A phase 1 study of regorafenib and sildenafil in adults with advanced solid tumors

The purpose of this study is to establish the recommended phase 2 dose for regorafenib in combination with sildenafil for patients with advanced solid tumors. Secondary outcomes included identification of antitumor effects of regorafenib and sildenafil, toxicity of the combination, determination of PDE5 expression in tumor samples, and the impact of sildenafil on the pharmacokinetics of regorafenib. This study was a phase 1, open-label single-arm dose-escalation trial using a 3 + 3 design. Additional patients were enrolled at the maximum tolerated dose (MTD) until a total of 12 patients were treated at the MTD. A total of 29 patients were treated in this study. The median duration of treatment was 8 weeks. The recommended phase 2 doses determined in this study are regorafenib 160 mg daily with sildenafil 100 mg daily. The most common toxicities included palmar-plantar erythrodysesthesia syndrome (20 patients, 69%) and hypophosphatemia (18 patients, 62%). Two patients (7%) experienced grade 4 lipase increase. Objective responses were not observed; however, 14 patients (48%) had a period of stable disease during the study. Stable disease for up to 12 months was observed in patients with ovarian cancer as well as up to 20 months for a patient with cervical cancer. The combination of regorafenib and sildenafil at the recommended phase 2 dose is safe and generally well tolerated. Disease control in patients with gynecologic malignancies was especially encouraging. Further evaluation of the combination of regorafenib and sildenafil in gynecologic malignancies is warranted. Clinical Trial Registration Number: NCT02466802.

Phase I study of regorafenib and sildenafil in advanced solid tumors

3593

Background: Regorafenib (R) is an oral multikinase inhibitor with anti-angiogenic properties approved for use in several solid tumors. Sildenafil (S) is an oral phosphodiesterase-5 (PDE5) inhibitor that interacts synergistically with R in both short-term and colony formation assays to kill multiple cancer cell types. Mechanistic studies identified that PDE5 knockdown enhances R lethality, suggesting a direct target effect for S. Methods: A single-center, open-label, dose-escalation study was conducted in adults with advanced solid tumors. Patients (pts) took R (120 or 160 mg) and S (50 or 100 mg) once daily days 1 through 21 of each 28-day cycle. Pts remained on study treatment until progression or excessive toxicity, with response assessments every 8 wks. The maximum tolerated dose (MTD) was defined as the maximum tested dose with ≤1/6 pts experiencing dose-limiting toxicity (DLT), with Cycle 1 as the DLT observation period. Results: 32 pts were enrolled and 29 treated at 3 dose levels (DLs). Median duration of treatment was 8 (range 2 – 101) wks. One of 6 evaluable pts treated at DL2 (160 mg R + 50 mg S) experienced DLT (grade 4 lipase increase). One of 12 evaluable pts treated at DL3A (160 mg R + 100 mg S, the MTD) experienced DLT (grade 3 rash and grade 3 muscle pain). The toxicity profile was generally consistent with that seen in R monotherapy at FDA-approved doses. 10 pts had a best response of progressive disease (PD). 14 pts had a best response of stable disease (SD), 5 of whom had stable disease duration > 24 wks. 5 treated pts were not evaluable for response. Notably, 2 pts with ovarian cancer and 1 with cervical cancer had stable disease > 24 wks. Analyses of correlative studies to examine pharmacokinetics and drug combination pharmacodynamic effects are underway. Conclusions: The combination was well-tolerated. The recommended phase 2 dose is 160 mg R + 100 mg S. Objective responses were not observed, but prolonged stable disease was seen in a subset of pts. Encouraging disease control was seen in gynecologic cancers. Dosing up to 100 mg S is safe concurrently with standard doses of R, and may be considered as an adjunct to R in future trials. Evaluation of R+S in gynecologic cancers warrants further consideration. Clinical trial information: NCT02466802 . [Table: see text]

Phase I trial of dimethyl fumarate, temozolomide, and radiation therapy in glioblastoma multiforme

