Baseline neutrophil-to-lymphocyte ratio as a predictive and prognostic biomarker in patients with metastatic castration-resistant prostate cancer treated with cabazitaxel versus abiraterone or enzalutamide in the CARD study

Background

There is growing evidence that a high neutrophil-to-lymphocyte ratio (NLR) is associated with poor overall survival (OS) for patients with metastatic castration-resistant prostate cancer (mCRPC). In the CARD study (NCT02485691), cabazitaxel significantly improved radiographic progression-free survival (rPFS) and OS versus abiraterone or enzalutamide in patients with mCRPC previously treated with docetaxel and the alternative androgen-receptor-targeted agent (ARTA). Here, we investigated NLR as a biomarker.

Patients and methods

CARD was a multicenter, open-label study that randomized patients with mCRPC to receive cabazitaxel (25 mg/m² every 3 weeks) versus abiraterone (1000 mg/day) or enzalutamide (160 mg/day). The relationships between baseline NLR [< versus ≥ median (3.38)] and rPFS, OS, time to prostate-specific antigen progression, and prostate-specific antigen response to cabazitaxel versus ARTA were evaluated using Kaplan–Meier estimates. Multivariable Cox regression with stepwise selection of covariates was used to investigate the prognostic association between baseline NLR and OS.

Results

The rPFS benefit with cabazitaxel versus ARTA was particularly marked in patients with high NLR {8.5 versus 2.8 months, respectively; hazard ratio (HR) 0.43 [95% confidence interval (CI) 0.27-0.67]; P < 0.0001}, compared with low NLR [7.5 versus 5.1 months, respectively; HR 0.69 (95% CI 0.45-1.06); P = 0.0860]. Higher NLR (continuous covariate, per 1 unit increase) independently associated with poor OS [HR 1.05 (95% CI 1.02-1.08); P = 0.0003]. For cabazitaxel, there was no OS difference between patients with high versus low NLR (15.3 versus 12.9 months, respectively; P = 0.7465). Patients receiving an ARTA with high NLR, however, had a worse OS versus those with low NLR (9.5 versus 13.3 months, respectively; P = 0.0608).

Conclusions

High baseline NLR predicts poor outcomes with an ARTA in patients with mCRPC previously treated with docetaxel and the alternative ARTA. Conversely, the activity of cabazitaxel is retained irrespective of NLR.

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Baseline NLR was evaluated as a biomarker in patients with mCRPC treated with cabazitaxel versus abiraterone or enzalutamide.

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High baseline NLR predicted poor outcomes with abiraterone or enzalutamide in patients with mCRPC.

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Clinical benefit from cabazitaxel was retained in higher baseline NLR patients.

Estimated GFR for Living Kidney Donor Evaluation

All living kidney donor candidates undergo evaluation of GFR. Guidelines recommend measured GFR (mGFR), using either an endogenous filtration marker or creatinine clearance, rather than estimated GFR (eGFR), but measurement methods are difficult, time consuming and costly. We investigated whether GFR estimated from serum creatinine (eGFRcr) with or without sequential cystatin C is sufficiently accurate to identify donor candidates with high probability that mGFR is above or below thresholds for clinical decision making. We combined the pretest probability for mGFR thresholds <60, <70, ≥80, and ≥90 mL/min per 1.73 m(2) based on demographic characteristics (from the National Health and Nutrition Examination Survey) with test performance of eGFR (categorical likelihood ratios from the Chronic Kidney Disease Epidemiology Collaboration) to compute posttest probabilities. Using data from the Scientific Registry of Transplant Recipients, 53% of recent living donors had predonation eGFRcr high enough to ensure ≥95% probability that predonation mGFR was ≥90 mL/min per 1.73 m(2) , suggesting that mGFR may not be necessary in a large proportion of donor candidates. We developed a Web-based application to compute the probability, based on eGFR, that mGFR for a donor candidate is above or below a range of thresholds useful in living donor evaluation and selection.

