A Multicentre Retrospective Study of Fulvestrant Use and Efficacy in Advanced/Metastatic Breast Cancer.

AIMS: Fulvestrant is a selective oestrogen receptor (ER) degrader used in postmenopausal women with hormone receptor-positive advanced breast cancer. The study aim was to analyse demographics and outcomes of UK patients treated with fulvestrant monotherapy at nine representative centres. MATERIALS AND METHODS: Medical records of 459 patients with locally advanced or metastatic ER-positive, HER2-negative breast cancer treated with fulvestrant between August 2011 and November 2018 at nine UK centres were reviewed. Data were collated on demographics, progression-free survival, overall survival and disease response at first radiological assessment following fulvestrant initiation. Patients still alive by December 2018 were censored. RESULTS: Data from 429 of the 459 patients identified were eligible for inclusion in the analysis. The median age was 69 (range 21-95) and 64% (n = 275) had Eastern Cooperative Oncology Group performance status 0-1. Bone was the most commonly involved metastatic site (72%, n = 306). However, 295 (69%) patients had visceral involvement. Patients had received a median 2 (range 0-5) prior lines of endocrine therapy and median 0 (range 0-6) prior chemotherapies. Fulvestrant was first-line therapy in 43 patients (10%). The median duration of treatment was 5 months (range 1-88). The median progression-free survival was 5.5 months. In 51% of 350 patients radiologically assessed, there was evidence of disease response to fulvestrant. Fifteen per cent of these had a complete/partial response. Fulvestrant was discontinued predominantly due to disease progression, with 3% discontinued solely due to adverse events. The median overall survival for the whole cohort was 22.5 months (range 0-88). CONCLUSIONS: This is one of the largest studied cohorts of breast cancer patients treated with fulvestrant. This heavily endocrine-pretreated population reflects real-life use in the UK. Within this context, our retrospective data show that patients can experience maintained disease response when treated with fulvestrant, supporting the importance of equitable availability for all UK patients.

The Safer Anaesthesia from Education (SAFE)® paediatric anaesthesia course: educational impact in five countries in East and Central Africa.

There is an urgent need to improve access to safe surgical and anaesthetic care for children living in many low- and middle-income countries. Providing quality training for healthcare workers is a key component of achieving this. The 3-day Safer Anaesthesia from Education (SAFE)® paediatric anaesthesia course was developed to address the specific skills and knowledge required in this field. We undertook a project to expand this course across five East and Central African countries (Ethiopia, Kenya, Malawi, Uganda and Zambia) and train local faculty. This study reports the outcomes from course evaluation data, exploring the impact on knowledge, skills and behaviour change in participants. Eleven courses were conducted in a 15-month period, with 381 participants attending. Fifty-nine new faculty members were trained. Knowledge scores (0-50 scale) increased significantly from mean (SD) 37.5 (4.7) pre-course to 43.2 (3.5) post-course (p < 0.0001). Skills scores (0-10 scale) increased significantly from 5.7 (2.0) pre-course to 8.0 (1.5) post-course (p < 0.0001). One hundred and twenty-six participants in Malawi, Uganda and Zambia were visited in their workplace 3-6 months later. Knowledge and skills were maintained at follow-up, with scores of 41.5 (5.0) and 8.3 (1.4), respectively (p < 0.0001 compared with pre-course scores). Content analysis from interviews with these participants highlighted positive behaviour changes in the areas of preparation, peri-operative care, resuscitation, management of the sick child, communication and teaching. This study indicates that the SAFE paediatric anaesthesia course is an effective way to deliver training, and could be used to help strengthen emergency and essential surgical care for children as a component of universal health coverage.

Investigation of the force associated with the formation of lacerations and skull fractures.

Post-mortem examination is often relied upon in order to determine whether a suspicious death was natural, accidental, suicidal or homicidal. However, in many cases the mechanism by which a single injury has been inflicted cannot be determined with certainty based on pathological examination alone. Furthermore the current method of assessing applied force relating to injury is restricted to an arbitrary and subjective scale (mild, moderate, considerable, or severe). This study investigates the pathophysiological nature of head injuries caused by blunt force trauma, specifically in relation to the incidence and formation of a laceration. An experimental model was devised to assess the force required to cause damage to the scalp and underlying skull of porcine specimens following a single fronto-parietal impact. This was achieved using a drop tower equipped with adapted instrumentation for data acquisition. The applied force and implement used could be correlated with resultant injuries and as such aid pathological investigation in the differentiation between falls and blows. Experimentation revealed prevalent patterns of injury specific to the reconstructed mechanism involved. It was found that the minimum force for the occurrence of a laceration was 4,000 N.

Pharmacokinetics and antitumor properties in tumor-bearing mice of an enediol analogue inhibitor of glyoxalase I.

