Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial

BACKGROUND: Prostate cancer might have high radiation-fraction sensitivity that would give a therapeutic advantage to hypofractionated treatment. We present a pre-planned analysis of the efficacy and side-effects of a randomised trial comparing conventional and hypofractionated radiotherapy after 5 years follow-up.

METHODS: CHHiP is a randomised, phase 3, non-inferiority trial that recruited men with localised prostate cancer (pT1b-T3aN0M0). Patients were randomly assigned (1:1:1) to conventional (74 Gy delivered in 37 fractions over 7·4 weeks) or one of two hypofractionated schedules (60 Gy in 20 fractions over 4 weeks or 57 Gy in 19 fractions over 3·8 weeks) all delivered with intensity-modulated techniques. Most patients were given radiotherapy with 3-6 months of neoadjuvant and concurrent androgen suppression. Randomisation was by computer-generated random permuted blocks, stratified by National Comprehensive Cancer Network (NCCN) risk group and radiotherapy treatment centre, and treatment allocation was not masked. The primary endpoint was time to biochemical or clinical failure; the critical hazard ratio (HR) for non-inferiority was 1·208. Analysis was by intention to treat. Long-term follow-up continues. The CHHiP trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN97182923.

FINDINGS: Between Oct 18, 2002, and June 17, 2011, 3216 men were enrolled from 71 centres and randomly assigned (74 Gy group, 1065 patients; 60 Gy group, 1074 patients; 57 Gy group, 1077 patients). Median follow-up was 62·4 months (IQR 53·9-77·0). The proportion of patients who were biochemical or clinical failure free at 5 years was 88·3% (95% CI 86·0-90·2) in the 74 Gy group, 90·6% (88·5-92·3) in the 60 Gy group, and 85·9% (83·4-88·0) in the 57 Gy group. 60 Gy was non-inferior to 74 Gy (HR 0·84 [90% CI 0·68-1·03], pNI=0·0018) but non-inferiority could not be claimed for 57 Gy compared with 74 Gy (HR 1·20 [0·99-1·46], pNI=0·48). Long-term side-effects were similar in the hypofractionated groups compared with the conventional group. There were no significant differences in either the proportion or cumulative incidence of side-effects 5 years after treatment using three clinician-reported as well as patient-reported outcome measures. The estimated cumulative 5 year incidence of Radiation Therapy Oncology Group (RTOG) grade 2 or worse bowel and bladder adverse events was 13·7% (111 events) and 9·1% (66 events) in the 74 Gy group, 11·9% (105 events) and 11·7% (88 events) in the 60 Gy group, 11·3% (95 events) and 6·6% (57 events) in the 57 Gy group, respectively. No treatment-related deaths were reported.

INTERPRETATION: Hypofractionated radiotherapy using 60 Gy in 20 fractions is non-inferior to conventional fractionation using 74 Gy in 37 fractions and is recommended as a new standard of care for external-beam radiotherapy of localised prostate cancer.

FUNDING: Cancer Research UK, Department of Health, and the National Institute for Health Research Cancer Research Network.

Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis

Background

It is unknown whether a conservative approach to fluid administration or deresuscitation (active removal of fluid using diuretics or renal replacement therapy) is beneficial following haemodynamic stabilisation of critically ill patients.

Purpose

To evaluate the efficacy and safety of conservative or deresuscitative fluid strategies in adults and children with acute respiratory distress syndrome (ARDS), sepsis or systemic inflammatory response syndrome (SIRS) in the post-resuscitation phase of critical illness.

Methods

We searched Medline, EMBASE and the Cochrane central register of controlled trials from 1980 to June 2016, and manually reviewed relevant conference proceedings from 2009 to the present. Two reviewers independently assessed search results for inclusion and undertook data extraction and quality appraisal. We included randomised trials comparing fluid regimens with differing fluid balances between groups, and observational studies investigating the relationship between fluid balance and clinical outcomes.

