P11.65.B GBM AGILE: A global, phase 2/3 adaptive platform trial to evaluate multiple treatment regimens in newly diagnosed and recurrent glioblastoma

Background

GBM AGILE (Glioblastoma Adaptive, Global, Innovative Learning Environment) is a biomarker based, multi-arm, international, seamless Phase 2/3 Response Adaptive Randomization platform trial designed to rapidly identify experimental therapies that improve overall survival and confirm efficacious experimental therapies and associated biomarker signatures to support new drug approvals and registration. It is a collaboration between academic investigators, patient organizations and industry, under the sponsorship of the non-profit organization, Global Coalition for Adaptive Research, to support new drug applications for newly diagnosed and recurrent GBM.

Material and Methods

The primary objective of GBM AGILE is to identify therapies that effectively improve overall survival in patients with newly diagnosed or recurrent GBM. Bayesian response adaptive randomization is used within subtypes of the disease to assign participants to investigational arms based on their performance. Operating under a master protocol, GBM AGILE allows multiple drugs from different pharmaceutical companies to be evaluated simultaneously and/or over time against a common control arm. Based on performance, a drug may graduate and move to a Stage 2 (Phase 3) within the trial, and the totality of the data can be used for a new drug application and registration process. New experimental therapies are added as information about promising new drugs is identified while other therapies are removed as they complete their evaluation. The master protocol/ trial infrastructure includes efficiencies through an adaptive trial design, shared control arm and operational processes such as risk-based monitoring and enhanced remote activities. With its adaptable structure, GBM AGILE has continued trial activation, inclusion of new investigational therapies, and enrollment globally through the challenges of a global pandemic.GBM AGILE provides an efficient mechanism to screen and develop robust information regarding the efficacy of proposed novel therapeutics and associated biomarkers for GBM and to quickly move therapies and biomarkers into clinic. GBM AGILE received initial approval from the United States FDA in April 2019, and in Europe through the Voluntary Harmonization Procedure (VHP) in April, 2021. As of 2022, AGILE has screened over 1000 patients studying multiple investigational treatments. Enrollment rates are 3 to 4 times greater than traditional GBM trials, with active sites averaging 0.75 to 1 patients/site/month.

Currently, there are 41 sites activated in the US, 4 in Canada and 2 in Switzerland and an estimated 24 sites yet to open in Germany, France, Switzerland, Italy and Austria. In addition to the continued expansion in Europe, effort is undergoing to extend the trial to China and Australia as well. Clinical trial information: NCT03970447

6 Improving Patient Flow in a Multi-Specialty Assessment Area by Introducing Referral Pathways for Orthopaedics and Plastic Surgery during the COVID-19 Pandemic

Introduction

The COVID-19 pandemic has seen fundamental organisational changes to emergency departments internationally. Specialties throughout the hospital setting have been asked to change their working practice, often with the aim of adapting to new processes in emergency departments. Early in the pandemic, the orthopaedic team at one district general hospital were required to provide 24/7 onsite cover in a multi-specialty area. Confusion over the referral pathways of two specialties (orthopaedics and plastic surgery) led to increase waiting times, constrained patient flow and poor patient and staff satisfaction.

Method

This quality improvement project occurred over three cycles of data collection and intervention over a two-month period. A novel referral pathway was developed and implemented after discussion with consultants in orthopaedics, plastics, and emergency medicine. Interventions included staff teaching, clarifying of roles at morning meetings and the deployment of posters.

Results

In cycle 1, 39% of orthopaedic referrals were inappropriately referred. By cycle 3, 0% of orthopaedic patients were inappropriately referred. Average time in department for patients referred to orthopaedics improved from 124 minutes to 88 minutes. Staff reported increased satisfaction, with appreciation for the clarification on referral criteria.

Conclusions

This QUIP demonstrates how simple interventions during times of crisis can solve complex organisational issues.

Match loads of university rugby union players between the 2016 and 2018 Varsity Cup competitions

Background

Rugby union is a popular and continuously growing sport globally. With the advance of technology, practices have been implemented to quantify the match running demands of rugby union players. The aim of this study was to analyse the match loads of rugby union players between the 2016 and 2018 Varsity Cup competitions.

