and oscillation amplitude, but inhibited both sparks and oscillations within 60 s. Both ryanodine (100 mu M) and tetracaine (100 mu M) reduced the frequency of sparks and oscillations, while tetracaine also reduced oscillation amplitude. None of these interventions affected spark amplitude. Nifedipine, which blocks store filling independently of any action on L-type Ca2+-channels in these cells, reduced the frequency and amplitude of both sparks and oscillations. Removal of external [Ca2+] (1 mM EGTA) also reduced the frequency of sparks and oscillations but these reductions were slower in onset than those in the presence of tetracaine or cyclopiazonic acid. Cyclopiazonic acid, nifedipine and low external [Ca2+] all reduced SR loading, as indicated by the amplitude of caffeine evoked Ca2+-transients. This study demonstrates for the first time that spontaneous Ca2+-events in small arterioles of the eye result from activation of ryanodine receptors in the SR and suggests that this activation is not tightly coupled to Ca2+-influx. The data also supports a model in which Ca2+-sparks act as building blocks for more prolonged, global Ca2+-signals. (c) 2006 Elsevier Ltd. All rights reserved.

Antioxidants and periodontitis in 60-70 year- old men

Objective: The aim was to investigate the association between periodontal health and the serum levels of various antioxidants including carotenoids, retinol and vitamin E in a homogenous group of Western European men.
Materials and Methods: A representative sample of 1258 men aged 60-70 years, drawn from the population of Northern Ireland, was examined between 2001 and 2003. Each participant had six or more teeth, completed a questionnaire and underwent a clinical periodontal examination. Serum lipid-soluble antioxidant levels were measured by high-performance liquid chromatography with diode array detection. Multivariable analysis was carried out using logistic regression with adjustment for possible confounders. Models were constructed using two measures of periodontal status (low- and high-threshold periodontitis) as dependent variables and the fifths of each antioxidant as a predictor variable.
Results: The levels of a- and ß-carotene, ß-cryptoxanthin and zeaxanthin were highly significantly lower in the men with low-threshold periodontitis (p<0.001). These carotenoids were also significantly lower in high-threshold periodontitis. There were no significant differences in the levels of lutein, lycopene, a- and ?-tocopherol or retinol in relation to periodontitis. In fully adjusted models, there was an inverse relationship between a number of carotenoids (a- and ß-carotene and ß-cryptoxanthin) and low-threshold periodontitis. ß-Carotene and ß-cryptoxanthin were the only antioxidants that were associated with an increased risk of high-threshold severe periodontitis. The adjusted odds ratio for high-threshold periodontitis in the lowest fifth relative to the highest fifth of ß-cryptoxanthin was 4.02 (p=0.003).
Conclusion: It is concluded that low serum levels of a number of carotenoids, in particular beta-cryptoxanthin and beta-carotene, were associated with an increased prevalence of periodontitis in this homogenous group of 60-70-year-old Western European men.