After the Liverpool Care Pathway clear guidance and support on end-of-life care is needed

Commentary on: Ramasamy Venkatasalu M, Whiting D, Cairnduff K. Life after the Liverpool Care Pathway (LCP): a qualitative study of critical care practitioners delivering end-of-life care. J Adv Nurs 2015;71:2108–18.

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.

Hypofractionated radiotherapy versus conventionally fractionated radiotherapy for patients with intermediate-risk localised prostate cancer: 2-year patient-reported outcomes of the randomised, non-inferiority, phase 3 CHHiP trial

BACKGROUND: Patient-reported outcomes (PROs) might detect more toxic effects of radiotherapy than do clinician-reported outcomes. We did a quality of life (QoL) substudy to assess PROs up to 24 months after conventionally fractionated or hypofractionated radiotherapy in the Conventional or Hypofractionated High Dose Intensity Modulated Radiotherapy in Prostate Cancer (CHHiP) trial.

METHODS: The CHHiP trial is a randomised, non-inferiority phase 3 trial done in 71 centres, of which 57 UK hospitals took part in the QoL substudy. Men with localised prostate cancer who were undergoing radiotherapy were eligible for trial entry if they had histologically confirmed T1b-T3aN0M0 prostate cancer, an estimated risk of seminal vesicle involvement less than 30%, prostate-specific antigen concentration less than 30 ng/mL, and a WHO performance status of 0 or 1. Participants were randomly assigned (1:1:1) to receive a standard fractionation schedule of 74 Gy in 37 fractions or one of two hypofractionated schedules: 60 Gy in 20 fractions or 57 Gy in 19 fractions. Randomisation was done with computer-generated permuted block sizes of six and nine, stratified by centre and National Comprehensive Cancer Network (NCCN) risk group. Treatment allocation was not masked. UCLA Prostate Cancer Index (UCLA-PCI), including Short Form (SF)-36 and Functional Assessment of Cancer Therapy-Prostate (FACT-P), or Expanded Prostate Cancer Index Composite (EPIC) and SF-12 quality-of-life questionnaires were completed at baseline, pre-radiotherapy, 10 weeks post-radiotherapy, and 6, 12, 18, and 24 months post-radiotherapy. The CHHiP trial completed accrual on June 16, 2011, and the QoL substudy was closed to further recruitment on Nov 1, 2009. Analysis was on an intention-to-treat basis. The primary endpoint of the QoL substudy was overall bowel bother and comparisons between fractionation groups were done at 24 months post-radiotherapy. The CHHiP trial is registered with ISRCTN registry, number ISRCTN97182923.

FINDINGS: 2100 participants in the CHHiP trial consented to be included in the QoL substudy: 696 assigned to the 74 Gy schedule, 698 assigned to the 60 Gy schedule, and 706 assigned to the 57 Gy schedule. Of these individuals, 1659 (79%) provided data pre-radiotherapy and 1444 (69%) provided data at 24 months after radiotherapy. Median follow-up was 50·0 months (IQR 38·4-64·2) on April 9, 2014, which was the most recent follow-up measurement of all data collected before the QoL data were analysed in September, 2014. Comparison of 74 Gy in 37 fractions, 60 Gy in 20 fractions, and 57 Gy in 19 fractions groups at 2 years showed no overall bowel bother in 269 (66%), 266 (65%), and 282 (65%) men; very small bother in 92 (22%), 91 (22%), and 93 (21%) men; small bother in 26 (6%), 28 (7%), and 38 (9%) men; moderate bother in 19 (5%), 23 (6%), and 21 (5%) men, and severe bother in four (<1%), three (<1%) and three (<1%) men respectively (74 Gy vs 60 Gy, ptrend=0.64, 74 Gy vs 57 Gy, ptrend=0·59). We saw no differences between treatment groups in change of bowel bother score from baseline or pre-radiotherapy to 24 months.

INTERPRETATION: The incidence of patient-reported bowel symptoms was low and similar between patients in the 74 Gy control group and the hypofractionated groups up to 24 months after radiotherapy. If efficacy outcomes from CHHiP show non-inferiority for hypofractionated treatments, these findings will add to the growing evidence for moderately hypofractionated radiotherapy schedules becoming the standard treatment for localised prostate cancer.

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

Analysis of groundwater-level response to rainfall and recharge estimates in fractured hard rock aquifers, NW Ireland

Despite fractured hard rock aquifers underlying over 65% of Ireland, knowledge of key processes controlling groundwater recharge in these bedrock systems is inadequately constrained. In this study, we examined 19 groundwater-level hydrographs from two Irish hillslope sites underlain by hard rock aquifers. Water-level time-series in clustered monitoring wells completed at the subsoil, soil/bedrock interface, shallow and deep bedrocks were continuously monitored hourly over two hydrological years. Correlation methods were applied to investigate groundwater-level response to rainfall, as well as its seasonal variations. The results reveal that the direct groundwater recharge to the shallow and deep bedrocks on hillslope is very limited. Water-level variations within these geological units are likely dominated by slow flow rock matrix storage. The rapid responses to rainfall (⩽2 h) with little seasonal variations were observed to the monitoring wells installed at the subsoil and soil/bedrock interface, as well as those in the shallow or deep bedrocks at the base of the hillslope. This suggests that the direct recharge takes place within these units. An automated time-series procedure using the water-table fluctuation method was developed to estimate groundwater recharge from the water-level and rainfall data. Results show the annual recharge rates of 42–197 mm/yr in the subsoil and soil/bedrock interface, which represent 4–19% of the annual rainfall. Statistical analysis of the relationship between the rainfall intensity and water-table rise reveal that the low rainfall intensity group (⩽1 mm/h) has greater impact on the groundwater recharge rate than other groups (>1 mm/h). This study shows that the combination of the time-series analysis and the water-table fluctuation method could be an useful approach to investigate groundwater recharge in fractured hard rock aquifers in Ireland.