Methods

The sample consisted of 562 match observations of male university rugby union players competing in the Varsity Cup tournaments.

Results

The backline players ran significantly longer total distances (5105 m; p = 0.001; ES = 0.49); have greater high-speed running (496 m; p = 0.001; ES = 1.03), very high-speed running (260 m; p = 0.001; ES = 1.50) and sprint distances (117 m; p = 0.001; ES = 1.32) than forward players. Backline players also accumulated a high number of metres per minute (238 ± 94; p = 0.001; ES = 0.46), total Player Load (488 ± 203; p = 0.001; ES = 0.31), RHIE (9 ± 8; p = 0.001; ES = 0.75) and number of accelerations (4 ± 5; p = 0.001; ES = 0.49).

Conclusion

These findings may assist coaches to develop player position specific training programmes to meet the physical demands of rugby.

Efficacy of a social support and problem-solving intervention on heart failure self-care: A pilot study

OBJECTIVE

The purpose of this study was to examine the preliminary effects of a coping partnership intervention comprised of social support and problem-solving on HF self-care maintenance, management, and confidence.

METHODS

A 3-group randomized controlled pilot study was conducted. The intervention group received 1 home visit, weekly (month 1), and biweekly (months 2 and 3) telephone calls. The attention group received telephone calls starting at week 2, following a similar pattern. The control group received usual care only. The Self-care of Heart Failure Index, was administered at baseline, 5, 9, and 13 weeks. Linear mixed modeling examined intervention effect on study outcomes.

RESULTS

A total of 66 participants completed the study. The participants were mean age 61 years; 54.2% male; 56% Non-Caucasian; and 43.9% New York Heart Association HF Class II. Significant treatment-by-time interaction effects were noted for self-care maintenance (F=4.813; p=0.010) and self-care confidence (F=4.469; p=0.014). There was no significant treatment-by-time interaction effect on self-care management.

CONCLUSIONS

Coping partnership interventions that strengthen support and social problem- solving may improve self-care maintenance and confidence in individuals with HF.

PRACTICE IMPLICATIONS

Clinicians should consider including these components in HF patient education and clinical follow-up.

Validation of an In-Mold Multivariate Sensor for Measurement of Melt Temperature, Pressure, Velocity, and Viscosity

A multivariate sensor (MVS) is described for measurement of melt temperature, melt pressure, melt velocity, and melt viscosity. Melt pressure and temperature are respectively obtained through the incorporation of a piezo-ceramic element and infrared thermopile. Melt velocity is derived from the initial response of the melt temperature as the polymer melt flows across the sensor lens. The apparent melt viscosity is then derived based on the melt velocity and the time derivative of the increasing melt pressure. The response of the MVS is analyzed using an instrumented mold including piezoelectric pressure sensors, an infrared pyrometer, and thermocouples. A 12-run, blocked half-fractional design of experiments (DOE) was run to characterize the effect of melt temperature, mold temperature, packing pressure, and ram velocity. The results show that the MVS provides excellent measurement of melt temperature and pressure. The accuracy of the melt velocity estimations depended on the ram velocity set-point, yielding a coefficient of determination of 0.91 for the lower ram velocities, and reaching saturation for melt velocities about 450 mm/s. The apparent melt viscosity estimated by the MVS are close to those predicted by the Cross-WLF model, exhibiting appropriate shear thinning but behavior but inconsistent temperature dependence.

Chemically Induced Hepatocellular Proliferative Changes in the Rat Without Evidence of Neoplastic Transformation,

The hypothesis that hepatocellular proliferative changes give rise to autonomous, neoplastic lesions in rodents was tested in this study in which hepatoproliferative lesions induced in rats by feeding an experimental psychoactive drug, cyproximide, were examined at various times during the course of a 24 month study. A total of 610 male and female rats (Charles River Laboratories COBS®CD®(SD)BR, Wilmington, Mass.) were distributed into three groups. Each of two treatment groups contained 230 rats given 0.1% or 0.4% of cyproximide in the diet. One hundred and fifty rats were given a drug-free diet and served as controls. Five males and five females from each group were sacrificed for postmortem examination after 6, 12 and 20 months of drug diet feeding after which remaining rats were retained for recovery (nontreatment) periods of 18, 12 and 4 months, respectively. An additional 25 males and 25 females from each dose level were treated for 24 months and then sacrificed along with all surviving recovery and control rats. The results of this study demonstrated that the incidence of proliferative lesions was greater in the liver of treated rats (especially females) than in control rats; however, the incidence of hepatocellular neoplasms was the same in treated and control rats.

