Radium-223 and concomitant therapies in patients with metastatic castration-resistant prostate cancer: an international, early access, open-label, single-arm phase 3b trial

BACKGROUND: In the previously reported ALSYMPCA trial in patients with castration-resistant prostate cancer and symptomatic bone metastases, overall survival was significantly longer in patients treated with radium-223 dichloride (radium-223) than in patients treated with placebo. In this study, we investigated safety and overall survival in radium-223 treated patients in an early access programme done after the ALSYMPCA study and before regulatory approval of radium-223.

METHODS: We did an international, prospective, interventional, open-label, single-arm, phase 3b study. Enrolled patients were aged 18 years or older with histologically or cytologically confirmed progressive bone-predominant metastatic castration-resistant prostate cancer with two or more skeletal metastases on imaging (with no restriction as to whether they were symptomatic or asymptomatic; without visceral disease but lymph node metastases were allowed). Patients received intravenous injections of radium-223, 50 kBq/kg (current recommendation 55 kBq/kg after implementation of National Institute of Standards and Technology update on April 18, 2016) every 4 weeks for up to six injections. Other concomitant anticancer therapies were allowed. Primary endpoints were safety and overall survival. The safety and efficacy analyses were done on all patients who received at least one dose of the study drug. The study has been completed, and we report the final analysis here. This study is registered with ClinicalTrials.gov, number NCT01618370, and the European Union Clinical Trials Register, EudraCT number 2012-000075-16.

FINDINGS: Between July 22, 2012, and Dec 19, 2013, 839 patients were enrolled from 113 sites in 14 countries. 696 patients received one or more doses of radium-223; 403 (58%) of these patients had all six planned injections. Any-grade treatment-emergent adverse events occurred in 523 (75%) of 696 patients; any-grade treatment-emergent adverse events deemed to be related to treatment were reported in 281 (40%) patients. The most common grade 3 or worse treatment-related treatment-emergent adverse events were anaemia in 32 (5%) patients, thrombocytopenia in 15 (2%) patients, neutropenia in ten (1%) patients, and leucopenia in nine (1%) patients. Any grade of serious adverse events were reported in 243 (35%) patients. Median follow-up was 7·5 months (IQR 5-11) and 210 deaths were reported; median overall survival was 16 months (95% CI 13-not available [NA]). In an exploratory analysis of overall survival with predefined factors, median overall survival was longer for: patients with baseline alkaline phosphatase concentration less than the upper limit of normal (ULN; median NA, 95% CI 16 months-NA) than for patients with an alkaline phosphatase concentration equal to or greater than the ULN (median 12 months, 11-15); patients with baseline haemoglobin levels 10 g/dL or greater (median 17 months, 14-NA) than for patients with haemoglobin levels less than 10 g/dL (median 10 months, 8-14); patients with a baseline Eastern Cooperative Oncology Group performance status (ECOG PS) of 0 (median NA, 17 months-NA) than for patients with an ECOG PS of 1 (median 13 months, 11-NA) or an ECOG PS of 2 or more (median 7 months, 5-11); and for patients with no reported baseline pain (median NA, 16 months-NA) than for those with mild pain (median 14 months, 13-NA) or moderate-severe pain (median 11 months, 9-13). Median overall survival was also longer in patients who received radium-223 plus abiraterone, enzalutamide, or both (median NA, 95% CI 16 months-NA) than in those who did not receive these agents (median 13 months, 12-16), and in patients who received radium-223 plus denosumab (median NA, 15 months-NA) than in patients who received radium-223 without denosumab (median 13 months, 12-NA).

INTERPRETATION: Our findings show that radium-223 can be safely combined with abiraterone or enzalutamide, which are now both part of the standard of care for patients with metastatic castration-resistant prostate cancer. Furthermore, our findings extend to patients who were asymptomatic at baseline, unlike those enrolled in the pivotal ALSYMPCA study. The findings of prolonged survival in patients treated with concomitant abiraterone, enzalutamide, or denosumab require confirmation in prospective randomised trials.

FUNDING: Pharmaceutical Division of Bayer.

