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.

Failure-Free Survival and Radiotherapy in Patients With Newly Diagnosed Nonmetastatic Prostate Cancer: Data From Patients in the Control Arm of the STAMPEDE Trial

Importance: The natural history of patients with newly diagnosed high-risk nonmetastatic (M0) prostate cancer receiving hormone therapy (HT) either alone or with standard-of-care radiotherapy (RT) is not well documented. Furthermore, no clinical trial has assessed the role of RT in patients with node-positive (N+) M0 disease. The STAMPEDE Trial includes such individuals, allowing an exploratory multivariate analysis of the impact of radical RT.

Objective: To describe survival and the impact on failure-free survival of RT by nodal involvement in these patients.

Design, Setting, and Participants: Cohort study using data collected for patients allocated to the control arm (standard-of-care only) of the STAMPEDE Trial between October 5, 2005, and May 1, 2014. Outcomes are presented as hazard ratios (HRs) with 95% CIs derived from adjusted Cox models; survival estimates are reported at 2 and 5 years. Participants were high-risk, hormone-naive patients with newly diagnosed M0 prostate cancer starting long-term HT for the first time. Radiotherapy is encouraged in this group, but mandated for patients with node-negative (N0) M0 disease only since November 2011.

Exposures: Long-term HT either alone or with RT, as per local standard. Planned RT use was recorded at entry.

Main Outcomes and Measures: Failure-free survival (FFS) and overall survival.

Results: A total of 721 men with newly diagnosed M0 disease were included: median age at entry, 66 (interquartile range [IQR], 61-72) years, median (IQR) prostate-specific antigen level of 43 (18-88) ng/mL. There were 40 deaths (31 owing to prostate cancer) with 17 months' median follow-up. Two-year survival was 96% (95% CI, 93%-97%) and 2-year FFS, 77% (95% CI, 73%-81%). Median (IQR) FFS was 63 (26 to not reached) months. Time to FFS was worse in patients with N+ disease (HR, 2.02 [95% CI, 1.46-2.81]) than in those with N0 disease. Failure-free survival outcomes favored planned use of RT for patients with both N0M0 (HR, 0.33 [95% CI, 0.18-0.61]) and N+M0 disease (HR, 0.48 [95% CI, 0.29-0.79]).

Conclusions and Relevance: Survival for men entering the cohort with high-risk M0 disease was higher than anticipated at study inception. These nonrandomized data were consistent with previous trials that support routine use of RT with HT in patients with N0M0 disease. Additionally, the data suggest that the benefits of RT extend to men with N+M0 disease.

Trial Registration: clinicaltrials.gov Identifier: NCT00268476; ISRCTN78818544.

Probing a 3,4'-bis-guanidinium diaryl derivative as an allosteric inhibitor of the Ras pathway

Mutations in the Ras-pathway occur in 40–45% of colorectal cancer patients and these are refractory to treatment with anti-EGFR-targeted therapies. With this in mind, we have studied novel guanidinium- based compounds with demonstrated ability to inhibit protein kinases. We have performed docking stud- ies with several proteins involved in the Ras-pathway and evaluated 3,40-bis-guanidinium derivatives as inhibitors of B-Raf. Compound 3, the most potent in this series, demonstrated strong cytotoxicity in WTB-Raf colorectal cancer cells and also cells with V600EB-Raf mutations. Cell death was induced by apop- tosis, detected by cleavage of PARP. Compound 3 also potently inhibited ERK1/2 signalling, inhibited EGFR activation, as well as Src, STAT3 and AKT phosphorylation. Mechanistically, compound 3 did not inhibit ATP binding to B-Raf, but direct assay of B-Raf activity was inhibited in vitro. Summarizing, we have identified a novel B-Raf type-III inhibitor that exhibits potent cellular cytotoxicity

Lipopolysaccharide modification in Gram-negative bacteria during chronic infection

The Gram-negative bacterial lipopolysaccharide (LPS) is a major component of the outer membrane that plays a key role in host-pathogen interactions with the innate immune system. During infection, bacteria are exposed to a host environment that is typically dominated by inflammatory cells and soluble factors, including antibiotics, which provide cues about regulation of gene expression. Bacterial adaptive changes including modulation of LPS synthesis and structure are a conserved theme in infections, irrespective of the type or bacteria or the site of infection. In general, these changes result in immune system evasion, persisting inflammation, and increased antimicrobial resistance. Here, we review the modifications of LPS structure and biosynthetic pathways that occur upon adaptation of model opportunistic pathogens (Pseudomonas aeruginosa, Burkholderia cepacia complex bacteria, Helicobacter pylori and Salmonella enterica) to chronic infection in respiratory and gastrointestinal sites. We also discuss the molecular mechanisms of these variations and their role in the host-pathogen interaction.