Multivariate analysis of the correlation between noctuidae subfamilies and the chemical structure of their sex pheromones or male attractants

Female-emitted pheromones and sex attractants of Noctuidae were investigated using a specific computer procedure to analyze data collected from the literature. Correspondence analysis was used to survey the structure-activity relationships of sex pheromones in seven subfamilies. Structural, stereochemical, and functional features of active molecules were related to taxonomy. This multidimensional analysis revealed that the prevalent chemical frame of noctuid moth pheromones was a monounsaturated acetate withZ stereochemistry and a double bond on the fifth carbon closest to the nonfunctional branch of the molecule. Possible phylogenetic relationships within Noctuidae and between Noctuidae and other families are discussed in light of the sex pheromone biochemistry. Female sex pheromones appeared to be an additional character to be considered in the classification of noctuid moths.

A randomized, phase II study of ATN-224 in patients with biochemically relapsed, hormone-naive prostate cancer: A DOD/PCF Prostate Cancer Clinical Trials Consortium trial

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Background: ATN-224 (choline tetrathiomolybdate) is an orally active, small molecule that has antiangiogenic and antitumor effects in prostate cancer (PCa) models. ATN-224 targets Cu2+/Zn2+superoxide dismutase 1 (SOD1) and suppress the generation of H2O2 leading to activation of a number of phosphatases, a group of negative growth regulatory enzymes. We hypothesized that ATN-224 may induce antitumor effect as an antiangiogenic (at 30 mg dose level) and possesses direct antitumor activity at higher dose (300 mg/day). Methods: PCa pts with PSA doubling time (PSADT) of < 12 months, no radiographic evidence of metastasis, no hormonal therapy within 6 months were enrolled. All pts had testosterone > 150 ng/dL at baseline. ATN-224 was administered at 2 dose levels. PSA progression was defined as at least a 50% increase in PSA and >5 ng/mL increase from baseline or post-treatment nadir and confirmed. Endpoints included the proportion of pts who did not have PSA progression for 24 weeks, change in PSA slope/PSADT, and assessment of safety and tolerability. The study was not powered to detect difference between the two groups. Results: 52 pts were enrolled at 6 centers. Fourteen of 27 (52%) in the low dose and 6/25 (24%) in the high dose cohort were PSA progression free for 24 weeks. One patient in high dose cohort showed PSA >50% decrease of 40 days duration. Pre- and on-treatment PSA kinetics are shown below. Median duration on study was 134 days in both groups. ATN-224 was well tolerated with a few reversible Grade 3/4 neutropenia and Grade 3 skin rash (both 4%). Conclusions: ATN-224 may have biologic activity in men with androgen-dependent PCa at low doses, as demonstrated by > 50% of pts being PSA progression free at 6 month and a significant decrease in mean PSA slope. The implication of this study is not clear without a comparative design and ceruloplasmin correlation which is still pending.

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Conservation status and biogeography of Australia's terrestrial mammals

This paper attempts to identify and explain patterns in the biogeography of Australia’s indigenous terrestrial mammals at the time of European settlement (before modern extinctions), and also compares species’ pre-European and current status by region. From subfossil, historical and contemporary sources, we compiled data on the past geographic range and present status of mammals for Australia’s 85 biogeographic regions. Of the 305 indigenous species originally present, 91 have disappeared from at least half of the bioregions in which they occurred before European settlement. Thirty-nine extant species ‘persist’ in less than 25% of their original bioregions; 28 of these are marsupials and 11 are rodents. Twenty-two of the original 305 species are extinct, a further eight became restricted to continental islands, and 100 have become extinct in at least one bioregion. Over the same period, 26 species of exotic mammals established wild populations and now occupy from one to 85 bioregions. When we classified the bioregions in terms of their original species composition, the 3-group level in the dendrogram approximated the Torresian, Eyrean and Bassian subregions proposed by Spencer in 1898, while the 4-group level separated southern semiarid Eyrean bioregions, including those in south-west Australia, from the arid Eyrean bioregions. The classification dendrogram showed geographically (and statistically) discrete clustering down to the 19-group level, suggesting that all four subregions can be further divided on the basis of their mammal faunas. Variation partitioning showed 66% of the biogeographical pattern can be explained by environmental factors (related to temperature and precipitation), the spatial position of each bioregion (a third-order polynomial of latitude and longitude), the area of each bioregion, and the richness of species in each bioregion. In addition to the marked distributional changes that indigenous mammals have experienced over the last 200 years, the 49% of variation explainable by temperature and precipitation implies further shifts with global climate change.