Results

Forty-nine studies met the inclusion criteria. Marked clinical heterogeneity was evident. In a meta-analysis of 11 randomised trials (2051 patients) using a random-effects model, we found no significant difference in mortality with conservative or deresuscitative strategies compared with a liberal strategy or usual care [pooled risk ratio (RR) 0.92, 95 % confidence interval (CI) 0.82–1.02, I2 = 0 %]. A conservative or deresuscitative strategy resulted in increased ventilator-free days (mean difference 1.82 days, 95 % CI 0.53–3.10, I2 = 9 %) and reduced length of ICU stay (mean difference −1.88 days, 95 % CI −0.12 to −3.64, I2 = 75 %) compared with a liberal strategy or standard care.

Conclusions

In adults and children with ARDS, sepsis or SIRS, a conservative or deresuscitative fluid strategy results in an increased number of ventilator-free days and a decreased length of ICU stay compared with a liberal strategy or standard care. The effect on mortality remains uncertain. Large randomised trials are needed to determine optimal fluid strategies in critical illness.

Random Access over Multi-Packet Reception Channels: A Mean-Field Approach

Thesis (Ph.D.)--University of Washington, 2016-06

Random path sampling applied to vector models of magnetism

The recently reported Monte Carlo Random Path Sampling method (RPS) is here improved and its application is expanded to the study of the 2D and 3D Ising and discrete Heisenberg models. The methodology was implemented to allow use in both CPU-based high-performance computing infrastructures (C/MPI) and GPU-based (CUDA) parallel computation, with significant computational performance gains. Convergence is discussed, both in terms of free energy and magnetization dependence on field/temperature. From the calculated magnetization-energy joint density of states, fast calculations of field and temperature dependent thermodynamic properties are performed, including the effects of anisotropy on coercivity, and the magnetocaloric effect. The emergence of first-order magneto-volume transitions in the compressible Ising model is interpreted using the Landau theory of phase transitions. Using metallic Gadolinium as a real-world example, the possibility of using RPS as a tool for computational magnetic materials design is discussed. Experimental magnetic and structural properties of a Gadolinium single crystal are compared to RPS-based calculations using microscopic parameters obtained from Density Functional Theory.

Modelo de Kuramoto com campos aleatórios em redes complexas

Neste trabalho é estudado o modelo de Kuramoto num grafo completo, em redes scale-free com uma distribuição de ligações P(q) ~ q-Y e na presença de campos aleatórios com magnitude constante e gaussiana. Para tal, foi considerado o método Ott-Antonsen e uma aproximação "annealed network". Num grafo completo, na presença de campos aleatórios gaussianos, e em redes scale-free com 2 < y < 5 na presença de ambos os campos aleatórios referidos, foram encontradas transições de fase contínuas. Considerando a presença de campos aleatórios com magnitude constante num grafo completo e em redes scale-free com y > 5, encontraram-se transições de fase contínua (h < √2) e descontínua (h > √2). Para uma rede SF com y = 3, foi observada uma transição de fase de ordem infinita. Os resultados do modelo de Kuramoto num grafo completo e na presença de campos aleatórios com magnitude constante foram comparados aos de simulações, tendo-se verificado uma boa concordância. Verifica-se que, independentemente da topologia de rede, a constante de acoplamento crítico aumenta com a magnitude do campo considerado. Na topologia de rede scale-free, concluiu-se que o valor do acoplamento crítico diminui à medida que valor de y diminui e que o grau de sincronização aumenta com o aumento do número médio das ligações na rede. A presença de campos aleatórios com magnitude gaussiana num grafo completo e numa rede scale-free com y > 2 não destrói a transição de fase contínua e não altera o comportamento crítico do modelo de Kuramoto.

Generating a state t-design by diagonal quantum circuits

We investigate protocols for generating a state t-design by using a fixed separable initial state and a diagonal-unitary t-design in the computational basis, which is a t-design of an ensemble of diagonal unitary matrices with random phases as their eigenvalues. We first show that a diagonal-unitary t-design generates a O (1/2(N))-approximate state t-design, where N is the number of qubits. We then discuss a way of improving the degree of approximation by exploiting non-diagonal gates after applying a diagonal-unitary t-design. We also show that it is necessary and sufficient to use O (log(2)(t)) -qubit gates with random phases to generate a diagonal-unitary t-design by diagonal quantum circuits, and that each multi-qubit diagonal gate can be replaced by a sequence of multi-qubit controlled-phase-type gates with discrete-valued random phases. Finally, we analyze the number of gates for implementing a diagonal-unitary t-design by non-diagonal two- and one-qubit gates. Our results provide a concrete application of diagonal quantum circuits in quantum informational tasks.

