Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Deficient cortical development in the hydrocephalic Texas (HTx) rat : a role for CSF.

The objectives of this study were to demonstrate the presence and nature of abnormal cortical development in a rat model of hydrocephalus, the hydrocephalic Texas (H-Tx) rat, and to test the hypothesis that the obstruction of CSF flow in affected animals can be linked to this effect. CSF is secreted continuously by the choroid plexus, located in the lateral, third and fourth ventricles. The fluid flows through the ventricular system, passing over all regions of germinal activity. In the H-Tx rat, obstruction and eventual blockage of CSF flow occurs in the cerebral aqueduct, between the third and fourth ventricles, at embryonic day 18. Prior to obstruction, neurogenesis and migration occur as in normal rats. Here we show that, following obstruction of fluid flow, neurogenesis from the germinal epithelium becomes abnormal. Cell proliferation decreases and proliferating cells are not retained in the germinal layer, as they appear to be in the normal brain. Cell migration is apparently unaffected, although a decrease in the number of migrating cells does occur after CSF obstruction. These data from our study indicate that a rapid primary effect of CSF obstruction, prior to any mechanical effects of fluid accumulation, is to alter the activity of cells in the germinal epithelium of the developing cortex. Further evidence for this is gained from in vitro studies. Once removed from their in vivo environment, cortical cells from the H-Tx rat have the ability to proliferate as normal. CSF extracted from the enlarged ventricles of affected brains is able to inhibit the proliferation of normal cells. Thus, we hypothesize that CSF has a potential role in the developmental process. The damming up and accumulation of CSF, whatever the cause, may result in abnormal cortical development through accumulation of CSF factors that are, or become, inhibitory to normal neuronal proliferation

Oxygen isotope analysis of the eyes of pelagic trilobites: testing the application of sea temperature proxies for the Ordovician

The oxygen isotope composition of well-preserved trilobite eye calcite, retaining its original optical properties, represents a possible source of information on Paleozoic sea temperatures. Species of the epipelagic telephinid genera Carolinites and Opipeuterella from strata of Early to Middle Ordovician age in Spitsbergen and Australia were analyzed, and compared with benthic asaphid species. Scanning electron microscope (SEM), cathodoluminescence (CL), electron microprobe and Electron Backscatter Diffraction (EBSD) techniques were used to assess eye preservation prior to isotope analysis. Some apparently well-preserved eyes are identified from the Valhallfonna (Spitsbergen) and Emanuel (Australia) formations. The eyes show a wide variation in δ18O values: −6.2‰ to −9.8‰ for the Valhallfonna Formation, −3.2‰ to −10.4‰ for the Emanuel Formation, and −3.6‰ to −7.4‰ for the Horn Valley Siltstone (Australia). Intra-eye Secondary Ion Mass Spectrometry (SIMS) isotope results reveal an even larger range in δ18O in some specimens (δ18O of −2.4‰ to −10.4‰), suggesting that the trilobite eyes have undergone cryptic recrystallization. A sub-set of trilobite cuticle from the three formations were analyzed for their carbonate clumped isotope compositions (Δ47), and yielded crystallization temperatures above 50 °C, consistent with diagenetic alteration. The SIMS and Δ47 results suggest that classic preservation assessment protocols for the stable isotope study of deep-time carbonate samples may be insufficient, especially for these techniques. There is a need for extensive microstructural characterization of lower Paleozoic biogenic carbonates, by techniques including EBSD, SIMS and Δ47, before their stable isotope signatures can be used with certainty in paleoclimate studies

The use of an ERP system to facilitate regulatory compliance

This paper reports the findings of a case study conducted in a multinational organization that aims to investigate how an enterprise resource planning system (ERP) can facilitate control over reporting processes and thus ensure compliance with regulatory requirements. The findings demonstrate how the use of an ERP to comply with financial regulation can impact organizational roles. In particular, IT managers must ensure that the ERP addresses regulatory requirements for internal control over financial reporting

Oxygen isotope analysis of the eyes of pelagic trilobites : testing the application of sea temperature proxies for the Ordovician

The oxygen isotope composition of well-preserved trilobite eye calcite, retaining its original optical properties, represents a possible source of information on Paleozoic sea temperatures. Species of the epipelagic telephinid genera Carolinites and Opipeuterella from strata of Early to Middle Ordovician age in Spitsbergen and Australia were analyzed, and compared with benthic asaphid species. Scanning electron microscope (SEM), cathodoluminescence (CL), electron microprobe and Electron Backscatter Diffraction (EBSD) techniques were used to assess eye preservation prior to isotope analysis. Some apparently well-preserved eyes are identified from the Valhallfonna (Spitsbergen) and Emanuel (Australia) formations. The eyes show a wide variation in δ18O values: −6.2‰ to −9.8‰ for the Valhallfonna Formation, −3.2‰ to −10.4‰ for the Emanuel Formation, and −3.6‰ to −7.4‰ for the Horn Valley Siltstone (Australia). Intra-eye Secondary Ion Mass Spectrometry (SIMS) isotope results reveal an even larger range in δ18O in some specimens (δ18O of −2.4‰ to −10.4‰), suggesting that the trilobite eyes have undergone cryptic recrystallization. A sub-set of trilobite cuticle from the three formations were analyzed for their carbonate clumped isotope compositions (Δ47), and yielded crystallization temperatures above 50 °C, consistent with diagenetic alteration. The SIMS and Δ47 results suggest that classic preservation assessment protocols for the stable isotope study of deep-time carbonate samples may be insufficient, especially for these techniques. There is a need for extensive microstructural characterization of lower Paleozoic biogenic carbonates, by techniques including EBSD, SIMS and Δ47, before their stable isotope signatures can be used with certainty in paleoclimate studies

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally