A Repurposing Programme Evaluating Transdermal Oestradiol Patches for the Treatment of Prostate Cancer Within the PATCH and STAMPEDE Trials: Current Results and Adapting Trial Design

AIMS

Androgen deprivation therapy (ADT), usually achieved with luteinising hormone releasing hormone analogues (LHRHa), is central to prostate cancer management. LHRHa reduce both testosterone and oestrogen and are associated with significant long-term toxicity. Previous use of oral oestrogens as ADT was curtailed because of cardiovascular toxicity. Transdermal oestrogen (tE2) patches are a potential alternative ADT, supressing testosterone without the associated oestrogen-depletion toxicities (osteoporosis, hot flushes, metabolic abnormalities) and avoiding cardiovascular toxicity, and we here describe their evaluation in men with prostate cancer.

MATERIALS AND METHODS

The PATCH (NCT00303784) adaptive trials programme (incorporating recruitment through the STAMPEDE [NCT00268476] platform) is evaluating the safety and efficacy of tE2 patches as ADT for men with prostate cancer. An initial randomised (LHRHa versus tE2) phase II study (n = 251) with cardiovascular toxicity as the primary outcome measure has expanded into a phase III evaluation. Those with locally advanced (M0) or metastatic (M1) prostate cancer are eligible. To reflect changes in both management and prognosis, the PATCH programme is now evaluating these cohorts separately.

RESULTS

Recruitment is complete, with 1362 and 1128 in the M0 and M1 cohorts, respectively. Rates of androgen suppression with tE2 were equivalent to LHRHa, with improved metabolic parameters, quality of life and bone health indices (mean absolute change in lumbar spine bone mineral density of -3.0% for LHRHa and +7.9% for tE2 with an estimated difference between arms of 9.3% (95% confidence interval 5.3-13.4). Importantly, rates of cardiovascular events were not significantly different between the two arms and the time to first cardiovascular event did not differ between treatment groups (hazard ratio 1.11, 95% confidence interval 0.80-1.53; P = 0.54). Oncological outcomes are awaited.

FUTURE

Efficacy results for the M0 cohort (primary outcome measure metastases-free survival) are expected in the final quarter of 2023. For M1 patients (primary outcome measure - overall survival), analysis using restricted mean survival time is being explored. Allied translational work on longitudinal samples is underway.

Adapting and testing a tool to map digital health resources use by older adults in Israel and Taiwan

Background

Despite the potential of digital health tools for improving health outcomes, older adults are known to use digital health tools differently than younger adults. Focusing on needs of older populations is critical, as their numbers and proportions are projected to increase dramatically in the coming decades, both in Israel and in Taiwan. A bi-national collaboration was developed to map existing digital health resources available to older adults, as part of a larger study on digital health services use among older adults.

Methods

A mapping tool was adapted from the WHO classification of digital health interventions, based on the experience in the Taiwanese and Israeli health systems. The areas included public health, prevention, self- monitoring and self-care information and services in primary and tertiary care. The mapping documented digital resources offered by governmental/Ministry of Health, public primary care (HMOs), hospitals, and non-governmental organizations. Sources of information were institutional websites, evaluated by two specially trained reviewers for each organization who assigned a dichotomous value (yes/no) for each category. Interrater reliability was computed using a Kappa coefficient.

Results

The instrument included 17 categories and 44 sub-categories of digital resources, ranging from public health information for emergency situations to specific health service characteristics. To date, the Kappa coefficients range from 0.59-0.68 for NGO, MOH and hospital resources, considered substantial; for 3 HMOs, the values ranged from 0.41-0.49, considered moderate.

Conclusions

The mapping tool adapted to the countries’ digital resources allowed for bi-national research to compare/contrast the countries’ experience. The next stage of the study will validate the results through expert interviews, followed by an end user survey with older adults to assess both reported use of services and enabling digital health literacy skills.

Key messages

• To meet the needs of aging populations, attention needs to be given to their engagement with digital health services and resources.

• Mapping digital health resources is essential for estimating how health needs are met nationally.

