Cisplatin and fluorouracil with or without panitumumab in patients with recurrent or metastatic squamous-cell carcinoma of the head and neck (SPECTRUM): an open-label phase 3 randomised trial

Background: Previous trials have shown that anti-EGFR monoclonal antibodies can improve clinical outcomes of patients with recurrent or metastatic squamous-cell carcinoma of the head and neck (SCCHN). We assessed the efficacy and safety of panitumumab combined with cisplatin and fluorouracil as first-line treatment for these patients. Methods: This open-label phase 3 randomised trial was done at 126 sites in 26 countries. Eligible patients were aged at least 18 years; had histologically or cytologically confi rmed SCCHN; had distant metastatic or locoregionally recurrent disease, or both, that was deemed to be incurable by surgery or radiotherapy; had an Eastern Cooperative Oncology Group performance status of 1 or less; and had adequate haematological, renal, hepatic, and cardiac function. Patients were randomly assigned according to a computer-generated randomisation sequence (1:1; stratifi ed by previous treatment, primary tumour site, and performance status) to one of two groups. Patients in both groups received up to six 3-week cycles of intravenous cisplatin (100 mg/m(2) on day 1 of each cycle) and fl uorouracil (1000 mg/m(2) on days 1-4 of each cycle); those in the experimental group also received intravenous panitumumab (9 mg/kg on day 1 of each cycle). Patients in the experimental group could choose to continue maintenance panitumumab every 3 weeks. The primary endpoint was overall survival and was analysed by intention to treat. In a prospectively defi ned retrospective analysis, we assessed tumour human papillomavirus (HPV) status as a potential predictive biomarker of outcomes with a validated p16-INK4A (henceforth, p16) immunohistochemical assay. Patients and investigators were aware of group assignment; study statisticians were masked until primary analysis; and the central laboratory assessing p16 status was masked to identifi cation of patients and treatment. This trial is registered with ClinicalTrials. gov, number NCT00460265. Findings: Between May 15, 2007, and March 10, 2009, we randomly assigned 657 patients: 327 to the panitumumab group and 330 to the control group. Median overall survival was 11.1 months (95% CI 9.8-12.2) in the panitumumab group and 9.0 months (8.1-11.2) in the control group (hazard ratio [HR] 0.873, 95% CI 0.729-1.046; p = 0.1403). Median progression-free survival was 5.8 months (95% CI 5.6-6.6) in the panitumumab group and 4.6 months (4.1-5.4) in the control group (HR 0.780, 95% CI 0.659-0.922; p = 0.0036). Several grade 3 or 4 adverse events were more frequent in the panitumumab group than in the control group: skin or eye toxicity (62 [19%] of 325 included in safety analyses vs six [2%] of 325), diarrhoea (15 [5%] vs four [1%]), hypomagnesaemia (40 [12%] vs 12 [4%]), hypokalaemia (33 [10%] vs 23 [7%]), and dehydration (16 [5%] vs seven [2%]). Treatment-related deaths occurred in 14 patients (4%) in the panitumumab group and eight (2%) in the control group. Five (2%) of the fatal adverse events in the panitumumab group were attributed to the experimental agent. We had appropriate samples to assess p16 status for 443 (67%) patients, of whom 99 (22%) were p16 positive. Median overall survival in patients with p16-negative tumours was longer in the panitumumab group than in the control group (11.7 months [95% CI 9.7-13.7] vs 8.6 months [6.9-11.1]; HR 0.73 [95% CI 0.58-0.93]; p = 0.0115), but this difference was not shown for p16-positive patients (11.0 months [7.3-12.9] vs 12.6 months [7.7-17.4]; 1.00 [0.62-1.61]; p = 0.998). In the control group, p16-positive patients had numerically, but not statistically, longer overall survival than did p16-negative patients (HR 0.70 [95% CI 0.47-1.04]). Interpretation: Although the addition of panitumumab to chemotherapy did not improve overall survival in an unselected population of patients with recurrent or metastatic SCCHN, it improved progression-free survival and had an acceptable toxicity profile. p16 status could be a prognostic and predictive marker in patients treated with panitumumab and chemotherapy. Prospective assessment will be necessary to validate our biomarker findings

Chemical nonlinearities in relating intercontinental ozone pollution to anthropogenic emissions

Model studies typically estimate intercontinental influence on surface ozone by perturbing emissions from a source continent and diagnosing the ozone response in the receptor continent. Since the response to perturbations is non-linear due to chemistry, conclusions drawn from different studies may depend on the magnitude of the applied perturbation. We investigate this issue for intercontinental transport between North America, Europe, and Asia with sensitivity simulations in three global chemical transport models. In each region, we decrease anthropogenic emissions of NOx and nonmethane volatile organic compounds (NMVOCs) by 20% and 100%. We find strong nonlinearity in the response to NOx perturbations outside summer, reflecting transitions in the chemical regime for ozone production. In contrast, we find no significant nonlinearity to NOx perturbations in summer or to NMVOC perturbations year-round. The relative benefit of decreasing NOx vs. NMVOC from current levels to abate intercontinental pollution increases with the magnitude of emission reductions

Safety and tolerability of sitagliptin in patients with type 2 diabetes: a pooled analysis