Cabazitaxel for Hormone-Relapsed Metastatic Prostate Cancer Previously Treated With a Docetaxel-Containing Regimen: An Evidence Review Group Perspective of a NICE Single Technology Appraisal

As part of its single technology appraisal (STA) process, the National Institute for Health and Care Excellence (NICE) invited the company that manufactures cabazitaxel (Jevtana(®), Sanofi, UK) to submit evidence for the clinical and cost effectiveness of cabazitaxel for treatment of patients with metastatic hormone-relapsed prostate cancer (mHRPC) previously treated with a docetaxel-containing regimen. The School of Health and Related Research Technology Appraisal Group at the University of Sheffield was commissioned to act as the independent Evidence Review Group (ERG). The ERG produced a critical review of the evidence for the clinical and cost effectiveness of the technology based upon the company's submission to NICE. Clinical evidence for cabazitaxel was derived from a multinational randomised open-label phase III trial (TROPIC) of cabazitaxel plus prednisone or prednisolone compared with mitoxantrone plus prednisone or prednisolone, which was assumed to represent best supportive care. The NICE final scope identified a further three comparators: abiraterone in combination with prednisone or prednisolone; enzalutamide; and radium-223 dichloride for the subgroup of people with bone metastasis only (no visceral metastasis). The company did not consider radium-223 dichloride to be a relevant comparator. Neither abiraterone nor enzalutamide has been directly compared in a trial with cabazitaxel. Instead, clinical evidence was synthesised within a network meta-analysis (NMA). Results from TROPIC showed that cabazitaxel was associated with a statistically significant improvement in both overall survival and progression-free survival compared with mitoxantrone. Results from a random-effects NMA, as conducted by the company and updated by the ERG, indicated that there was no statistically significant difference between the three active treatments for both overall survival and progression-free survival. Utility data were not collected as part of the TROPIC trial, and were instead taken from the company's UK early access programme. Evidence on resource use came from the TROPIC trial, supplemented by both expert clinical opinion and a UK clinical audit. List prices were used for mitoxantrone, abiraterone and enzalutamide as directed by NICE, although commercial in-confidence patient-access schemes (PASs) are in place for abiraterone and enzalutamide. The confidential PAS was used for cabazitaxel. Sequential use of the advanced hormonal therapies (abiraterone and enzalutamide) does not usually occur in clinical practice in the UK. Hence, cabazitaxel could be used within two pathways of care: either when an advanced hormonal therapy was used pre-docetaxel, or when one was used post-docetaxel. The company believed that the former pathway was more likely to represent standard National Health Service (NHS) practice, and so their main comparison was between cabazitaxel and mitoxantrone, with effectiveness data from the TROPIC trial. Results of the company's updated cost-effectiveness analysis estimated a probabilistic incremental cost-effectiveness ratio (ICER) of £45,982 per quality-adjusted life-year (QALY) gained, which the committee considered to be the most plausible value for this comparison. Cabazitaxel was estimated to be both cheaper and more effective than abiraterone. Cabazitaxel was estimated to be cheaper but less effective than enzalutamide, resulting in an ICER of £212,038 per QALY gained for enzalutamide compared with cabazitaxel. The ERG noted that radium-223 is a valid comparator (for the indicated sub-group), and that it may be used in either of the two care pathways. Hence, its exclusion leads to uncertainty in the cost-effectiveness results. In addition, the company assumed that there would be no drug wastage when cabazitaxel was used, with cost-effectiveness results being sensitive to this assumption: modelling drug wastage increased the ICER comparing cabazitaxel with mitoxantrone to over £55,000 per QALY gained. The ERG updated the company's NMA and used a random effects model to perform a fully incremental analysis between cabazitaxel, abiraterone, enzalutamide and best supportive care using PASs for abiraterone and enzalutamide. Results showed that both cabazitaxel and abiraterone were extendedly dominated by the combination of best supportive care and enzalutamide. Preliminary guidance from the committee, which included wastage of cabazitaxel, did not recommend its use. In response, the company provided both a further discount to the confidential PAS for cabazitaxel and confirmation from NHS England that it is appropriate to supply and purchase cabazitaxel in pre-prepared intravenous-infusion bags, which would remove the cost of drug wastage. As a result, the committee recommended use of cabazitaxel as a treatment option in people with an Eastern Cooperative Oncology Group performance status of 0 or 1 whose disease had progressed during or after treatment with at least 225 mg/m(2) of docetaxel, as long as it was provided at the discount agreed in the PAS and purchased in either pre-prepared intravenous-infusion bags or in vials at a reduced price to reflect the average per-patient drug wastage.