Treatment-Refractory, Castration-Resistant Prostate Cancer With Liver Metastasis: A Promising Modality of Therapy

Although significant advances in the treatment of prostate cancer (PC) have recently been made, the treatment of metastatic liver disease remains challenging. Recent advances have led to multiple novel therapies and multi-treatment approaches combining systemic and locoregional modalities, such as thermal ablation, representing a promising strategy that has received attention in recent years. Nevertheless, no standard locoregional treatment regimens exist for the management of liver metastases of PC. In addition, regional therapy alone is unlikely to provide durable cancer control. Here, we report for the first time a successful treatment of hepatic metastases of PC using stereotactic image-guided percutaneous microwave ablation and the poly (ADP-ribose) polymerase-1 inhibitor, olaparib.

Allowable room temperature excursions for refrigerated medications: A 20-year review

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

The aim of this review was to build upon previous literature describing the maximum duration for which refrigerated medications can tolerate room temperature excursions while maintaining stability and potency.

METHODS

During a 12-month period ending in June 2021, the prescribing information and published monographs from multiple pharmacy compendia were reviewed for all medications and biologic products approved by the US Food and Drug Administration (FDA) for human use since January 2000. Products that were subsequently withdrawn from the US market were excluded. When temperature excursion data was unavailable in published form, product manufacturers were surveyed via telephone and/or email. Acceptable storage information for all products for which storage is recommended at temperatures below room temperature (20-25 °C [68-77 °F]) was compiled and arranged in tabular format.

RESULTS

Of the 705 products or formulations approved by FDA during the predefined time period, 246 were identified as requiring storage at temperatures below room temperature. After review of available prescribing information and manufacturer communications, if applicable, acceptable periods of excursion to temperatures at room temperature or higher were identified for 214 products (87%).

CONCLUSION

Information related to acceptable periods of room temperature excursion was compiled for a total of 214 products approved for US distribution since 2000. The included tables may increase patient safety and decrease medication loss or related expenditures.

Comprehensive genomic profiling unravels molecular targets in patients with metastatic spinal cord compression from prostate cancer

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Background: Spinal cord compression (SCC) from prostatic cancer is an oncologic emergency with significant negative impact on morbidity and survival. However, the molecular mechanisms involved in spinal metastases remains largely unclear. The aim of this study was to evaluate the histopathology, molecular profiles, and outcome in these patients. Methods: Twenty patients with magnetic resonance imaging-confirmed metastatic SCC from prostate cancer were identified at Dignity health Cancer Institute. Pathology slides were reviewed and the molecular analysis of 324 cancer-related genes was performed on tumor specimens using targeted next-generation sequencing. Characteristics including age, Gleason score, SCC anatomical site, time to diagnosis of SCC, gene alterations, number of lines of treatment and clinical outcome were analyzed. Results: At the time of diagnosis of SCC, the median age at diagnosis of SCC was 60.5 years old (range=50-76). The median PSA value was 626 ng/ml, 100% of patients have a Gleason score above 7, 30% of patients had visceral metastases. The thoracic spine affecting (15/20) patients is the most common site of SCC. Seventeen patients (75%) were initially treated with surgery combined with radiation therapy (RT), whereas 3 (15%) were managed with RT alone. At the time of this study, 11 patients remain alive (55%), median overall survival (OS) is 20 months, 18 months in treatment naive and 22 months in hormone refractory patients. Molecular analysis revealed gene mutations in all (100%) tumors, The most common gene alterations were PTEN (16%), followed by AR alterations AR (13%), TP53 (11%), TMPRSS2-ERG (8 %), BRCA1/2(4%), RB1(1%) and ATM (1%). Conclusions: Comprehensive genomic profiling revealed several molecular targets in patients with metastatic spinal cord compression from prostate cancer.[Table: see text]

Lignocaine versus opioids in coronary intervention: assessing antiplatelet activity and ticagrelor levels (LOCAL) study

Background

Opioid analgesia impairs the bioavailability and antiplatelet effect of oral P2Y12 inhibitors prompting investigation of mitigation strategies including identifying alternative analgesic agents.

Purpose

To assess the impact of intravenous fentanyl and lignocaine on the bioavailability and antiplatelet effect of ticagrelor in patients with unstable angina and non-ST elevation myocardial infarction, as well as their procedural analgesic efficacy and safety.

Methods

The LOCAL trial was a prospective, single centre, double-blind, randomized, controlled trial where intravenous lignocaine was the experimental analgesic agent assessed in this trial compared to intravenous fentanyl as procedural analgesia during coronary angiography and percutaneous coronary intervention. Patients with an indication for dual antiplatelet therapy and no contraindication were given 180mg of ticagrelor orally as integral tablets with 250 mL of tap water at the end of the case. Blood was sampled at time 0, 0.5, 1, 2 and 4 hours post administration of ticagrelor for pharmacokinetic and comprehensive pharmacodynamic analysis.