Prognostic impact of bone marrow CD138 immunohistochemistry (IHC) prior to autologous stem cell transplant (ASCT) for multiple myeloma (MM)

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Background: Low bone marrow plasma cell (BMPC) burden prior to ASCT for MM is associated with favorable outcomes, but is usually determined by morphologic evaluation of marrow aspirates, a method subject to variability in sampling and interpretation. It is unknown if CD138 IHC, a more sensitive measure of BMPC, predicts progression-free survival (PFS), overall survival (OS) or post-ASCT response. Methods: Consecutive patients (n=93) who underwent single ASCT for MM from 2001 to 2008 and had available, stainable bone marrow core biopsies (BMB) obtained <90 days prior to ASCT were included in this single-center retrospective cohort study. BMB and/or clot CD138 IHC staining were reviewed by blinded hematopathologists. Post-ASCT response, PFS, and OS were determined using the International Myeloma Working Group uniform response criteria. Results: Patients were highly cytoreduced prior to ASCT, with 50.5% of pts having 0–5%, 21.5% having 6–10%, 20.4% having 11–20%, and 7.5% having >20% BMPC by CD138 analysis. BMPC% by CD138 IHC correlated with aspirate BMPC% [Pearson correlation coefficient=0.48, 95%CI (0.30, 0.63)]. In 12.6% of patients, BMPC% by CD138 IHC was ≥10% more than the aspirate count. Patients with ≤5% BMPC were more likely to achieve or maintain a CR or VGPR at initial post-ASCT restaging than those with >5% BMPC: Odds Ratio (95% CI) 6.91 (2.12, 22.57), p=. 0005 (chi-squared). With median follow up of 15.4 months for the ≤5% BMPC group and 19.3 months for the >5% BMPC group, 34/93 patients have progressed or died, with no difference between groups. By Kaplan-Meier analysis, PFS was similar regardless of BMPC [3 year estimated PFS (95%CI): ≤5%BMPC, 49.9% (29.4, 70.4) vs. >5%BMPC, 45.5% (26.7, 64.3); HR=1.24 (0.62, 2.49), p=.55, log-rank]. There was no difference in OS [3 year estimated OS (95%CI): ≤5%BMPC, 71.0% (49.7, 92.3) vs. >5%BMPC, 81.8% (66.2, 97.4); HR=0.61 (0.21, 1.78), p=.36, log-rank]. Conclusions: Detection of ≤5% BMPC by CD138 IHC prior to ASCT predicts attainment or maintenance of post-transplant CR/VGPR and correlates with plasma cell morphology. Differences in PFS or OS may emerge with additional follow-up, or if more patients with a higher content of residual plasma cells were transplanted.

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K2(NbO)2Si4O12: a new ferroelectric

The atomic coordinates of K2(NbO)2Si4O12reported in space groupP4bmsatisfy the structural criteria for ferroelectricity. The estimated phase-transition temperature,Tc= 2230 (250) K, is substantially in excess ofTmelting= 1476 (5) K; the hypothetical paraelectric phase in space groupP4/mbmis hence experimentally inaccessible. A strong indication that the phase transition does not occur atT<Tmeltingis provided by the absence of both calorimetric and dielectric permittivity anomalies belowTmelting, the linear thermal dependence of unit-cell parameters with expansion coefficients α11= –0.53 (12) × 10–6and α33= 24.66 (11) × 10–6 K–1between 5 and 843 K, and the generation of second harmonics between 300 and 1353 K. Demonstration of dielectric hysteresis under both direct and alternating current, with spontaneous polarizationPs≃ 0.2 C m–2, provides unambiguous verification of the ferroelectric property.

An audit of prostate-specific antigen and clinical symptoms in general practice

The objective was to devise local guidelines for the referral of patients with suspected prostatic carcinoma following evaluation by a retrospective audit of the value of the prostate-specific antigen concentration, together with age, urological symptoms, and digital rectal examination in the diagnosis of carcinoma of the prostate. Relevant details were collected from the notes of 582 patients from general practice and hospital. The significant diagnostic factors were ascertained by stepwise logistic regression. Prostate-specific antigen concentration, digital rectal examination and significant terminal dribbling were the most powerful factors in the diagnosis of carcinoma of the prostate. When prostate-specific antigen concentration was considered in isolation, a value of 6.5 ng/ml appeared appropriate for referral. Age was not significant, perhaps due to the narrow patient age range. The significant diagnostic factors were built into an algorithm calculating the probability of carcinoma of the prostate. This algorithm, together with prostate-specific antigen concentration results and digital rectal examination findings, forms the basis of the referral guidelines and a subsequent prospective study.