PURPOSE: The enediol analogue S-(N-p-chlorophenyl-N-hydroxycarbamoyl)glutathione (CHG) is a powerful, mechanism-based, competitive inhibitor of the methylglyoxal-detoxifying enzyme glyoxalase I. The [glycyl,glutamyl]diethyl ester prodrug form of this compound (CHG(Et)2) inhibits the growth of different tumor cell lines in vitro, apparently by inducing elevated levels of intracellular methylglyoxal. The purpose of this study was to evaluate the pharmacokinetic properties of CHG(Et)2 in plasma esterase-deficient C57BL/6 (Es-1e) mice after intravenous (i.v.) or intraperitoneal (i.p.) administration of bolus doses of CHG(Et)2. In addition, the in vivo antitumor properties of CHG(Et)2 were evaluated against murine B16 melanoma in these mice, and against androgen-independent human prostate PC3 tumor and human colon HT-29 adenocarcinoma in plasma esterase-deficient nude mice. METHODS: Pharmacokinetics were evaluated after either i.v. or i.p. administration of CHG(Et)2 at the maximally tolerated dose of 120 mg/kg to both tumor-free male and female mice and male and female mice bearing subcutaneous B16 tumors. Tissue concentrations of CHG(Et)2, CHG and the [glycyl]monoethyl ester CHG(Et) were measured as a function of time by reverse-phase C18 high-performance liquid chromatography of deproteinized tissue samples. The efficacy of CHG(Et)2 in tumor-bearing mice was evaluated after i.v. bolus administration of CHG(Et)2 at 80 or 120 mg/kg for 5 days each week for 2 weeks, or after 14 days continuous infusion of CHG(Et)2 using Alzet mini-osmotic pumps. Hydroxypropyl-beta-cyclodextrin was used as a vehicle in the efficacy studies. RESULTS: Intravenous administration of CHG(Et)2 resulted in the rapid appearance of CHG(Et)2 in the plasma of tumor-bearing mice with a peak value of 40-60 microM, followed by a first-order decrease with a half-life of about 10 min. There was a corresponding increase in the concentration of inhibitory CHG in the B16 tumors, with a maximum concentration in the range 30-60 microM occurring at 15 min, followed by a decrease to a plateau value of about 6 microM after 120 min. Neither CHG(Et)2 nor its hydrolysis products were detectable in plasma, after i.p. administration of CHG(Et)2 to tumor-free female mice. From the efficacy studies, dosing schedules were identified that resulted in antitumor effects comparable to those observed with the standard antitumor agents Adriamycin (with B16 tumors), cisplatin (with PC3 tumors), and vincristine (with HT-29 tumors). CONCLUSION: This is the first demonstration that a mechanism-based competitive inhibitor of glyoxalase I effectively inhibits the growth of solid tumors in mice when delivered as the diethyl ester prodrug.

Maillard reactions in lens proteins: methylglyoxal-mediated modifications in the rat lens.

The nonenzymatic Maillard reaction is thought to contribute to aging and cataract formation in the lens. As levels of methylglyoxal (MG) and glutathione (GSH) affect the reaction, we examined the relationship of these factors and determined the effect of a glyoxalase I inhibitor on the Maillard reaction. Rat lens cultures were maintained for up to 3 days in TC-199 medium with or without 20 m m glyceraldehyde (GLD) and 250 microm S-[N-hydroxy-N-(4-chlorophenyl) carbamoyl] glutathione diethyl ester (HCCG diester). We measured GSH, MG, D-lactate, glyoxalase I activity, immunoreactive MG-derived advanced glycation endproducts (MG-AGEs) and imidazolysine in organ cultured rat lenses. In vitro experiments with isolated rat lens proteins revealed that HCCG alone inhibited glyoxalase I activity in a dose-dependent manner. In organ cultured rat lens protein, GLD increased MG levels 24-fold, and the addition of HCCG diester further increased it by about two-fold. GSH levels fell sharply in the presence of GLD and this was prevented to some extent by the presence of HCCG diester. D-lactate production in the lens was suppressed by HCCG diester treatment. Dialysed lens proteins retained glyoxalase I activity, indicating that the enzyme was unaltered during incubation. MG-AGEs and imidazolysine levels were significantly higher (P<0.05) in GLD-treated lenses, but a combination of HCCG diester and GLD lowered immunoreactive MG-AGEs and imidazolysine levels compared to GLD alone. HCCG had no significant effect on MG-AGE formation in lens proteins incubated with GLD or MG. We conclude that exogenous GLD enhances MG and MG-AGE levels in the rat lens and that this increase is accompanied by a loss in GSH. In addition, inhibition of glyoxalase I promotes MG accumulation.

A new method for rapidly generating inhibitors of glyoxalase I inside tumor cells using S-(N-aryl-N-hydroxycarbamoyl)ethylsulfoxides.

The enediol analogue S-(N-p-chlorophenyl-N-hydroxycarbamoyl)glutathione is a powerful mechanism-based competitive inhibitor of the anticancer target enzyme glyoxalase I. Nevertheless, this compound exhibits limited toxicity toward tumor cells in vitro because it does not readily diffuse across cell membranes. We describe an efficient method for indirectly delivering the enzyme inhibitor into murine leukemia L1210 cells via acyl interchange between intracellular glutathione and the cell-permeable prodrug S-(N-p-chlorophenyl-N-hydroxycarbamoyl)ethylsulfoxide. The second-order rate constant for the acyl-interchange reaction in a cell-free system is 1.84 mM-1 min-1 (100 mM potassium phosphate buffer, 5% ethanol, pH 7.5, 25 degrees C). Incubation of L1210 cells with the sulfoxide in vitro results in a rapid increase in the intracellular concentration of the glyoxalase I inhibitor (kapp = 1. 41 +/- 0.03 min-1 (37 degrees C)) and inhibition of cell growth (GI50 = 0.5 +/- 0.1 microM). This represents an improvement in both efficiency and potency over the dialkyl ester prodrug strategy in which the inhibitor is indirectly delivered into tumor cells as the [glycyl,glutamyl] diethyl or dicyclopentyl esters. The fact that pi-glutathione transferase catalyzes the acyl-interchange reaction between GSH and the sulfoxide suggests that the sulfoxide, or related compounds, might exhibit greater selective toxicity toward tumor cells that overexpress the transferase.