Anytime Point-Based Approximations for Large POMDPs

The Partially Observable Markov Decision Process has long been recognized as a rich framework for real-world planning and control problems, especially in robotics. However exact solutions in this framework are typically computationally intractable for all but the smallest problems. A well-known technique for speeding up POMDP solving involves performing value backups at specific belief points, rather than over the entire belief simplex. The efficiency of this approach, however, depends greatly on the selection of points. This paper presents a set of novel techniques for selecting informative belief points which work well in practice. The point selection procedure is combined with point-based value backups to form an effective anytime POMDP algorithm called Point-Based Value Iteration (PBVI). The first aim of this paper is to introduce this algorithm and present a theoretical analysis justifying the choice of belief selection technique. The second aim of this paper is to provide a thorough empirical comparison between PBVI and other state-of-the-art POMDP methods, in particular the Perseus algorithm, in an effort to highlight their similarities and differences. Evaluation is performed using both standard POMDP domains and realistic robotic tasks.

Preventing multipartite disentanglement by local modulations

An entangled multipartite system coupled to a zero-temperature bath undergoes rapid disentanglement in many realistic scenarios due to local, symmetry-breaking differences in the particle-bath couplings. We show that locally controlled perturbations, addressing each particle individually, can impose a symmetry allowing the existence of decoherence-free multipartite entangled systems.

Flexible monitoring in the management of patient care processes: one year after the pilot study

A pilot study at a large metropolitan hospital in Auckland identified a specific group of patients that can be safely monitored outside the Coronary Care Unit using Flexible Monitoring technology. This article describes the project management processes used to further develop the remote monitoring system into a hospital network of remote monitoring. The educational and staff support resources required throughout the project are described as are the strategies adopted to meet those needs including the utilization of online learning. Outcomes from the introduction of the system include improved electrokardiogram interpretation by nursing staff and improved ECG resource allocation.

Monitoring change in the vertebrate fauna of central Queensland, Australia, over a period of broad-scale vegetation clearance, 1973—2002

This study reports change in the bird, mammal and amphibian fauna of the Emerald district, central Queensland, as detected from comparison of an inventory study undertaken in 1973–76, with a resurvey undertaken in 2001–02. Over this period, the region was subjected to unusually high rates of vegetation clearance, with the extent of native vegetation declining from 87% to 41%. In Australia, and elsewhere, there are remarkably few such long-term longitudinal studies, and particularly so for those that sample the same sites using identical procedures, and for those undertaken in a region of such dramatic environmental change. The ability to detect change from this dataset is constrained by the relatively small number of survey sites (24–45 survey sites, depending upon the taxonomic group considered). The interpretation of change is also affected by very different climatic conditions between the baseline and resurvey. Higher rainfall in the baseline survey period contributed to the most evident change, a major reduction in the number of waterbirds. However, even with waterbirds excluded, there was a significant change in the bird assemblage across the set of survey sites between the two periods. There were significant increases for a number of typically grassland birds (e.g. red-backed fairy-wren (Malurus melanocephalus), brown quail (Coturnix ypsilophora)) and significant decreases for a range of typically forest or woodland birds (e.g. grey shrike-thrush (Colluricincla harmonica), spiny-cheeked honeyeater (Acanthagenys rufogularis), striped honeyeater (Plectorhyncha lanceolata), grey fantail (Rhipidura fuliginosa)). These changes were largely maintained even when the dataset was restricted to only those sites that remained uncleared: that is, changes were evident not only across the changing landscape as a whole but there were also significant (consequential) changes at uncleared sites. Most of the native mammal species that were recorded sufficiently often to test for change showed a pattern of decline. Again, for some species (pale field-rat (Rattus tunneyi), greater glider (Petauroides volans) and eastern grey kangaroo (Macropus giganteus)), this decline occurred even within uncleared woodland sites. The most notable change in the frog fauna was the major increase in the exotic cane toad (Bufo marinus), but there were also significant declines for two native frog species. These results suggest a general trajectory of decline in distinctive woodland species, and their broad-scale replacement by more commensal species (weedy generalists favoured by human modification of the landscape).