Results

Seventy patients undergoing coronary angiography with an indication for ticagrelor loading were included in the pharmacokinetic and pharmacodynamic analysis. Plasma ticagrelor levels at 2 h post loading dose were significantly lower in the fentanyl compared to lignocaine treatment arm (476 vs. 792 ng/mL, p=0.02, see figure 1). The area under the plasma-time curves for ticagrelor (987 vs. 2189 ng.h/mL, p=0.001) and its active metabolite (173 vs. 394 ng.h/mL, p<0.001) were both significantly lower in the fentanyl arm. Platelet reactivity assessed by the VerifyNow assay was higher at all time points after baseline in the fentanyl compared to lignocaine arm. The VASP flow cytometry assay demonstrated higher platelet reactivity at 2 hours in the fentanyl group (40% vs. 22% platelet reactivity index, p=0.001). The Multiplate Analyzer demonstrated higher platelet reactivity in the fentanyl arm at 60 minutes (43 vs. 26 area under the curve units, p=0.001) as did expression of activated platelet GpIIb/IIIa receptor (2829 vs. 1426 geometric mean fluorescence intensity (GMFI), p=0.006) and P-selectin (439 vs. 211 GMFI, p=0.001). High on-treatment platelet reactivity (HPR) was significantly higher in the fentanyl arm at 60 min using the MPA (41% vs. 9%, p=0.002) and 120 min using the VFN (30% vs. 3%, p=0.003) and VASP (37% vs. 6%, p=0.002) assays (see figure 2). Both drugs were well tolerated with a high level of patient satisfaction (fentanyl 94% vs. lignocaine 97%, p=0.56).

Conclusion(s)

Unlike fentanyl, lignocaine does not impair the bioavailability or delay the antiplatelet effect of ticagrelor. Both drugs were well tolerated and effective with a high level of patient satisfaction for procedural analgesia. Systemic pain medication during PCI should be reconsidered and if performed, lignocaine is a beneficial alternative to fentanyl.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): TBA Figure 1. Ticagrelor and AM pharmacokineticsFigure 2. Ticagrelor pharmacodynamics

Successful use of immunotherapy to treat advanced cutaneous squamous cell carcinoma in recessive dystrophic epidermolysis bullosa

Recessive dystrophic epidermolysis bullosa (RDEB) is a multisystem inherited disorder associated with fragile skin, blister formation and poor wound healing. Patients with RDEB are at significantly increased risk of recurrent and aggressive cutaneous squamous cell carcinoma (cSCC) and because of their disease complexity, conventional therapies may not be possible. Recent advances in cancer immunotherapy have led to the successful use of immune checkpoint inhibitors (ICIs) in melanoma and other malignancies. However, the effects of ICIs in patients with cSCC and RDEB are currently unknown. A 30-year-old woman with RDEB and multiple unresectable cSCCs was found to have high tumour mutational burden and PD-L1 (programmed cell death-ligand 1) expression. She was started on an ICI, which yielded disease control and was well tolerated. Furthermore, her RDEB wounds improved. This case demonstrates successful use of immunotherapy for advanced cSCC in RDEB, a disease that is often challenging to treat with local therapies.

Refined functional carbohydrates reduce adhesion of Salmonella and Campylobacter to poultry epithelial cells in vitro

The development of interventions to reduce human foodborne pathogens in the gastrointestinal (GI) tract of chickens will be important for improving the microbial food safety of poultry. Saccharomyces-derived prebiotic refined functional carbohydrates (RFC), composed primarily of β-glucans, mannanoligosaccharides (MOS), and D-mannose have been demonstrated to reduce GI colonization of Salmonella and Campylobacter when administered to poultry. Although they are presumed to inhibit adhesion of pathogens to the GI epithelium, this functionality of RFC has not been well characterized. In this study, we investigated the effects of RFC and other prebiotics on the adhesion of Salmonella Typhimurium and Campylobacter jejuni to the LMH chicken epithelial cell line in vitro. The reduction of adherent pathogens was observed to be dose-dependent with C. jejuni being more sensitive than Salmonella to inhibition by RFC. Comparison of the primary constituent carbohydrates of RFC found D-mannose to inhibit both pathogens less effectively than β-glucan and MOS, suggesting that it contributes less to inhibition of pathogen adhesion than the other carbohydrates. Finally, the reduction of adherent pathogens by RFC was compared with that of fructooligosaccharides (FOS), galactooligosaccharides (GOS), and raffinose. All 4 prebiotics inhibited adhesion of both pathogens to chicken epithelial cells. Reduction of adherent Salmonella was greatest with FOS and lowest with GOS, whereas reduction of adherent C. jejuni was greater with RFC and raffinose than with FOS and GOS. These results will inform future research elucidating mechanisms important to adhesion inhibition of pathogens by RFC and other prebiotics.