Large Numerical Models in Continuous Hybrid Simulation

Hybrid simulation is a technique that combines experimental and numerical testing and has been used for the last decades in the fields of aerospace, civil and mechanical engineering. During this time, most of the research has focused on developing algorithms and the necessary technology, including but not limited to, error minimisation techniques, phase lag compensation and faster hydraulic cylinders. However, one of the main shortcomings in hybrid simulation that has pre- vented its widespread use is the size of the numerical models and the effect that higher frequencies may have on the stability and accuracy of the simulation. The first chapter in this document provides an overview of the hybrid simulation method and the different hybrid simulation schemes, and the corresponding time integration algorithms, that are more commonly used in this field. The scope of this thesis is presented in more detail in chapter 2: a substructure algorithm, the Substep Force Feedback (Subfeed), is adapted in order to fulfil the necessary requirements in terms of speed. The effects of more complex models on the Subfeed are also studied in detail, and the improvements made are validated experimentally. Chapters 3 and 4 detail the methodologies that have been used in order to accomplish the objectives mentioned in the previous lines, listing the different cases of study and detailing the hardware and software used to experimentally validate them. The third chapter contains a brief introduction to a project, the DFG Subshake, whose data have been used as a starting point for the developments that are shown later in this thesis. The results obtained are presented in chapters 5 and 6, with the first of them focusing on purely numerical simulations while the second of them is more oriented towards a more practical application including experimental real-time hybrid simulation tests with large numerical models. Following the discussion of the developments in this thesis is a list of hardware and software requirements that have to be met in order to apply the methods described in this document, and they can be found in chapter 7. The last chapter, chapter 8, of this thesis focuses on conclusions and achievements extracted from the results, namely: the adaptation of the hybrid simulation algorithm Subfeed to be used in conjunction with large numerical models, the study of the effect of high frequencies on the substructure algorithm and experimental real-time hybrid simulation tests with vibrating subsystems using large numerical models and shake tables. A brief discussion of possible future research activities can be found in the concluding chapter.

Continuation of Benchmark Project - Phase IV, 1999 Calendar Year, 2000

This is the final Report to the Iowa DOT Offices of Construction and the Highway Division for the calendar year 1999 research project entitled - Continuation of Benchmarking Project: Phase IV. This project continues efforts started in 1995 with the development of a performance measurement system. The performance measurements were used to identify areas that required improvement and process improvement teams (PITs) were launched to make recommendations for improvement. This report provides a brief historical background, documents Benchmark Steering Team Activities, describes measurement activities including the employee survey and collection of non-survey data. Then a retrospective of past PIT activities is given, which sets the stage for the substantial increase in PIT activity that occurred during the winter of 1998/9. Finally, the report closes with suggestions for future directions in Benchmarking Activity.

Laboratory performance evaluation of CIR-emulsion and its comparison against CIR-foam test results from Phase III, TR-578

Currently, no standard mix design procedure is available for CIR-emulsion in Iowa. The CIR-foam mix design process developed during the previous phase is applied for CIR-emulsion mixtures with varying emulsified asphalt contents. Dynamic modulus test, dynamic creep test, static creep test and raveling test were conducted to evaluate the short- and long-term performance of CIR-emulsion mixtures at various testing temperatures and loading conditions. A potential benefit of this research is a better understanding of CIR-emulsion material properties in comparison with those of CIR-foam material that would allow for the selection of the most appropriate CIR technology and the type and amount of the optimum stabilization material. Dynamic modulus, flow number and flow time of CIR-emulsion mixtures using CSS-1h were generally higher than those of HFMS-2p. Flow number and flow time of CIR-emulsion using RAP materials from Story County was higher than those from Clayton County. Flow number and flow time of CIR-emulsion with 0.5% emulsified asphalt was higher than CIR-emulsion with 1.0% or 1.5%. Raveling loss of CIR-emulsion with 1.5% emulsified was significantly less than those with 0.5% and 1.0%. Test results in terms of dynamic modulus, flow number, flow time and raveling loss of CIR-foam mixtures are generally better than those of CIR-emulsion mixtures. Given the limited RAP sources used for this study, it is recommended that the CIR-emulsion mix design procedure should be validated against several RAP sources and emulsion types.

Generic wind estimation and compensation based on residual generators and higher-order sliding mode schemes

This master thesis proposes a solution to the approach problem in case of unknown severe microburst wind shear for a fixed-wing aircraft, accounting for both longitudinal and lateral dynamics. The adaptive controller design for wind rejection is also addressed, exploiting the wind estimation provided by suitable estimators. It is able to successfully complete the final approach phase even in presence of wind shear, and at the same time aerodynamic envelope protection is retained. The adaptive controller for wind compensation has been designed by a backstepping approach and feedback linearization for time-varying systems. The wind shear components have been estimated by higher-order sliding mode schemes. At the end of this work the results are provided, an autonomous final approach in presence of microburst is discussed, performances are analyzed, and estimation of the microburst characteristics from telemetry data is examined.