Estruturação de um modelo de avaliação global difuso na análise do risco de investimento em bens imóveis residenciais (residential real estate)

Dissertação, Mestrado, Contabilidade e Finanças, Instituto Politécnico de Santarém, Escola Superior de Gestão e Tecnologia, 2014

A qualidade do serviço prestado pelos Serviços Académicos da Escola Superior ABC

A globalização dos mercados transformou a realidade em que vivem as nossas organizações criando a necessidade de, face à concorrência cada vez mais agressiva, lutar por uma posição de destaque no mercado onde se encontram, sendo a “qualidade” cada vez mais o fator de destaque. A qualidade vai muito além de um produto, hoje em dia a qualidade estende-se ao ensino passando pelos serviços. A qualidade preocupa não só a indústria como todas as atividades económicas, inclusive os serviços, quer estes sejam prestados por entidades privadas quer por entidades públicas. Dentro desta visão de “qualidade” de serviços, pretende este projeto de intervenção estudar a qualidade do serviço prestado, pelos serviços académicos de uma escola de ensino superior público e elaborar uma proposta de medidas de melhoria. Numa primeira fase estudámos a satisfação dos alunos face ao serviço prestado tendo sido recolhida a opinião de 120 alunos. De seguida analisámos os processos e procedimentos dos SAC e posteriormente elaborámos uma proposta de melhoria para obtermos um serviço que vá ao encontro das necessidades do seu público-alvo, correspondendo em tempo e formato às suas expectativas, por forma a obter qualidade contínua no serviço prestado. Durante a elaboração deste projeto conseguimos colocar em prática algumas das medidas propostas, sobre as quais obtivemos resultados e opiniões muito positivas.-Market globalization has transformed the reality in which our organizations live, thus creating an increasingly aggressive competition and the need to fight for a position in the market in which they are where "quality" has become an increasingly prominent factor. Quality goes far beyond a product. Nowadays, quality extends to education and even services. Quality concerns not only the industry and all economic activities including services, whether they are provided by private or by public entities. Within this vision of "quality" in services, this project aims to study the quality of the services provided by the academic department of a higher education school and develop a proposal for improvement measures. At the beginning we studied the extent to which students were satisfied with the service provided and we collected the opinions of 120 students. Then we examined the processes and procedures of SAC and subsequently drafted a proposal aiming to improve and to obtain a service which would meet the needs of our target audience, with time and format corresponding to their expectations, in order to achieve continuous quality in service. During the preparation of this project we were able to put some of the measures into practice, during obtained very positive results and opinions.

A Nova Gestão Pública aplicada em contexto hospitalar:impacto na Cultura Organizacional do Hospital Distrital de Santarém, EPE

Dissertação, Mestrado, Gestão Pública, Instituto Politécnico de Santarém, Escola Superior de Gestão e Tecnologia, 2014

Estudo de extractos de Genista tenera actividade antioxidante e inibição de enzimas do metabolismo da glucose

Objectivo: Estudar a actividade antidiabética e antioxidante de extractos de Genista tenera. Materiais e métodos: Investigou-se a actividade antioxidante pelo método das espécies reactivas ao ácido tiobarbitúrico e o método do MTT (3-(4,5- dimetiltiazol-2-il)-2,5-difenil brometo de tetrazolio). Procurou-se clarificar o mecanismo de acção antidiabética pelo estudo da actividade inibitória nas enzimas α-glucosidase, glucose-6-fosfatase e glicogénio fosforilase. Resultados: No ensaio de MTT os extractos em éter, butanol e acetato de etilo possuem boa actividade antioxidante (87,80 %, 67,82 % e 67,70 % de viabilidade celular respectivamente). Na α-glucosidase os extractos em butanol e acetato de etilo apresentaram inibição (0,97% e 2,36% de actividade enzimática). Os extractos em acetato de etilo, butanol e éter são inibidores da glucose-6- fosfatase (48,33%, 80,25% e 64,42% de actividade enzimática). Conclusões: Os extractos de Genista tenera em acetato de etilo, butanol e éter poderão ser no futuro incluídos em nutracêuticos para prevenir ou tratar a diabetes tipo 2.

Papel do educador na avaliação e intervenção de crianças com necessidades educativas especiais

Relátorio de estágio apresentado para obtenção do grau de Mestre na especialidade de Educação Pré-escolar