Finding Approximate POMDP solutions Through Belief Compression

Standard value function approaches to finding policies for Partially Observable Markov Decision Processes (POMDPs) are generally considered to be intractable for large models. The intractability of these algorithms is to a large extent a consequence of computing an exact, optimal policy over the entire belief space. However, in real-world POMDP problems, computing the optimal policy for the full belief space is often unnecessary for good control even for problems with complicated policy classes. The beliefs experienced by the controller often lie near a structured, low-dimensional subspace embedded in the high-dimensional belief space. Finding a good approximation to the optimal value function for only this subspace can be much easier than computing the full value function. We introduce a new method for solving large-scale POMDPs by reducing the dimensionality of the belief space. We use Exponential family Principal Components Analysis (Collins, Dasgupta & Schapire, 2002) to represent sparse, high-dimensional belief spaces using small sets of learned features of the belief state. We then plan only in terms of the low-dimensional belief features. By planning in this low-dimensional space, we can find policies for POMDP models that are orders of magnitude larger than models that can be handled by conventional techniques. We demonstrate the use of this algorithm on a synthetic problem and on mobile robot navigation tasks.

Chemoprevention for Barrett's esophagus trial. Design and outcome measures

Barrett's esophagus is a premalignant condition in which normal squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium. It is a known risk factor for the development of esophageal adenocarcinoma. With the incidence of esophageal adenocarcinoma rising, it is reasonable to study Barrett's esophagus as a potential target for therapy that may prevent, delay and/or reverse ongoing tumorigenic processes. Epidemiologic and animal studies support the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the chemoprevention of several cancers, including esophageal cancer. Cyclo-oxygenase-2 (COX-2) inhibitors are a new class of NSAIDs that inhibit prostaglandin synthesis by selectively blocking the COX-2 enzyme. The COX-2 enzyme has been reported to be over-expressed in premalignant and malignant states, including in Barrett's esophagus and esophageal adenocarcinoma. The Chemoprevention for Barrett's Esophagus Trial (CBET) is a phase IIb, multicenter, randomized, double-masked, placebo-controlled study of the selective COX-2 inhibitor, celecoxib, in patients with Barrett's dysplasia. The sample size is 200 patients with high or low grade Barrett's dysplasia. Celecoxib is administered orally, 200 mg twice per day; the dosing schedule for placebo is the same. Randomization is stratified by dysplasia grade and by clinic. Endoscopy with biopsies is performed at specified time intervals according to the highest grade of dysplasia determined at randomization. The primary outcome measure is the change from baseline to 1 year in the proportion of biopsies exhibiting dysplasia. Secondary outcomes include change from baseline in the maximal grade, extent and surface area of dysplasia. Tertiary outcomes will include measurements of various relevant biomarkers.

The spontaneous remission of juvenile idiopathic arthritis is characterized by CD30+ T cells directed to human heat-shock protein 60 capable of producing the regulatory cytokine interleukin-10

OBJECTIVE

To test the hypothesis that T cell reactivity to self heat-shock protein 60 (Hsp60) in patients with remitting juvenile idiopathic arthritis (JIA) is part of an antiinflammatory, regulatory mechanism.

METHODS

Using peripheral blood-derived mononuclear cells (PBMCs) and synovial fluid-derived mononuclear cells (SFMCs) obtained from patients with JIA, we analyzed the expression of CD30 and the induction of regulatory cytokines in response to human and mycobacterial Hsp60.