Biomarker responses to folic acid intervention in healthy adults: a meta-analysis of randomized controlled trials

BACKGROUND: The task of revising dietary folate recommendations for optimal health is complicated by a lack of data quantifying the biomarker response that reliably reflects a given folate intake.

OBJECTIVE: We conducted a dose-response meta-analysis in healthy adults to quantify the typical response of recognized folate biomarkers to a change in folic acid intake.

DESIGN: Electronic and bibliographic searches identified 19 randomized controlled trials that supplemented with folic acid and measured folate biomarkers before and after the intervention in apparently healthy adults aged ≥18 y. For each biomarker response, the regression coefficient (β) for individual studies and the overall pooled β were calculated by using random-effects meta-analysis.

RESULTS: Folate biomarkers (serum/plasma and red blood cell folate) increased in response to folic acid in a dose-response manner only up to an intake of 400 μg/d. Calculation of the overall pooled β for studies in the range of 50 to 400 μg/d indicated that a doubling of folic acid intake resulted in an increase in serum/plasma folate by 63% (71% for microbiological assay; 61% for nonmicrobiological assay) and red blood cell folate by 31% (irrespective of whether microbiological or other assay was used). Studies that used the microbiological assay indicated lower heterogeneity compared with studies using nonmicrobiological assays for determining serum/plasma (I(2) = 13.5% compared with I(2) = 77.2%) and red blood cell (I(2) = 45.9% compared with I(2) = 70.2%) folate.

CONCLUSIONS: Studies administering >400 μg folic acid/d show no dose-response relation and thus will not yield meaningful results for consideration when generating dietary folate recommendations. The calculated folate biomarker response to a given folic acid intake may be more robust with the use of a microbiological assay rather than alternative methods for blood folate measurement.

Repply to: Brito, A.C., Brotas, V., Caetano, M., Coutinho, T.P., Bordalo, A.A., Icely, J., Neto, J.M., Serôdio, J., Moita, T. (2012) "Defining phytoplankton class boundaries in Portuguese transitional waters: an evaluation of the ecological quality status according to the Water Framework Directive" [Ecological Indicators 19, 5-14]

We write to comment on the recently published paper “Defining phytoplankton class boundaries in Portuguese transitional waters: an evaluation of the ecological quality status according to the Water Framework Directive” (Brito et al., 2012). This paper presents an integrated methodology to analyse the ecological quality status of several Portuguese transitional waters, using phytoplanktonrelated metrics. One of the systems analysed, the Guadiana estuary in southern Portugal, is considered the most problematic estuary, with its upstream water bodies classified as Poor in terms of ecological status. We strongly disagree with this conclusion and we would like to raise awareness to some methodological constraints that, in our opinion, are the basis of such deceptive conclusions and should therefore not be neglected when using phytoplankton to assess the ecological status of natural waters.

Arbeitszeit und Sonntagsruhe : Stellungnahmen zur Sonntagsarbeit als Beitrag kirchlicher Sozialkritik im 19. Jahrhundert

Mit der Forderung nach einem arbeitsfreien Sonntag haben die Kirchen im 19. Jahrhundert in die Diskussion um die Wochenarbeitszeit eingegriffen. Auch wenn das Thema der menschlichen Arbeit in der evangelischen Theologie des vergangenen Jahrhunderts nicht in dem Maße bedacht worden ist, wie es die neuzeitliche Veränderung im Verständnis der Arbeit und die Industrialisierung erfordert hätten, so lässt sie die bekannte Formel vom "Versagen der Kirche gegenüber der sozialen Frage" nicht aufrechterhalten. Die vorliegende Untersuchung fragt nach der Begründung der Sonntagsruhe für die Arbeit: Kann Sonntagsruhe im Gegensatz zu Freizeit als ein Begriff bestimmt werden, der in keinem komplementären Verhältnis zur Arbeit steht, nicht im Sinn eines Primats der Ruhe, sondern in dem Sinn, daß der Sonntag Kontrapost ist gegen den Primat der Arbeit in der Gegenwart?

Der Kampf um den freien Sonntag im 19. Jahrhundert

Im Aufsatz geht es um das kirchliche und politische Engagement im Kampf gegen die Sonntagsarbeit im 19. Jahrhundert.

TAG & RELEASE Volume 19, No. 1 March 2014

Tag & Release is the newsletter for the South Carolina Governor's Cup Billfishing Series, an official program of the South Carolina Department of Natural Resources in cooperation with the South Carolina Department of Parks, Recreation and Tourism and the Harry R.E. Hampton Memorial Wildlife Fund.

TAG & RELEASE Volume 19, No. 2 May 2014

Tag & Release is the newsletter for the South Carolina Governor's Cup Billfishing Series, an official program of the South Carolina Department of Natural Resources in cooperation with the South Carolina Department of Parks, Recreation and Tourism and the Harry R.E. Hampton Memorial Wildlife Fund.

TAG & RELEASE Volume 19, No. 4 Nov. 2014

Tag & Release is the newsletter for the South Carolina Governor's Cup Billfishing Series, an official program of the South Carolina Department of Natural Resources in cooperation with the South Carolina Department of Parks, Recreation and Tourism and the Harry R.E. Hampton Memorial Wildlife Fund.