2060

Background: Evidence is increasing for altered immune responses in malignant gliomas. Tumor-associated microglia/macrophages infiltrate human glioma tissue and produce cytokines that promote glioma growth, invasion and angiogenesis. Dimethyl fumarate (DMF), approved for relapsing-remitting multiple sclerosis, is toxic to in vitro activated microglial cells. Based on pre-clinical data demonstrating synergism with radiation (RT) and temozolomide (TMZ), we conducted a phase I study of DMF in patients with newly-diagnosed glioblastoma (GBM) in combination with RT and TMZ. Methods: Using a standard 3+3 dose escalation design (3 dose levels: 120 mg bid, 240 mg bid and 240 mg tid), newly-diagnosed GBM patients received daily DMF with RT (60 Gy) and concurrent TMZ 75 mg/m2 daily, followed by adjuvant DMF (continuously) and TMZ for up 6 maintenance cycles (150-200 mg/m2 on days 1-5 of each 28 day cycle). The maximum tolerated dose (MTD) was defined as the dose with ≤ 1/6 dose-limiting toxicities (DLT). The MTD was determined by evaluation of DLTs during the first 6 weeks of therapy. Results: Twelve patients were treated at the three dose levels, and no DLT was identified. There were no unexpected toxicities. The most common toxicities were lymphopenia (11 grade 3/4 events) and thrombocytopenia (2 grade 3/4 events). The only grade 3/4 non-heme toxicity was a grade 3 hemorrhoid event. Of the 12 evaluable patients, one remains on active treatment in maintenance phase. Three patients completed all treatment (concurrent and maintenance) with stable disease. Two patients had a partial response (RANO criteria) but then experienced disease progression during maintenance. Five patients had disease progression during study treatment and one patient chose to withdraw from the study during maintenance. Conclusions: These data suggest that DMF may be safely combined with RT and TMZ in GBM patients. A phase II study is under consideration. Clinical trial information: NCT02337426.

Hyperglycaemia monitoring and management in stroke care: policy vs. practice

AIM

To evaluate the extent to which hyperglycaemia was monitored and managed among patients admitted to hospital with acute stroke and transient ischaemic attack.

METHODS

We conducted a retrospective cohort study involving a review of the records of 112 patients consecutively admitted with acute stroke or transient ischaemic attack to all three district general hospitals in one Health and Social Care Trust in Northern Ireland from 1 January to 15 April 2008. Glucose results for each of the first 5 days of hospital admission were ascertained. We compared interventions, clinical outcome and discharge planning between patients who experienced glucose ≥ 7.8 mmol/l in the first 5 days, and patients with lower glucose results.

RESULTS

The daily prevalence rate of hyperglycaemia > 7.8 mmol/l across the first 5 days ranged from 24 to 34%. A total of 41 (37%) patients experienced hyperglycaemia on at least one occasion during the first 5 days. A history of diabetes mellitus prompted near patient glucose testing, but, among patients without diagnosed diabetes, glycaemia was under-monitored. Hyperglycaemia was a persisting trend, was under-treated and under-reported to general practitioners. Elevated glucose results failed to influence higher rates of fasting plasma glucose tests and BMI assessment.

CONCLUSIONS

There is a need for greater vigilance in the detection of hyperglycaemia and undiagnosed diabetes mellitus among patients admitted to hospital with stroke or transient ischaemic attack.

Recombinant Mycobacterium bovis bacillus Calmette-Guérin (BCG) expressing mouse IL-18 augments Th1 immunity and macrophage cytotoxicity

Interleukin-18 (IL-18) has been demonstrated to synergize with BCG for induction of a T-helper-type 1 (Th1) immune response. Since successful treatment of superficial bladder cancer with BCG requires proper induction of Th1 immunity, we have developed a recombinant (r) BCG strain that functionally secretes mouse (m) IL-18. This rBCG-mIL-18 strain significantly increased production of the major Th1 cytokine IFN-gamma in splenocyte cultures, at levels comparable to that elicited by control BCG plus exogenous rIL-18. IFN-gamma production by splenocytes was eliminated by addition of neutralizing anti-IL-18 antibody. Endogenous IL-12 played a favourable role whereas IL-10 played an adverse role in rBCG-mIL-18-induced IFN-gamma production. Enhanced host antimycobacterial immunity was observed in mice infected with rBCG-mIL-18 which showed less splenic enlargement and reduced bacterial load compared to control mice infected with BCG. Further, splenocytes from rBCG-mIL-18-infected mice, in response to BCG antigen, displayed increased production of IFN-gamma and GMCSF, decreased production of IL-10, elevated cellular proliferation and higher differentiation of IFN-gamma-secreting cells. rBCG-mIL-18 also enhanced BCG-induced macrophage cytotoxicity against bladder cancer MBT-2 cells in a dose-dependent manner. Neutralizing all endogenous macrophage-derived cytokines tested (IL-12, IL-18 and TNF-alpha) as well as IFN-gamma severely diminished the rBCG-mIL-18-induced macrophage cytolytic activity, indicating a critical role for these cytokines in this process. Cytokine analysis for supernatants of macrophage-BCG mixture cultures manifested higher levels of IFN-gamma and TNF-alpha in rBCG-mIL-18 cultures than in control BCG cultures. Taken together, this rBCG-mIL-18 strain augments BCG's immunostimulatory property and may serve as a better agent for bladder cancer immunotherapy and antimycobacterial immunization.

