Development of a core outcome set for cutaneous squamous cell carcinoma trials: identification of core domains and outcomes.

BACKGROUND: The lack of uniformity in the outcomes reported in clinical studies of the treatment of cutaneous squamous cell carcinoma (cSCC) complicates efforts to compare treatment effectiveness across trials. OBJECTIVES: To develop a core outcome set (COS), a minimum set of agreed-upon outcomes to be measured in all clinical trials of a given disease or outcome, for the treatment of cSCC. METHODS: One hundred and nine outcomes were identified via a systematic literature review and interviews with 28 stakeholders. After consolidation of this long list, 55 candidate outcomes were rated by 19 physician and 10 patient stakeholders, in two rounds of Delphi exercises. Outcomes scored 'critically important' (score of 7, 8 or 9) by ≥ 70% of patients and ≥ 70% of physicians were provisionally included. At the consensus meeting, after discussion and voting of 44 international experts and patients, the provisional list was reduced to a final core set, for which consensus was achieved among all meeting participants. RESULTS: A core set of seven outcomes was finalized at the consensus meeting: (i) serious or persistent adverse events, (ii) patient-reported quality of life, (iii) complete response, (iv) partial response, (v) recurrence-free survival, (vi) progression-free survival and (vii) disease-specific survival. CONCLUSIONS: In order to increase the comparability of results across trials and to reduce selective reporting bias, cSCC researchers should consider reporting these core outcomes. Further work needs to be performed to identify the measures that should be reported for each of these outcomes.

TNF-α modulates genome-wide redistribution of ΔNp63α/TAp73 and NF-κB cREL interactive binding on TP53 and AP-1 motifs to promote an oncogenic gene program in squamous cancer.

The Cancer Genome Atlas (TCGA) network study of 12 cancer types (PanCancer 12) revealed frequent mutation of TP53, and amplification and expression of related TP63 isoform ΔNp63 in squamous cancers. Further, aberrant expression of inflammatory genes and TP53/p63/p73 targets were detected in the PanCancer 12 project, reminiscent of gene programs comodulated by cREL/ΔNp63/TAp73 transcription factors we uncovered in head and neck squamous cell carcinomas (HNSCCs). However, how inflammatory gene signatures and cREL/p63/p73 targets are comodulated genome wide is unclear. Here, we examined how the inflammatory factor tumor necrosis factor-α (TNF-α) broadly modulates redistribution of cREL with ΔNp63α/TAp73 complexes and signatures genome wide in the HNSCC model UM-SCC46 using chromatin immunoprecipitation sequencing (ChIP-seq). TNF-α enhanced genome-wide co-occupancy of cREL with ΔNp63α on TP53/p63 sites, while unexpectedly promoting redistribution of TAp73 from TP53 to activator protein-1 (AP-1) sites. cREL, ΔNp63α and TAp73 binding and oligomerization on NF-κB-, TP53- or AP-1-specific sequences were independently validated by ChIP-qPCR (quantitative PCR), oligonucleotide-binding assays and analytical ultracentrifugation. Function of the binding activity was confirmed using TP53-, AP-1- and NF-κB-specific REs or p21, SERPINE1 and IL-6 promoter luciferase reporter activities. Concurrently, TNF-α regulated a broad gene network with cobinding activities for cREL, ΔNp63α and TAp73 observed upon array profiling and reverse transcription-PCR. Overlapping target gene signatures were observed in squamous cancer subsets and in inflamed skin of transgenic mice overexpressing ΔNp63α. Furthermore, multiple target genes identified in this study were linked to TP63 and TP73 activity and increased gene expression in large squamous cancer samples from PanCancer 12 TCGA by CircleMap. PARADIGM inferred pathway analysis revealed the network connection of TP63 and NF-κB complexes through an AP-1 hub, further supporting our findings. Thus, inflammatory cytokine TNF-α mediates genome-wide redistribution of the cREL/p63/p73, and AP-1 interactome, to diminish TAp73 tumor suppressor function and reciprocally activate NF-κB and AP-1 gene programs implicated in malignancy.

Smoked heroin and cocaine base (speedball) combinations in rhesus monkeys.