Ba6CoNb9O30 and Ba6FeNb9O30: Two New Tungsten-Bronze-Type Ferroelectrics. Centrosymmetry of Ba5.2K0.8U2.4Nb7.6O30 at 300 K

Ba6CoNb9O30 and Ba6FeNb9O30 in space group P4bm are shown to satisfy the structural criteria for ferroelectricity. Ba6CoNb9O30 undergoes a diffuse phase transition at 660 (11) K, as observed calorimetrically, in addition to a dielectric permittivity anomaly with an onset temperature of 685 (10) K. The demonstration of dielectric hysteresis at room temperature under the application of a varied DC field reaching a maximum of ± 300 kV m−1, corresponding to a spontaneous polarization of 1.2 (5) × 10−2C m−2, provides unambiguous verification that it is a new ferroelectric. Ba6FeNb9O30 also undergoes a diffuse phase transition at 605 (16) K, with a dielectric anomaly at 583 (5) K, and exhibits dielectric hysteresis at room temperature under a varied DC field ranging to ± 310 kV m−1 corresponding to a spontaneous polarization of 2.2(5) × 10−2Cm−2; it too is demonstrably a new ferroelectric. Although Ba5.2K0.8U2.4Nb7.6O30 has also been reported in space group P4bm, all atomic displacements from the corresponding centrosymmetric positions are less than their refined root-mean-square thermal or static amplitudes. Such an arrangement is likely to be thermodynamically unstable. Either its space group has been incorrectly assigned, and reinvestigation will show the space group is P4/mbm, or the structural refinement is incomplete.

Elemental composition of secretory granules in pancreatic islets of Langerhans

We have characterized, by electron probe microanalysis, rapidly frozen cultured rat islets at the level of individual secretory granules. Elemental analysis of thin, dried cryosections showed that beta granules could be distinguished by high Zn, Ca, and S, whereas non-beta (mainly alpha) granules contained elevated P and Mg. Although a single granule type predominated in a particular cell, some rebel granules were found in A cells that had the compositional fingerprint of B cell granules. Zn, which was found in millimolar concentrations in B cell granules, was considered a marker for the insulin storage complex. The data indicate that non-B islet cells in the adult pancreas may produce insulin-containing organelles and that, when glucagon and insulin are coexpressed, these hormones are packaged in separate granules.

Effects of serotonin and carbachol on glial and neuronal rubidium uptake in leech CNS

Effects of serotonin (5-HT) and carbachol on Rb uptake (used as a K marker) in leech neuron and glia were studied by electron probe microanalysis (EPMA). Hirudo medicinalis ganglia were perfused 60 s in 4 mM Rb substituted normal leech Ringer's with and without 5-HT (dosage range 5-500 microM) or carbachol (range 10-1000 microM), quench frozen cryosectioned, and subjected to EPMA to determine elemental mass fractions and cell water content. Both 5-HT and carbachol altered leech neuron and glial cell elemental distribution and water content. In glial cells, a dose-dependent increase in Rb uptake was observed following 5-HT (control: 26 +/- 2 microM; 5 microM: 47 +/- 4; 50 microM: 62 +/- 4; 500 microM: 82 +/- 11 mmol/kg dry wt. +/- S.E.M.) and carbachol (10 microM: 35 +/- 3; 100 microM: 52 +/- 3; 1000 microM: 68 +/- 3 mmol/kg dry wt. +/- S.E.M.). In neurons, 5-HT and carbachol had small effects. 5-HT decreased glial and neuronal cell water content. Carbachol decreased neuronal (but not glial) water content by approximately the same amount (mean decrease 9%) regardless of dose. Both 5-HT and carbachol affected glial cell K-accumulating properties, providing evidence that certain neurotransmitters may modulate invertebrate glial cells' K clearance function.