Exploring the emotional support needs and coping strategies of family carers

This paper explores the emotional support needs and coping strategies of family carers derived from two focus group interviews, each group comprising seven family carers. The interviews were carried out in Northern Ireland as part of phase one of the ACTION (Assisting Carers using Telematics Interventions to meet Older persons Needs) project. The purpose of the interviews was to investigate family carers' needs and experiences, but this paper focuses specifically on the emotional support needs and coping strategies identified by group members. The issues discussed included information and social support needs, the emotional impact of caring, and coping with and adaptation to the caring role. The findings reveal that for the majority of family carers their experience was one of constant searching for support and information. The anxiety and frustration associated with inconsistent and irregular support and lack of information was a major source of concern for the carers in the study. However, the carers employed a number of positive and negative coping strategies to deal with the stress associated with their caregiving role. The study concluded with the recommendation for nurses and other health care professionals to become more proactive in assessing and meeting carers' emotional support needs.

Nursing home placement: an exploration of the experiences of family carers

This study examines some of the factors leading family carers to place their older relatives in a nursing home. It also explores their thoughts and feelings about their relatives' admission to a nursing home. Analysis of in-depth interviews with relatives (n=10) found that the decision to place an older relative in a nursing home was a difficult one for families. The interviewed carers stated that admission to a nursing home was held off as long as possible but the deteriorating health of the older relative and in some cases their own health meant that there was no other option. Admission to institutional care usually followed a period of prolonged home care and occurred at a time of crisis. Family carers complained that they were given inadequate support from health care professionals and often had no choice in the decision-making process. This was particularly evident in the case of carers whose relative was transferred directly from hospital to a nursing home setting. The majority of carers in this study experienced ambiguous feelings about placing their elderly relative in a nursing home. Feelings of relief that the burden of care had been lifted, contrasted sharply with feelings of guilt that they could not continue with their 'duty of care'. Families also felt a need to justify their decision by emphasizing how friends and other family members agreed that they could not continue with home care in the interests of both their own and the older relative's health. The findings suggest that while many carers are relieved of the physical exhaustion surrounding home care, the emotional turmoil continues long after admission to a nursing home.

Family and staff perceptions of the role of families in nursing homes

Family and staff perceptions of the role of families in nursing homes Admission to a nursing home is generally regarded as the termination of family care and the commencement of institutional care. Research suggests that following placement families are often expected to relinquish their dependent older relative to the bureaucracy of the institution. The aim of this study was to investigate family and nursing home staff perceptions of the role of families caring for residents in nursing homes. A convenience sample of 44 family carers and 78 nursing home staff completed questionnaires, and interviews were conducted with 10 family carers and 10 nursing home staff. The results suggest that family carers perceived themselves to have a greater role in caring for relatives than that perceived by the nursing home staff. Either families overestimated their involvement, or staff underestimated family involvement in caring for residents in nursing homes. Families were mostly satisfied with their role and with the care provided in nursing homes. They perceived nurses as providers of technical care and they perceived themselves as having an important role in providing social and emotional care. Families trusted the clinical judgement of the staff but the staff were reluctant to trust family carers, especially in situations where care involved an element of risk. Family roles were limited by members' own ability to care and the dependency of the resident, while professional responsibility and accountability discouraged nurses from sharing some caring roles. The results indicate that families in this study were more willing to help in nursing home care and were perhaps under-valued as a resource within the nursing home setting.