The purpose of this investigation was to compare the self-administration of heroin and cocaine base, alone and in combination, in rhesus monkeys (Macaca mulatta) self-administering a combination of heroin (0.1 mg/kg/delivery) and cocaine base (1.0 mg/kg/delivery) via the smoking route. Smoke deliveries were contingent on completion of a chained fixed ratio (FR; lever press), FR 5 (inhalation) schedule. The lever press FR values (64, 128, 256, 512, and 1024) represented increasing drug price. Demand functions (Consumption X price) were obtained for the heroin and cocaine combination and compared with previously determined demand functions for smoked heroin and cocaine alone. As the FR increased and the number of responses emitted increased, the number of drug deliveries decreased. The demand functions were not different for heroin versus cocaine alone or for the cocaine alone versus the cocaine-heroin combination. However, the demand for heroin alone was significantly less than the demand for the cocaine-heroin combination, suggesting that smoked cocaine base enhances the behavioral effects of smoked heroin.

Effects of buprenorphine and an alternative nondrug reinforcer, alone and in combination on smoked cocaine self-administration in monkeys.

The abuse of smoked cocaine base, also known as 'crack', continues to be a major public health problem and to date the success of pharmacological or behavioral interventions has been limited. The purpose of this study was to evaluate the efficacy of a behavioral (alternative reinforcer-saccharin) and pharmacological (0.01 mg/kg buprenorphine) treatment alone and in combination. Five adult male rhesus monkeys self-administered cocaine base (1.0 mg/kg/delivery) via the smoking/inhalation route. Each day ten smoke deliveries were available contingent upon completion of a chained FR (lever press), FR (inhalation response) response schedule during 4 hr sessions. The data were analyzed using a behavioral economic framework in which the lever press response requirements were varied from 64 to 1024 to generate a demand function (consumption x FR) for cocaine under the following conditions: (1) buprenorphine pretreatment alone (0.01 mg/kg, i.m., 30 min presession); (2) concurrent access to saccharin alone (0.03% wt/vol); and (3) buprenorphine pretreatment in the presence of concurrent access to saccharin. Under all conditions, increases in the lever FR resulted in significant decreases in smoked cocaine base deliveries. Neither buprenorphine pretreatment alone nor concurrent saccharin alone produced significant decreases in smoked cocaine deliveries; however, the combination of buprenorphine pretreatment and concurrent saccharin significantly decreased the mean number of smoked cocaine deliveries from the no treatment baseline and from the buprenorphine alone condition. These data suggest that the combination of pharmacotherapy and alternative reinforcers may be an effective treatment strategy to alter smoked cocaine self-administration.

Smoked heroin self-administration in rhesus monkeys.

The purpose of the present study was to evaluate behavioral and pharmacological determinants of smoked heroin self-administration. Eight rhesus monkeys were trained to self-administer smoked heroin under a chained fixed-ratio, (FR, 64-1024) for lever presses, FR 5 for inhalations schedule during daily experimental sessions. Demand for heroin was determined by plotting consumption (smoke deliveries) as a function of price which was varied by increasing the FR lever press requirement from 64 to 1024. The heroin demand curve was compared to that obtained with smoked cocaine base. Dose-effect determinations were obtained by varying the unit dose of heroin from 0.025 to 1.6 mg/kg per delivery. Pretreatment with naloxone (0.01-1.0 mg/kg IM, 10 min presession) and substitution tests with the peripherally acting opioid loperamide (0.1 mg/kg per delivery) were also conducted. Deliveries of smoked heroin decreased, but lever responding per delivery increased as the FR increased. Demand for heroin was elastic and comparable to demand for smoked cocaine base. Varying the dose of heroin available for self-administration resulted in an asymptotic dose-effect curve. Naloxone pretreatment produced dose-dependent decreases in heroin self-administration. Substitution of loperamide for heroin produced extinction-like responding within one or two sessions, with the total smoke deliveries decreasing by 80% of heroin levels within 8-15 days. Reinstatement of heroin resulted in a rapid return to baseline levels of self-administration. These data suggest that rhesus monkeys will readily and reliably self-administer heroin via the inhalation route, and behavioral and pharmacological manipulations indicate that smoked heroin functioned as a positive reinforcer.

Conditioned reinforcing effects of capsules associated with high versus low monetary payoff.