Preferential uptake of rubidium from extracellular space by glial cells compared to neurons in leech ganglia

Glial cells play a significant role in maintaining extracellular space (ECS) potassium (K) by temporarily buffering or accumulating excess ECS K and then returning that K to neurons. Yet, little is known about the relative affinity of neurons or glial cells for K when both cells are simultaneously exposed to the same ECS K, in situ. Also, the process by which glial cells return K to neurons remains unknown. Therefore, electron probe X-ray microanalysis was used to measure rubidium (Rb) uptake, as a K tracer, into leech packet neurons and glial cells, and to measure the distribution of cell water content, K, Na and Cl. When ECS Rb was increased from 4 mM to 20 mM, there was a clear preferential Rb uptake into glial cells compared to neurons. At 4 mM extracellular Rb there was only a small difference between uptake velocity of neurons and glial cells (maximum mean uptake velocity at 4 mM Rb was 1.09 for glia, and 0.41 mmol Rb/kg dry wt/s for neurons), whereas at 20 mM extracellular Rb, glial uptake velocity was dramatically greater than of neurons (max. mean Rb uptake velocity for glia was 4.3 compared to 1.47 mmol Rb/kg dry wt/s for neurons). Glial Rb uptake velocity was enhanced by low temperature (max. mean Rb uptake velocity at 20 mM ECS Rb at 6 degrees C was 6.04 for glia compared to 0.78 mmol Rb/kg dry wt/s for neurons) and by substitution of Cl with isethionate (max. mean Rb uptake velocity was 10.6 for glia compared to 1.33 mmol Rb/kg dry wt/s for neurons).(ABSTRACT TRUNCATED AT 250 WORDS)

Personal-computer-based system for electron beam X-ray microanalysis of biological samples

A system based on a personal computer has been developed which provides a relatively inexpensive way to equip an electron microscopy laboratory for quantitative elemental analyses of cryosectioned biological samples. This system demonstrates the feasibility of making an X-ray analyser from a personal computer, together with commercially available hardware and software components. Hardware and software have been assembled to drive the beam in a scanning electron microscope, collect and analyse X-ray spectra, and save, retrieve, and analyse data. Our software provides a menu-controlled user interface to direct spectra acquisition and analysis. Spot analyses, video images, and quantitative elemental images may be obtained and results transferred in ASCII format to other computers. Wet weight, as well as dry weight, concentrations are calculated, if measurements were made of areas of the hydrated sample before it was freeze-dried. Grey-level copies of video and quantitative elemental images may be made on a laser printer.

Urological myths

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Using self-help support groups: a framework for nursing practice and research

Social support groups are receiving increased attention in professional literature and the media and the number of groups is growing. Nurses are often urged to utilize social support groups as part of client care. These groups cannot be effectively used by nurses unless they are approached from the framework of the nursing process. This approach helps assure individualization of referrals and evaluation of the support group in relation to the client's needs. Based on the literature reviewed and the proposed nursing process framework, many research questions are identified.

Carcinoma of the prostate masquerading as rectal carcinoma. Report of 3 cases and review of the literature

We present 3 patients with prostatic tumours who presented with symptoms of rectal stenosis. In all 3 cases digital examination of the rectum revealed a mass suggestive of rectal carcinoma, but carcinoma of the prostate was suspected because of other clinical features and this was confirmed by biopsy. Treatment by hormonal manipulation resulted in a dramatic improvement in symptoms. The diagnostic and management difficulties associated with this unusual presentation of carcinoma of the prostate are described, together with a review of the literature.

Health visitors as educators

This paper describes some models of health education as a context for considering data from a recent study of mothers' and health visitors' perspectives on good child health care. Most health visitors favoured an individualistic top-down approach aimed at changing mothers' behaviour. Mothers preferred a dialogue which started from their own priorities.

Characteristics of cadaveric renal allograft recipients developing chronic rejection

As the early results of renal transplantation improve, chronic rejection is increasing in relative importance as a cause of graft loss. The aetiology of the condition is unknown. In order to identify possible predisposing factors, the characteristics of 22 patients with chronic rejection were compared with those of 50 patients with stable graft function 2 years or more after transplantation. Patients with chronic rejection had significantly more acute rejection episodes in the first 6 months after transplant (P less than 0.01), a higher incidence of acute rejection with vascular features (P less than 0.01), and longer ischaemic times (P less than 0.05) compared to patients with stable graft function. In a logistic regression analysis both frequency and severity of acute rejection episodes were significantly associated with the subsequent development of chronic rejection. Thus chronic rejection is associated with early injury to the transplanted kidney.