Administration of dietary prebiotics improves growth performance and reduces pathogen colonization in broiler chickens

Dietary prebiotics are thought to be potentially important alternatives to antibiotic growth promoters in poultry production because of their beneficial performance and health effects. The administration of dietary prebiotics has been demonstrated to improve animal health, growth performance, and microbial food safety in poultry production. In this study, we evaluated the effects of Saccharomyces- derived prebiotic refined functional carbohydrates (RFC) with yeast culture on growth performance and gastrointestinal and environmental microbiota when administered in-feed and through drinking water to broiler chickens. Broilers were administered 2 doses of prebiotic in-feed through 42 d of production and prebiotic-treated water in the final 72 h. Administration of prebiotic RFC improved ADG and decreased cecal Campylobacter counts, while the high dose also increased final BW. Additionally, significant main effects of prebiotic RFC dose were observed with the high dose improving ADG and ADFI over the finisher phase and final BW. Although the effects were not significant, the prevalence of Campylobacter in the cecum after feed withdrawal was 17% lower when broilers were administered the high prebiotic dose, and recovery of Campylobacter from litter was up to 50% lower when broilers were administered prebiotic RFC. Our results suggest that co-administration of RFC with yeast culture as a prebiotic can be used to improve growth performance and reduce human foodborne pathogens in poultry.

Targeted gene inactivation in Lactobacillus gallinarum ATCC 33199 using chromosomal integration

Although Lactobacillus species have been administered widely as probiotics in poultry production, the mechanisms responsible for their functionality are not well understood. The genetic tools available for use in lactobacilli are advanced but have not been applied widely to investigate their probiotic functionality in poultry. The genome sequence of Lactobacillus gallinarum ATCC 33199, originally isolated from the chicken crop, has recently been made available suggesting this organism as a potentially important model organism for probiotic research in poultry. In this study, we demonstrated the functionality of the pORI28 system for construction of isogenic knockout mutants in L. gallinarum ATCC 33199 using insertional inactivation of lacL as proof-of-principle. The establishment of an effective chromosomal integration system for use in L. gallinarum ATCC 33199 will provide a platform for functional genomic analyses to investigate the functionality of this model organism in the gastrointestinal tract of poultry.

Effects of direct-fed microorganisms and enzyme blend co-administration on intestinal bacteria in broilers fed diets with or without antibiotics

Direct-fed microorganisms (DFM) and exogenous enzymes have been demonstrated to improve growth performance in poultry and are potentially important alternatives to antibiotic growth promoters (AGP). We investigated the administration of a feed additive composed of a DFM product containing spores of 3 Bacillus amyloliquefaciens strains and an enzyme blend of endo-xylanase, α-amylase, and serine-protease in diets with or without sub-therapeutic antibiotics in broiler chickens over a 42-d growth period. Evaluation of growth performance determined feed efficiency of broiler chickens which were administered the feed additive was comparable to those fed a diet containing AGPs. Characterization of the gastrointestinal microbiota using culture-dependent methods determined administration of the feed additive increased counts of total Lactic Acid Bacteria (LAB) relative to a negative control and reduced Clostridium perfringens to levels similar to antibiotic administration. Additionally, greater counts of total LAB were observed to be significantly associated with reduced feed conversion ratio, whereas greater counts of C. perfringens were observed to be significantly associated with increased feed conversion ratio. Our results suggest the co-administration of DFMs and exogenous enzymes may be an important component of antibiotic free poultry production programs and LAB and C. perfringens may be important targets in the development of alternatives to AGPs in poultry production.