Evaluation, Selection and Planning the Implementation of a Pavement Management Optimization Model, Phase II Report, 1994

The missions of the research are to assist the Iowa Department of Transortation (Iowa DOT) to: Define pavement management (PM) optimization; Identify the characteristics of PM optimization systems being developed or implemented; Identify specific and achievable objectives for the Iowa DOT pavement management optimization; Evaluate different PM optimization methodologies; Identify a methodology to perform PM optimization that best satisfies the Iowa DOT's objectives; Develop a plan for the implementation of the PM optimization selected. The project is divided into three (3) phases. The first phase has been completed and accomplished the first three missions (identified above). The second phase has been completed and accomplished the next two missions. Phase three will accomplish the last mission.

Digital predistortion for compensation of nonlinearities in Radio over Fiber Links

In order to cope up with the ever increasing demand for larger transmission bandwidth, Radio over Fiber technology is a very beneficial solution. These systems are expected to play a major role within future fifth generation wireless networks due to their inherent capillary distribution properties. Nonlinear compensation techniques are becoming increasingly important to improve the performance of telecommunication channels by compensating for channel nonlinearities. Indeed, significant bounds on the technology usability and performance degradation occur due to nonlinear characteristics of optical transmitter, nonlinear generation of spurious frequencies, which, in the case of RoF links exploiting Directly Modulated Lasers , has the combined effect of laser chirp and optical fiber dispersion among its prevailing causes. The purpose of the research is to analyze some of the main causes of harmonic and intermodulation distortion present in Radio over Fiber (RoF) links, and to suggest a solution to reduce their effects, through a digital predistortion technique. Predistortion is an effective and interesting solution to linearize and this allows to demonstrate that the laser’s chirp and the optical fiber’s dispersion are the main causes which generate harmonic distortion. The improvements illustrated are only theoretical, based on a feasibility point of view. The simulations performed lead to significant improvements for short and long distances of radio over fiber link lengths. The algorithm utilized for simulation has been implemented on MATLAB. The effects of chirp and fiber nonlinearity in a directly modulated fiber transmission system are investigated by simulation, and a cost effective and rather simple technique for compensating these effects is discussed. A detailed description of its functional model is given, and its attractive features both in terms of quality improvement of the received signal, and cost effectiveness of the system are illustrated.

Rheology of bituminous mastics and mortars containing crumb rubber from tyres: a novel dry-hybrid technology

This report studied the effect of crumb rubber in the asphalt mixture. The mixtures were also having limestone filler as a modifier. Mastic and mortar (mastic-fine aggregate system) mixture having different quantities of crumb rubber and limestone filler modifiers have been tested in order to find the best rutting resistance combination with an acceptable stiffness. The rheological tests on bituminous mastics and mortars have done in the laboratories in Nottingham Transport Engineering Centre (NTEC) and University of Bologna (DICAM). In the second chapter, an extensive literature review about the binders, additives, asphalt mixtures, various modelling and testing methods have been reviewed. In the third chapter, the physical and rheological properties of the binders have been investigated using both traditional devices and DSRs. The forth chapter is dedicated to finding the behaviour of the modified mastics (Binder-modifier system) with different combinations. Five different combinations of crumb rubber and limestone filler mastic tested with various methods using Dynamic Shear Rheometers. In the fifth chapter, in order to find the effect of the modifiers in the rheological properties of the complete asphalt mixture, the fine aggregates added to the same mastic combinations. In this phase, the behaviour of the system so-called mortar; binder, rubber, filler and fine aggregates) has been studied using the DSR device and the traditional tests. The results show that using fine crumb rubber reduces the thermo sensibility of the mastic (Binder Bitumen System) and improves its elasticity. Limestone filler in the other hand increases the mixture stiffness at high Frequencies. Another important outcome of this research was that the rheological properties of the mortars were following the same trend of the mastics, therefore study the rheological properties of the mastic gives an upright estimation of the mortar.

Modulateurs intégrés sur silicium pour la transmission de signaux à modulation d'amplitude multi-niveau