Early experience of the gittes "no-incision" pubovaginal suspension for stress urinary incontinence

A series of 20 women with stress urinary incontinence underwent bladder neck suspension according to the method in which there are no suprapubic or vaginal incisions and no buttresses. Follow-up was between 9 weeks and 8 months. Twelve patients (60%) were cured, 2 (10%) were significantly improved and 6 (30%) were not improved; 3 patients had pre-operative detrusor instability; when they were excluded the failure rate fell to 23%. These results are inferior to those obtained in this unit using the Stamey procedure, although the difference is not significant. The operation is quick and easy to perform and was well tolerated with minimal complications; we believe it is worthy of further evaluation.

The increasing importance of chronic rejection as a cause of renal allograft failure

A consequence of reducing early graft failure due to acute rejection has been that more patients are at risk of chronic rejection, something which has become an increasingly important cause of graft loss. We examine the graft survival rates and reasons for failure in our unit from 1981 to 1986. Patients were divided into two series according to treatment of acute rejection episodes. From 1983 onwards, by treating acute vascular (poor prognosis) episodes with antilymphocyte globulin (ALG), we have significantly improved the 6-month actuarial graft survival rate. However, the percentage of total graft failure due to chronic rejection in this second series has significantly increased. The need for greater understanding of the aetiology of chronic rejection, together with its present unsatisfactory treatment, is discussed.

The late results of renal transplantation and the importance of chronic rejection as a cause of graft loss

The results of 279 renal transplants performed in a single centre between 1974 and 1986 are reviewed. Improvements in the management of acute rejection and a reduction in mortality have resulted in an improvement in 1-year actuarial graft survival rates from 44% for transplants performed before 1980 to 68% for those performed after 1983. After the second year post-transplant there has been a steady rate of graft failure (6% per annum), mainly due to chronic rejection. In total 52 grafts have developed chronic rejection (19% of the total and 30% of those at risk at 6 months). Chronic rejection is assuming greater relative importance as a cause of graft loss as early results improve.

Use of older patients as cadaveric kidney donors

We have no fixed upper age limit for cadaveric kidney donors and donors over the age of 50 provided kidneys for 22 per cent of our adult transplant recipients between 1983 and 1986. Immediate function following transplantation occurred in 17 per cent of these kidneys compared with 58 per cent for kidneys from donors under the age of 50. The 1-year actuarial graft survival rate for transplants from donors over 50 was 52 per cent, compared with 70 per cent for transplants from donors under 50 (P less than 0.05). Thus kidneys from older donors make an important contribution to the total pool of organs available for transplantation, but their use leads to inferior results in comparison with kidneys from younger donors.

Perioperative prophylaxis with sulbactam and ampicillin compared with metronidazole and cefotaxime in the prevention of wound infection in children undergoing appendectomy

Sulbactam is a beta-lactamase inhibitor, which when administered with ampicillin, increases the latter agents antibacterial activity against beta-lactamase producing organisms. One hundred children between the ages of 5 and 14 undergoing emergency appendectomy were entered into a prospective randomized trial comparing sulbactam and ampicillin (SA) with metronidazole and cefotaxime (MC) as prophylaxis against postoperative wound infection. Patients in whom the appendix was perforated or gangrenous received a 72-hour course of antibiotics, others received a single dose only. The overall wound infection rate was 8% (14% in patients with perforation or gangrene and 4% in those without). There was no difference in infection rate between the two antibiotic groups; there were three wound infections and one subphrenic abscess in patients receiving SA and four wound infections in patients receiving MC. SA, therefore, appears to be a suitable antibiotic combination for use as prophylaxis in appendicitis in children.