RESULTS

In oligoarticular JIA patients, in vitro activation of PBMCs and SFMCs with Hsp60 induced a high expression of CD30 on CD4+, activated (HLA-DR-positive), memory (CD45RO+) T cells. The expression of CD30 induced by human Hsp60 was much higher than that induced by mycobacterial Hsp60. In oligoarticular JIA patients with active disease, the expression of CD30 in response to human Hsp60 was paralleled by a high interleukin-10 (IL-10):interferon-gamma (IFNgamma) ratio. In addition, restimulated human Hsp60-specific T cell lines from oligoarticular JIA patients showed a high production of IL-10 and a low production of IFNgamma. In contrast, PBMCs and SFMCs from polyarticular JIA patients responded to human Hsp60 with virtually no expression of CD30 and a low IL-10:IFNgamma ratio.

CONCLUSION

The results show that T cells responding to human Hsp60 in oligoarticular JIA patients express CD30, and during active phases of the disease, these T cells have a cytokine profile with a high IL-10:IFNgamma ratio. These findings suggest that in oligoarticular JIA patients, human Hsp60-specific CD4+ cells have a regulatory function and contribute to disease remission.

Cytomegalovirus and cyclosporin-induced gingival overgrowth in children with liver grafts

OBJECTIVE

To determine whether cytomegalovirus (CMV) is associated with gingival overgrowth in paediatric liver graft recipients treated with cyclosporin.

STUDY DESIGN

Thirty-four children, 25 of whom were under 5 years of age, who had undergone liver transplantation, were examined. An Index of Severity of Gingival Overgrowth was used to measure the prevalence and severity of the gingival overgrowth. The trough cyclosporin level was recorded and the CMV status of the patient matched to the dental findings. The association between the severity of gingival overgrowth and CMV infection was examined using the contingency coefficient. An anova was used to assess the association between the circulating trough cyclosporin concentration and the severity of gingival overgrowth. Pearson's Product Moment Correlation Coefficient was used to examine the association between the duration of exposure to cyclosporin and the severity of gingival overgrowth.

RESULTS

There was a significant inverse association between the duration of exposure to cyclosporin and the severity of gingival overgrowth. There was no relationship between the trough cyclosporin concentration and the severity of gingival overgrowth. There was no association between CMV and gingival overgrowth.

CONCLUSION

Gingival overgrowth was related to the duration of cyclosporin therapy but was neither more prevalent nor more severe in subjects who were CMV seropositive.

Kinetics and mechanism of catalytic decomposition and oxidation of chlorine dioxide by the hypochlorite ion

The oxidation of ClO(2) by OCl(-)is first order with respect to both reactants in the neutral to alkaline pH range: -d[ClO(2)]/dt = 2k(OCl)[ClO(2)][OCl(-)]. The rate constant (T = 298 K, mu = 1.0 M NaClO(4)) and activation parameters are k(OCl) = 0.91 +/- 0.02 M(-1) s(-1), DeltaH = 66.5 +/- 0.9 kJ/mol, and DeltaS(++) = -22.3 +/- 2.9 J/(mol K). In alkaline solution, pH > 9, the primary products of the reaction are the chlorite and chlorate ions and consumption of the hypochlorite ion is not observed. The hypochlorite ion is consumed in increasing amounts, and the production of the chlorite ion ceases when the pH is decreased. The stoichiometry is kinetically controlled, and the reactants/products ratios are determined by the relative rates of the production and consumption of the chlorite ion in the ClO(2)/OCl(-) and HOCl/ClO(2)(-) reactions, respectively.

Flexible monitoring in the management of patient care processes: a pilot study

This article describes a study conducted on the internal medicine, general surgical, and vascular wards of a large metropolitan hospital to assess the impact of a networked monitoring system and portable patient monitors. This pilot study was developed to address the need of hospital patients who require continuous noninvasive vital signs monitoring (including heart rate, noninvasive blood pressure, pulse oximetry, cardiac waveform monitoring) with the addition of surveillance from a cardiac intensive care area. Data were collected from 114 patients over a 3-month period to identify a patient group that could be managed appropriately under the new system and to determine the effect that flexible monitoring had on patient care management. Findings include identification of a specific patient group that can be managed successfully outside the cardiac intensive care area using this system. Other findings suggest a way to improve the management of patient monitoring in the general ward areas.