The ability of a placebo drug capsule to serve as a conditioned reinforcer as a function of being paired with money reinforcement was evaluated. Volunteers were administered two differently colored capsules that presumably contained two different drugs. Although the volunteers were told they might contain a stimulant, sedative, or placebo, both capsules contained only a placebo. During sessions, volunteers participated in performance tasks. The tasks were programmed so that following one capsule, the amount of money obtained contingent upon responding was greater (high frequency of reinforcement) than following the other capsule (low frequency of reinforcement). During experiment 1, participants were exposed twice each to the two reinforcement conditions (sampling). During these choice sessions, 9 of 12 participants chose the capsule associated with the high frequency of reinforcement 2 or 3 times. Experiment 2 was designed to explore further whether the differential mood effects observed during sampling sessions could be conditioned. Although this could not be demonstrated, the self-administration results demonstrating the control of choice behavior even in the absence of pharmacological effects suggest that drugs may function as conditioned reinforcers. This finding has implications for broadening our understanding of the determinants of initiation and continued drug use.

Pharmacological analysis of the rate-decreasing effects of mu and kappa opioids in pigeons.

The present study investigated the rate-decreasing effects of several mu (morphine and l-methadone) and kappa (bremazocine, U69,593 and U50,488) opioid agonists in pigeons. Mu and kappa agonists were examined alone, in combination with naltrexone or the mu-selective opioid antagonist, beta-funaltrexamine (beta-FNA), and in pigeons treated chronically with U50,488. Naltrexone was equipotent in shifting the morphine, l-methadone and bremazocine dose-effect curves to the right, but was less potent in shifting the U69,593 dose-effect curve and did not shift the U50,488 dose-effect curve. Beta-FNA shifted the l-methadone dose-effect curve to the right but did not shift the bremazocine, U69,593 or U50,488 dose-effect curves. Pigeons that developed tolerance to U50,488 following daily administration were cross-tolerant to bremazocine but not to l-methadone. Taken together, these experiments indicate that the rate-decreasing effects of morphine and l-methadone are mediated by mu opioid receptors, whereas the rate-decreasing effects of bremazocine, U69,593 and U50,488 in pigeons differ depending on the pharmacological procedures used to assess their effects.

Effect of antagonists selective for mu, delta and kappa opioid receptors on the reinforcing effects of heroin in rats.

Antagonists selective for mu, delta and kappa-opioid receptors were evaluated for their effects on responding maintained by i.v. injections of heroin (60.0 micrograms/kg/injection) in rats during daily 3-hr sessions. Under base-line conditions, rats self-administered 10 to 20 heroin injections during each session, and injections were separated by relatively constant interinjection intervals of about 10 to 20 min. The mu-selective antagonist beta-funaltrexamine (beta-FNA; 5.0-20.0 mg/kg, s.c.) produced a dose-dependent increase in responding for heroin, with some doses of beta-FNA producing an extinction-like pattern of responding. These results were qualitatively similar to the effect obtained by lowering the unit dose per injection of heroin. The mu 1-selective antagonist naloxonazine (NXZ; 7.5-30.0 mg/kg, i.v.) and the delta-selective antagonist naltrindole (1.0-17.0 mg/kg) also produced dose-dependent increases in heroin self-administration, but neither naloxonazine nor naltrindole produced extinction-like patterns of responding. The kappa-selective antagonist nor-binaltorphimine (nor-BNI; 5.0-10.0 mg/kg, s.c.) had no effect on heroin self-administration. These results indicate that mu receptors play an important role in mediating the reinforcing effects of heroin in the rat. Delta and mu 1 receptors, but not kappa receptors, may also be involved.

Relationship between response to phenelzine and MAO inhibition in a clinical trial of phenelzine, amitriptyline and placebo.

This report examines the hypothesis that for phenelzine to be more effective than placebo it is necessary to achieve at least 80% inhibition of platelet MAO activity. This hypothesis was examined in the context of a double-blind comparison of phenelzine, amitriptyline and placebo in depressed patients. When phenelzine became significantly more effective than placebo at 4 weeks, the average MAO inhibition was 85%. By the 5th week, with MAO inhibition greater than 90%, phenelzine was significantly more effective than amitriptyline. A highly significant correlation was noted between improvement and MAO inhibition within the phenelzine group.