Development of a patient-reported outcome measure for upper limb function in Duchenne muscular dystrophy: DMD Upper Limb PROM

AIM

To develop a patient-reported outcome measure (PROM) assessing upper limb function related to activities of daily living (ADL) that cannot be observed in a clinical setting, specifically for patients with Duchenne muscular dystrophy (DMD) across a wide age range, applicable in the different stages of the disease.

METHOD

The developmental process was based on US Food and Drug Administration guidelines. This included item generation from a systematic review of existing tools and expert opinion on task difficulty and relevance, involving individuals with DMD. Cultural aspects affecting ADL were taken into consideration to make this tool applicable to the broad DMD community. Items were selected in relation to a conceptual framework reflecting disease progression covering the full range of upper limb function across different ADL domains.

RESULTS

After pilot testing and iterative Rasch analyses, redundant or clinically irrelevant items were removed. The final questionnaire consists of 32 items covering four domains of ADL (food, self-care, household and environment, leisure and communication). Test-retest reliability was excellent.

INTERPRETATION

A DMD-specific upper limb PROM was developed on the basis of clinical relevance and psychometric robustness. Its main purpose is to document the patient self-reported natural history of DMD and assess the efficacy of interventions.

Phototheranostic nanoplatform based on a single cyanine dye for image-guided combinatorial phototherapy

This study represents a novel phototheranostic nanoplatform based on the near-infrared (NIR) heptamethine cyanine dye, IR775, which is capable of concurrent real-time fluorescence imaging and cancer eradication with combinatorial phototherapy. To achieve water solubility and enhance tumor delivery, the hydrophobic IR775 dye was loaded into a biocompatible polymeric nanoparticle with a diameter of ~40nm and slightly negative surface charge (-2.34mV). The nanoparticle-encapsulated hydrophobic IR775 dye (IR775-NP) is characterized by an enhanced fluorescence quantum yield (16%) when compared to the water soluble analogs such as ICG (2.7%) and IR783 (8%). Furthermore, the developed IR-775-NP efficiently generates both heat and reactive oxygen species under NIR light irradiation, eradicating cancer cells in vitro. Finally, animal studies revealed that the IR775-NP accumulates in cancer tumors after systemic administration, efficiently delineates them with NIR fluorescence signal and completely eradicates chemo resistant cancer tissue after a single dose of combinatorial phototherapy.

Dendrimer-encapsulated naphthalocyanine as a single agent-based theranostic nanoplatform for near-infrared fluorescence imaging and combinatorial anticancer phototherapy

Multifunctional theranostic platforms capable of concurrent near-infrared (NIR) fluorescence imaging and phototherapies are strongly desired for cancer diagnosis and treatment. However, the integration of separate imaging and therapeutic components into nanocarriers results in complex theranostic systems with limited translational potential. A single agent-based theranostic nanoplatform, therefore, was developed for concurrent NIR fluorescence imaging and combinatorial phototherapy with dual photodynamic (PDT) and photothermal (PTT) therapeutic mechanisms. The transformation of a substituted silicon naphthalocyanine (SiNc) into a biocompatible nanoplatform (SiNc-NP) was achieved by SiNc encapsulation into the hydrophobic interior of a generation 5 polypropylenimine dendrimer following surface modification with polyethylene glycol. Encapsulation provides aqueous solubility to SiNc and preserves its NIR fluorescence, PDT and PTT properties. Moreover, an impressive photostability in the dendrimer-encapsulated SiNc has been detected. Under NIR irradiation (785 nm, 1.3 W cm(-2)), SiNc-NP manifested robust heat generation capability (ΔT = 40 °C) and efficiently produced reactive oxygen species essential for PTT and PDT, respectively, without releasing SiNc from the nanopaltform. By varying the laser power density from 0.3 W cm(-2) to 1.3 W cm(-2) the therapeutic mechanism of SiNc-NP could be switched from PDT to combinatorial PDT-PTT treatment. In vitro and in vivo studies confirmed that phototherapy mediated by SiNc can efficiently destroy chemotherapy resistant ovarian cancer cells. Remarkably, solid tumors treated with a single dose of SiNc-NP combined with NIR irradiation were completely eradicated without cancer recurrence. Finally, the efficiency of SiNc-NP as an NIR imaging agent was confirmed by recording the strong fluorescence signal in the tumor, which was not photobleached during the phototherapeutic procedure.