<p>Abstract</p> <p>Background</p> <p>Sitagliptin, a highly selective dipeptidyl peptidase-4 inhibitor, is the first in a new class of oral antihyperglycemic agents (AHAs) for the treatment of patients with type 2 diabetes. Type 2 diabetes is a life-long disease requiring chronic treatment and management. Therefore, robust assessment of the long-term safety and tolerability of newer therapeutic agents is of importance. The purpose of this analysis was to assess the safety and tolerability of sitagliptin by pooling 12 large, double-blind, Phase IIb and III studies up to 2 years in duration. Methods: This analysis included 6139 patients with type 2 diabetes receiving either sitagliptin 100 mg/day (N = 3415) or a comparator agent (placebo or an active comparator) (N = 2724; non-exposed group). The 12 studies from which this pooled population was drawn represent the double-blind, randomized, Phase IIB and III studies that included patients treated with the clinical dose of sitagliptin (100 mg/day) for at least 18 weeks up to 2 years and that were available in a single safety database as of November 2007. These 12 studies assessed sitagliptin as monotherapy, initial combination therapy with metformin, or add-on combination therapy with other oral AHAs (metformin, pioglitazone, sulfonylurea, sulfonylurea + metformin, or metformin + rosiglitazone). Patients in the non-exposed group were taking placebo, pioglitazone, metformin, sulfonylurea, sulfonylurea + metformin, or metformin + rosiglitazone. This safety analysis used patient-level data from each study to evaluate clinical and laboratory adverse experiences.</p> <p>Results</p> <p>For clinical adverse experiences, the incidence rates of adverse experiences overall, serious adverse experiences, and discontinuations due to adverse experiences were similar in the sitagliptin and non-exposed groups. The incidence rates of specific adverse experiences were also generally similar in the two groups, with the exception of an increased incidence rate of hypoglycemia observed in the non-exposed group. The incidence rates of drug-related adverse experiences overall and discontinuations due to drug-related adverse experiences were higher in the non-exposed group, primarily due to the increased incidence rate of hypoglycemia in this group. For cardiac- and ischemia-related adverse experiences (including serious events), there were no meaningful between-group differences. No meaningful differences between groups in laboratory adverse experiences, either summary measures or specific adverse experiences, were observed.</p> <p>Conclusion</p> <p>In patients with type 2 diabetes, sitagliptin 100 mg/day was well tolerated in clinical trials up to 2 years in duration.</p

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Sex and sensibility: stories of a lesbian generation

In the first book to analyze shifts in lesbian identity, consciousness, and culture from the 1970s to the 1990s, Arlene Stein contributes an important chapter to the study of the women's movement and offers a revealing portrait of the exchange between a radical generation of feminists and its successors. Tracing the evolution of the lesbian movement from the bar scene to the growth of alternative families, Stein illustrates how a generation of women transformed the woman-centered ideals of feminism into a culture and a lifestyle. Sex and Sensibility relates the development of a "queer" sensibility in the 1990s to the foundation laid by the gay rights and feminist movements a generation earlier. Beginning with the stories of thirty women who came of age at the climax of the 70s women's movement - many of whom defined lesbianism as a form of resistance to dominant gender and sexual norms - Stein explores the complex issues of identity that these women confronted as they discovered who they were and defined themselves in relation to their communities and to society at large. Sex and Sensibility ends with interviews of ten younger women, members of the post-feminist generation who have made it a fashion to dismiss lesbian feminism as overly idealistic and reductive. Enmeshed in Stein's compelling and personal narrative are coming-out experiences, questions of separatism, work, desire, children, and family. Stein considers the multiple identities of women of color and the experiences of intermittent and "ex" lesbians.Was the lesbian feminist experiment a success? What has become of these ideas and the women who held them? In answering these questions, Stein illustrates the lasting and profound effect that the lesbian feminist movement had, and continues to have, on contemporary women's definitions of sexual identity

Trauma and Origins: Post-Holocaust Genealogists and the Work of Memory

In the 1970s, as children of Holocaust survivors reached adulthood, many began to excavate, piece together, and re-fashion their fractured family histories. This movement achieved momentum in the 1980s and 1990s, as the so-called "second generation" moved into middle age. Drawing from data gleaned from participant observation on a listserv for children of survivors and from interviews, I argue that those who engage in post-Holocaust genealogy are searching for coherent narratives that place their own origin in the context of the families into which they were born. By seeking, borrowing from and selectively appropriating traces of the past, they are using them as raw material in the production of new stories about the past and, by implication, the present

MS

thesisThe work in this study was done to determine if the skin of hospitalized patients is a source of two pathogenic organisms which are known to cause nosocomial infections: Pseudomanas aeruginosa and Staphylococcus aureaus. Four selected skin sites from adult medical and surgical patients were cultured at intervals of 12 hours, 3 days, and 7 days after the patient's admission to the hospital, to determine the number of these organisms that were presence of these organisms in the patient's surroundings. Selective culture media were used to facilitate the isolation and identification of Pseudomanas aeruginosa and Staphylococcus aureus. This study showed that a higher percentage of patients carried Staphylococcus on their skin than Pseudomanas aeruginosa, and that the colony counts of Staphylococcus aureus were higher than those of Pseudomonas aeruginosa. The patient's age, sex, diagnosis, or length of hospitalization did not alter these numbers. The type of soap used at home by the patients appeared to alter the number of these two organisms found on the skin, but because of the small sample size, no definite conclusions can be made from this study. The environmental sampling revealed very low numbers of both organisms in the areas sampled