A comparative study of the attitudes of users and non-users towards computerized care planning

The aim of this study was to compare the attitudes of nurses who had little or no experience of computerized care planning (non-users) with those who had at least two years' experience (users). The study also assessed levels of computer literacy among both cohorts and the training methods that were considered most appropriate to meet their needs. The approach was quantitative, using a questionnaire to collect data from 15 non-users and 14 users. The overall results suggest that both non-users and users had favourable attitudes towards the use of computerized care plans. However, non-users with previous computer experience had more favourable attitudes towards the introduction of computerized care planning than those with no previous experience. The preferred teaching method identified by both groups was training by technical staff in the clinical area.

Medication compliance and older people: a review of the literature

The purpose of this paper is to critically review a select body of literature pertaining to medication compliance among older people. As there is a vast amount of literature on the topic, this review is selective to include (1) a critique of the more commonly cited compliance theories, (2) an analysis of the key variables influencing medication compliance among older people and (3) a critical evaluation of the literature which examines these phenomena. In addition, studies, which explore the benefits of Self-Administration of Medication Schemes, are the subject of particular scrutiny, by virtue of the fact that they address not only the education component but also the behavioural component of a well-organised patient education programme. The review is limited to material published in English since 1980 with the exception of the literature on compliance theories, which originated in previous decades. Key search terms including medication, compliance, older people, self-medication and education were used to derive the relevant material from the Medline and CINAHL databases. The literature was then critically reviewed using the criteria identified by Roe (1993) [Roe, B., 1993. Undertaking a critical review of the literature. Nurse Researcher 1(1), 35-46.] which emphasises the need for clarity in key areas such as research design, sample selection, research methods, results, discussion and conclusions. Empirical research which met this criteria was included in the review and in the main, this was found in academic rather than professional journals. The review concludes with a summary of the main points and a discussion of the implications for nursing practice, education and research.

Developing an audit tool for primary nursing

Despite the proliferation of research on primary nursing, most studies have investigated the effects of primary nursing on quality of care, job satisfaction and collegial relationships. Few researchers have attempted to isolate the key dimensions of primary nursing in an observable and measurable form. The purpose of this exploratory study was to devise an audit tool for primary nursing that builds on Mead's research and incorporates views of patients/clients, relatives, nurses and other members of the multidisciplinary team. Preliminary findings suggest that the audit is a useful indicator of the extent to which the crucial elements of primary nursing are present or absent in any clinical setting. Furthermore it suggests that while many wards claim to practise primary nursing there is a considerable variation in the extent to which this is actually carried out.

A systematic approach to self-medication in older people

This aim of this study was to evaluate the effectiveness of an individualized education programme on older patients' knowledge of prescribed medication. A questionnaire for assessment of medication knowledge was used to collect data from 15 patients before and after an individualized education programme which lasted approximately 2 weeks. Following the collection of pre-intervention data, an individualized education programme was developed for each patient. In addition to verbal instruction, each patient was provided with written information on his/her drug regimen. As part of the education programme each patient also had an opportunity to self-administer his/her medication. The results of the study showed that all participants scored higher in the post-test than the pre-test, although the degree of improvement varied between participants. The average increase in knowledge was 26%. Patient satisfaction with the education programme was also assessed using a questionnaire. Results suggested that there was a very high level of satisfaction with the programme.

A comparative study of the attitudes of nursing and medical students to aspects of patient care and the nurse's role in organizing that care

The purpose of this study was a comparative analysis of the attitudes of nursing and medical students toward some issues relating to patient care and the role of the nurse in organizing that care. The data were collected from 11 medical students and 19 undergraduate nursing students in their fourth or final year of study. Findings suggested that there was a statistically significant difference in the attitudes of both groups of students to the areas under investigation. Medical students were rather more cure-oriented than nursing students who showed a care orientation. Further, the nursing students had a more positive attitude towards the need for a nursing assessment than their medical colleagues. Finally there was a marked difference in the way in which each group perceived the nurse's role, the nursing students emphasizing its independent scope while the medical students were less convinced on this issue. The conclusions suggest that both nursing and medical students need to develop a mutual understanding and respect for each other's roles if interprofessional relations are to improve.