The influence of nano-scale second-phase particles on deformation of fine grained calcite mylonites

Grey and white carbonate mylonites were collected along thrust planes of the Helvetic Alps. They are characterised by very small grain sizes and non-random grain shape (SPO) and crystallographic preferred orientation (CPO). Presumably they deformed in the field of grain size sensitive flow by recrystallisation accommodated intracrystalline deformation in combination with granular flow. Both mylonites show a similar mean grain size, but in the grey mylonites the grain size range is larger, the grain shapes are more elongate and the dynamically recrystallised calcite grains are more often twinned. Grey mylonites have an oblique CPO, while the CPO in white mylonites is symmetric with respect to the shear plane. Combustion analysis and TEM investigations revealed that grey mylonites contain a higher amount of highly structured kerogens with particle sizes of a few tens of nanometers, which are finely dispersed at the grain boundaries. During deformation of the rock, nano-scale particles reduced the migration velocity of grain boundaries by Zener drag resulting in slower recrystallisation rates of the calcite aggregate. In the grey mylonites, more strain increments were accommodated by individual grains before they became refreshed by dynamic recrystallisation than in white mylonites, where grain boundary migration was less hindered and recrystallisation cycles were faster. Consequently, grey mylonites represent ‘deformation’ microfabrics while white mylonites are characterised by ‘recrystallisation’ microfabrics. Field geologists must utilise this different deformation behavior when applying the obliquity in CPO and SPO of the respective mylonites as reliable shear sense indicators.

Phase transitions in gene networks evolved under different selection rules

Mathematical models of gene regulation are a powerful tool for understanding the complex features of genetic control. While various modeling efforts have been successful at explaining gene expression dynamics, much less is known about how evolution shapes the structure of these networks. An important feature of gene regulatory networks is their stability in response to environmental perturbations. Regulatory systems are thought to have evolved to exist near the transition between stability and instability, in order to have the required stability to environmental fluctuations while also being able to achieve a wide variety of functions (corresponding to different dynamical patterns). We study a simplified model of gene network evolution in which links are added via different selection rules. These growth models are inspired by recent work on `explosive' percolation which shows that when network links are added through competitive rather than random processes, the connectivity phase transition can be significantly delayed, and when it is reached, it appears to be first order (discontinuous, e.g., going from no failure at all to large expected failure) instead of second order (continuous, e.g., going from no failure at all to very small expected failure). We find that by modifying the traditional framework for networks grown via competitive link addition to capture how gene networks evolve to avoid damage propagation, we also see significant delays in the transition that depend on the selection rules, but the transitions always appear continuous rather than `explosive'.

Transient scaling and resurgence of chimera states in networks of Boolean phase oscillators.

We study networks of nonlocally coupled electronic oscillators that can be described approximately by a Kuramoto-like model. The experimental networks show long complex transients from random initial conditions on the route to network synchronization. The transients display complex behaviors, including resurgence of chimera states, which are network dynamics where order and disorder coexists. The spatial domain of the chimera state moves around the network and alternates with desynchronized dynamics. The fast time scale of our oscillators (on the order of 100ns) allows us to study the scaling of the transient time of large networks of more than a hundred nodes, which has not yet been confirmed previously in an experiment and could potentially be important in many natural networks. We find that the average transient time increases exponentially with the network size and can be modeled as a Poisson process in experiment and simulation. This exponential scaling is a result of a synchronization rate that follows a power law of the phase-space volume.

Machine learning per l'idrologia: applicazione del metodo random forests per la previsione degli eventi di piena fluviale con un approccio probabilistico

Le tecniche di Machine Learning sono molto utili in quanto consento di massimizzare l’utilizzo delle informazioni in tempo reale. Il metodo Random Forests può essere annoverato tra le tecniche di Machine Learning più recenti e performanti. Sfruttando le caratteristiche e le potenzialità di questo metodo, la presente tesi di dottorato affronta due casi di studio differenti; grazie ai quali è stato possibile elaborare due differenti modelli previsionali. Il primo caso di studio si è incentrato sui principali fiumi della regione Emilia-Romagna, caratterizzati da tempi di risposta molto brevi. La scelta di questi fiumi non è stata casuale: negli ultimi anni, infatti, in detti bacini si sono verificati diversi eventi di piena, in gran parte di tipo “flash flood”. Il secondo caso di studio riguarda le sezioni principali del fiume Po, dove il tempo di propagazione dell’onda di piena è maggiore rispetto ai corsi d’acqua del primo caso di studio analizzato. Partendo da una grande quantità di dati, il primo passo è stato selezionare e definire i dati in ingresso in funzione degli obiettivi da raggiungere, per entrambi i casi studio. Per l’elaborazione del modello relativo ai fiumi dell’Emilia-Romagna, sono stati presi in considerazione esclusivamente i dati osservati; a differenza del bacino del fiume Po in cui ai dati osservati sono stati affiancati anche i dati di previsione provenienti dalla catena modellistica Mike11 NAM/HD. Sfruttando una delle principali caratteristiche del metodo Random Forests, è stata stimata una probabilità di accadimento: questo aspetto è fondamentale sia nella fase tecnica che in fase decisionale per qualsiasi attività di intervento di protezione civile. L'elaborazione dei dati e i dati sviluppati sono stati effettuati in ambiente R. Al termine della fase di validazione, gli incoraggianti risultati ottenuti hanno permesso di inserire il modello sviluppato nel primo caso studio all’interno dell’architettura operativa di FEWS.

Ultracold Bose-Fermi mixtures with pairing: quantum phase transition, mechanical stability, and trap confinement

Ultracold dilute gases occupy an important role in modern physics and they are employed to verify fundamental quantum theories in most branches of theoretical physics. The scope of this thesis work is the study of Bose-Fermi (BF) mixtures at zero temperature with a tunable pairing between bosons and fermions. The mixtures are treated with diagrammatic quantum many-body methods based on the so-called T-matrix formalism. Starting from the Fermi-polaron limit, I will explore various values of relative concentrations up to mixtures with a majority of bosons, a case barely considered in previous works. An unexpected quantum phase transition is found to occur in a certain range of BF coupling for mixture with a slight majority of bosons. The mechanical stability of mixtures has been analysed, when the boson-fermion interaction is changed from weak to strong values, in the light of experimental results recently obtained for a double-degenerate Bose-Fermi mixture of 23 Na - 40 K. A possible improvement in the description of the boson-boson repulsion based on Popov's theory is proposed. Finally, the effects of a harmonic trapping potential are described, with a comparison with the experimental data for the condensate fraction recently obtained for a trapped 23 Na - 40 K mixture.

Angiogenic Effects Of Cryosurgery With Liquid Nitrogen On The Normal Skin Of Rats, Through Morphometric Study.

Cryosurgery is an efficient therapeutic technique used to treat benign and malignant cutaneous diseases. The primary active mechanism of cryosurgery is related to vascular effects on treated tissue. After a cryosurgical procedure, exuberant granulation tissue is formed at the injection site, probably as a result of angiogenic stimulation of the cryogen and inflammatory response, particularly in endothelial cells. To evaluate the angiogenic effects of freezing, as part of the phenomenon of healing rat skin subjected to previous injury. Two incisions were made in each of the twenty rats, which were divided randomly into two groups of ten. After 3 days, cryosurgery with liquid nitrogen was performed in one of incisions. The rats' samples were then collected, cut and stained to conduct histopathological examination, to assess the local angiogenesis in differing moments and situations. It was possible to demonstrate that cryosurgery, in spite of promoting cell death and accentuated local inflammation soon after its application, induces quicker cell proliferation in the affected tissue and maintenance of this rate in a second phase, than in tissue healing without this procedure. These findings, together with the knowledge that there is a direct relationship between mononuclear cells and neovascularization (the development of a rich system of new vessels in injury caused by cold), suggest that cryosurgery possesses angiogenic stimulus, even though complete healing takes longer to occur. The significance level for statistical tests was 5% (p<0,05).