A randomized comparative study of sulbactam plus ampicillin vs. metronidazole plus cefotaxime in the management of acute appendicitis in children

Sulbactam is a beta-lactamase inhibitor that, when combined with ampicillin, gives the latter antibiotic a broad spectrum of activity, making it suitable for use as a prophylactic agent in acute appendicitis. In a single-blind, randomized trial, the efficacy of sulbactam plus ampicillin was compared with that of metronidazole plus cefotaxime. Thirty-five children undergoing appendectomy received intravenous sulbactam and ampicillin, while 38 children received metronidazole and cefotaxime. Single doses were given unless the appendix was considered gangrenous or perforated, in which case the drugs were administered for 72 hr. There were three wound infections in the group given sulbactam and ampicillin and five in the group given metronidazole and cefotaxime. The combination of sulbactam and ampicillin was well tolerated and appeared to be at least as effective as that of metronidazole and cefotaxime in the prevention of sepsis following appendectomy.

A review of 155 extra-anatomic bypass grafts

Extra-anatomic bypass grafting has been used as treatment for patients with aorto-iliac disease who were considered unfit for aortic surgery. Eighty five percent of the patients had ischaemic pain at rest or skin necrosis. One hundred and three femorofemoral (FF) grafts, 40 axillounifemoral and 12 axillobifemoral grafts were performed. Femoropopliteal extension grafts were performed in 39 cases. The three year cumulative graft patency rate was 69% for FF grafts and 48% for both types of axillofemoral (AF) graft, falling to 61% for FF grafts and 32% for AF grafts at five years. The long term patient survival rate was poor, particularly for AF grafts, 27% at five years, reflecting the poor general condition of these patients. In addition almost a quarter of AF grafts required declotting at some stage. However, worthwhile limb salvage rates were obtained with both types of grafts, 69% for FF and 72% for AF at three years and 61% for FF and 65% for AF at five years, suggesting that these grafts should be employed as a means of avoiding amputation in poor risk patients.

Serial effects on left ventricular load and contractility during hemodialysis in patients with concentric hypertrophy

To separate the effects of hemodialysis on loading conditions from those on contractile state, six patients with concentric left ventricular hypertrophy and normal left ventricular function were studied before, during, and after hemodialysis. Two-dimensional-directed M-mode ultrasound was used to measure left ventricular dimensions and wall thickness; a sphygmomanometer and carotid pulse recording were used to determine peak and end-systolic blood pressure. From these data, meridional stress at end systole was calculated and stress-dimension and stress-shortening relations were derived; measurements of metabolic parameters were made simultaneously. Heart rate and systolic blood pressure were stable throughout dialysis. Reductions in left ventricular dimensions and increased shortening were evident by 30 minutes of dialysis and were largely complete by mid-dialysis. These changes coincided with a decrease in potassium and an increase in ionized calcium but not in pH, which changed only in the latter half of dialysis. When stress-dimension and stress-shortening relations were examined, both individual and group data for all coordinates before, during, and after dialysis demonstrated an excellent linear fit consistent with a single contractile state. We conclude that in stable patients with left ventricular hypertrophy, the reduction in heart size and improvement in shortening are due primarily to reductions in preload and afterload.

Plumber's knee: calcinosis cutis after repeated minor trauma in a plumber

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Use of verapamil to control an inappropriate chronic sinus tachycardia

Sinus tachycardia is an expected physiologic response to endogenous catecholamine stimulation, although it may limit the use of exogenous agents. We report a case in which persistent sinus tachycardia occurring in a patient with severe bronchospastic pulmonary disease was effectively treated with verapamil.

Divergent views of hospital staff on detecting and managing hypertension

A questionnaire about detecting and managing hypertension was answered by 76 out of 110 (69%) doctors and 116 out of 195 (63%) qualified nurses in a large hospital. There was no general agreement on the method of taking diastolic blood pressures or on the level of hypertension requiring treatment. Most of the clinicians treated mild hypertension, although no proof exists that such treatment is beneficial. Almost everyone questioned agreed that measuring blood pressure in all patients attending hospital is important. Agreement should be reached, however, on which phase of diastolic blood pressure should be used.

A total synthesis of indospicine, 6-Amidino-2-aminohexanoic acid

Indospicine (1), the hepatotoxic amino acid from Indigofera spicata Forsk. is synthesized from 2-amino-6-hydroxyhexanoic acid (6- hydroxynorleucine) by stepwise replacement of hydroxyl by tosyloxy, cyano, imidoester, and amidine groupings.