Au cours des dernières années, la photonique intégrée sur silicium a progressé rapidement. Les modulateurs issus de cette technologie présentent des caractéristiques potentiellement intéressantes pour les systèmes de communication à courte portée. En effet, il est prévu que ces modulateurs pourront être opérés à des vitesses de transmission élevées, tout en limitant le coût de fabrication et la consommation de puissance. Parallèlement, la modulation d’amplitude multi-niveau (PAM) est prometteuse pour ce type de systèmes. Ainsi, ce travail porte sur le développement de modulateurs de silicium pour la transmission de signaux PAM. Dans le premier chapitre, les concepts théoriques nécessaires à la conception de modulateurs de silicium sont présentés. Les modulateurs Mach-Zehnder et les modulateurs à base de réseau de Bragg sont principalement abordés. De plus, les effets électro-optiques dans le silicium, la modulation PAM, les différents types d’électrodes intégrées et la compensation des distorsions par traitement du signal sont détaillés.Dans le deuxième chapitre, un modulateur Mach-Zehnder aux électrodes segmentées est présenté. La segmentation des électrodes permet la génération de signaux optiques PAM à partir de séquences binaires. Cette approche permet d’éliminer l’utilisation de convertisseur numérique-analogique en intégrant cette fonction dans le domaine optique, ce qui vise à réduire le coût du système de communication. Ce chapitre contient la description détaillée du modulateur, les résultats de caractérisation optique et de la caractérisation électrique, ainsi que les tests systèmes. De plus, les tests systèmes incluent l’utilisation de pré-compensation ou de post-compensation du signal sous la forme d’égalisation de la réponse en fréquence pour les formats de modulation PAM-4 et PAM-8 à différents taux binaires. Une vitesse de transmission de 30 Gb/s est démontrée dans les deux cas et ce malgré une limitation importante de la réponse en fréquence suite à l’ajout d’un assemblage des circuits radiofréquences (largeur de bande 3 dB de 8 GHz). Il s’agit de la première démonstration de modulation PAM-8 à l’aide d’un modulateur Mach-Zehnder aux électrodes segmentées. Finalement, les conclusions tirées de ce travail ont mené à la conception d’un deuxième modulateur Mach-Zehnder aux électrodes segmentées présentement en phase de test, dont les performances montrent un très grand potentiel. Dans le troisième chapitre, un modulateur à réseau de Bragg à deux sauts de phase est présenté. L’utilisation de réseaux de Bragg est une approche encore peu développée pour la modulation. En effet, la réponse spectrale de ces structures peut être contrôlée précisément, une caractéristique intéressante pour la conception de modulateurs. Dans ces travaux, nous proposons l’ajout de deux sauts de phase à un réseau de Bragg uniforme pour obtenir un pic de transmission dans la bande de réflexion de celui-ci. Ainsi, il est possible d’altérer l’amplitude du pic de transmission à l’aide d’une jonction pn. Comme pour le deuxième chapitre, ce chapitre inclut la description détaillée du modulateur, les résultats des caractérisations optique et électrique, ainsi que les tests systèmes. De plus, la caractérisation de jonctions pn à l’aide du modulateur à réseau de Bragg est expliquée. Des vitesses de transmission PAM-4 de 60 Gb/s et OOK de 55 Gb/s sont démontrées après la compensation des distorsions des signaux. À notre connaissance, il s’agit du modulateur à réseau de Bragg le plus rapide à ce jour. De plus, pour la première fois, les performances d’un tel modulateur s’approchent de celles des modulateurs de silicium les plus rapides utilisant des microrésonateurs en anneau ou des interféromètres Mach-Zehnder.

Supporting data for Blossey et al (2016): CGILS Phase 2 LES intercomparison of response of subtropical marine low cloud regimes to CO2 quadrupling and a CMIP3-composite forcing change

This archive provides supporting data with forcings, data and plotting scripts for the paper P. N. Blossey, C. S. Bretherton, A. Cheng, S. Endo, T. Heus, A. Lock and J. J. van der Dussen, 2016. CGILS Phase 2 LES intercomparison of response of subtropical marine low cloud regimes to CO2 quadrupling and a CMIP3-composite forcing change. J. Adv. Model. Earth Syst., Under revision.

Technology strategies in the process of student retention and efficiency of academic management

This article discusses the application of Information and Communication Technologies and strategies for best practices in order to capture and maintain faculty students' attention. It is based on a case study of ten years, using a complete information system. This system, in addition to be considered an ERP, to support the activities of academic management, also has a strong component of SRM that provides support to academic and administrative activities. It describes the extent to which the presented system facilitates the interaction and communication between members of the academic community, using the Internet, with services available on the Web complementing them with email, SMS and CTI. Through a perception, backed by empirical analysis and results of investigations, it demonstrates how this type of practice may raise the level of satisfaction of the community. In particular, it is possible to combat failure at school, avoid that students leave their course before its completion and also that they recommend them to potential students. In addition, such a strategy also allows strong economies in the management of the institution, increasing its value. As future work, we present the new phase of the project towards implementation of Business Intelligence to optimize the management process, making it proactive. The technological vision that guides new developments to a construction based on Web services and procedural languages is also presented.

Degradation toolkit for predicting the amount of degradation of particulate solids in lean phase pneumatic conveyors

Abstract not available