Predictive Value Of Phase I Trials For Safety In Later Trials And Final Approved Dose: Analysis Of 61 Approved Cancer Drugs.

Phase I trials use a small number of patients to define a maximum tolerated dose (MTD) and the safety of new agents. We compared data from phase I and registration trials to determine whether early trials predicted later safety and final dose. We searched the U.S. Food and Drug Administration (FDA) website for drugs approved in nonpediatric cancers (January 1990-October 2012). The recommended phase II dose (R2PD) and toxicities from phase I were compared with doses and safety in later trials. In 62 of 85 (73%) matched trials, the dose from the later trial was within 20% of the RP2D. In a multivariable analysis, phase I trials of targeted agents were less predictive of the final approved dose (OR, 0.2 for adopting ± 20% of the RP2D for targeted vs. other classes; P = 0.025). Of the 530 clinically relevant toxicities in later trials, 70% (n = 374) were described in phase I. A significant relationship (P = 0.0032) between increasing the number of patients in phase I (up to 60) and the ability to describe future clinically relevant toxicities was observed. Among 28,505 patients in later trials, the death rate that was related to drug was 1.41%. In conclusion, dosing based on phase I trials was associated with a low toxicity-related death rate in later trials. The ability to predict relevant toxicities correlates with the number of patients on the initial phase I trial. The final dose approved was within 20% of the RP2D in 73% of assessed trials.

Assessment Of Robustness On Analysis Using Headspace Solid-phase Microextraction And Comprehensive Two-dimensional Gas Chromatography Through Experimental Designs.

Plackett-Burman experimental design was applied for the robustness assessment of GC×GC-qMS (Comprehensive Two-Dimensional Gas Chromatography with Fast Quadrupolar Mass Spectrometric Detection) in quantitative and qualitative analysis of volatiles compounds from chocolate samples isolated by headspace solid-phase microextraction (HS-SPME). The influence of small changes around the nominal level of six factors deemed as important on peak areas (carrier gas flow rate, modulation period, temperature of ionic source, MS photomultiplier power, injector temperature and interface temperature) and of four factors considered as potentially influential on spectral quality (minimum and maximum limits of the scanned mass ranges, ions source temperature and photomultiplier power). The analytes selected for the study were 2,3,5-trimethylpyrazine, 2-octanone, octanal, 2-pentyl-furan, 2,3,5,6-tetramethylpyrazine, and 2-nonanone e nonanal. The factors pointed out as important on the robustness of the system were photomultiplier power for quantitative analysis and lower limit of mass scanning range for qualitative analysis.

Chemical Immobilization Of Crosslinked Polymeric Ionic Liquids On Nitinol Wires Produces Highly Robust Sorbent Coatings For Solid-phase Microextraction.

Super elastic nitinol (NiTi) wires were exploited as highly robust supports for three distinct crosslinked polymeric ionic liquid (PIL)-based coatings in solid-phase microextraction (SPME). The oxidation of NiTi wires in a boiling (30%w/w) H2O2 solution and subsequent derivatization in vinyltrimethoxysilane (VTMS) allowed for vinyl moieties to be appended to the surface of the support. UV-initiated on-fiber copolymerization of the vinyl-substituted NiTi support with monocationic ionic liquid (IL) monomers and dicationic IL crosslinkers produced a crosslinked PIL-based network that was covalently attached to the NiTi wire. This alteration alleviated receding of the coating from the support, which was observed for an analogous crosslinked PIL applied on unmodified NiTi wires. A series of demanding extraction conditions, including extreme pH, pre-exposure to pure organic solvents, and high temperatures, were applied to investigate the versatility and robustness of the fibers. Acceptable precision of the model analytes was obtained for all fibers under these conditions. Method validation by examining the relative recovery of a homologous group of phthalate esters (PAEs) was performed in drip-brewed coffee (maintained at 60 °C) by direct immersion SPME. Acceptable recoveries were obtained for most PAEs in the part-per-billion level, even in this exceedingly harsh and complex matrix.