Prednisolone or pentoxifylline for alcoholic hepatitis.

BACKGROUND: Alcoholic hepatitis is a clinical syndrome characterized by jaundice and liver impairment that occurs in patients with a history of heavy and prolonged alcohol use. The short-term mortality among patients with severe disease exceeds 30%. Prednisolone and pentoxifylline are both recommended for the treatment of severe alcoholic hepatitis, but uncertainty about their benefit persists. METHODS: We conducted a multicenter, double-blind, randomized trial with a 2-by-2 factorial design to evaluate the effect of treatment with prednisolone or pentoxifylline. The primary end point was mortality at 28 days. Secondary end points included death or liver transplantation at 90 days and at 1 year. Patients with a clinical diagnosis of alcoholic hepatitis and severe disease were randomly assigned to one of four groups: a group that received a pentoxifylline-matched placebo and a prednisolone-matched placebo, a group that received prednisolone and a pentoxifylline-matched placebo, a group that received pentoxifylline and a prednisolone-matched placebo, or a group that received both prednisolone and pentoxifylline. RESULTS: A total of 1103 patients underwent randomization, and data from 1053 were available for the primary end-point analysis. Mortality at 28 days was 17% (45 of 269 patients) in the placebo-placebo group, 14% (38 of 266 patients) in the prednisolone-placebo group, 19% (50 of 258 patients) in the pentoxifylline-placebo group, and 13% (35 of 260 patients) in the prednisolone-pentoxifylline group. The odds ratio for 28-day mortality with pentoxifylline was 1.07 (95% confidence interval [CI], 0.77 to 1.49; P=0.69), and that with prednisolone was 0.72 (95% CI, 0.52 to 1.01; P=0.06). At 90 days and at 1 year, there were no significant between-group differences. Serious infections occurred in 13% of the patients treated with prednisolone versus 7% of those who did not receive prednisolone (P=0.002). CONCLUSIONS: Pentoxifylline did not improve survival in patients with alcoholic hepatitis. Prednisolone was associated with a reduction in 28-day mortality that did not reach significance and with no improvement in outcomes at 90 days or 1 year. (Funded by the National Institute for Health Research Health Technology Assessment program; STOPAH EudraCT number, 2009-013897-42 , and Current Controlled Trials number, ISRCTN88782125 ).

ProCAID: a phase I clinical trial to combine the AKT inhibitor AZD5363 with docetaxel and prednisolone chemotherapy for metastatic castration resistant prostate cancer.

Background Docetaxel and prednisolone chemotherapy (DP) extends survival in metastatic castration resistant prostate cancer (mCRPC). However, emergent clinical resistance is almost inevitable. AKT pathway activation is highly prevalent in mCRPC contributing to disease progression and DP resistance. AZD5363 is a potent oral pan-AKT inhibitor with pre-clinical data indicating activity in mCRPC and synergy with docetaxel. Methods This phase I trial was to determine an AZD5363 recommended phase II dose (RP2D) for combination with DP. Eligibility criteria included chemotherapy naive mCRPC, PSA or radiographic disease progression and ECOG performance status 0 or 1. Treatment comprised DP (75 mg/m2, IV, day 1 and 5 mg BID, PO, day 1-21 respectively for ten cycles) and AZD5363 to disease progression for all patients. We utilised a 3 + 3 dose escalation design to determine a maximum tolerated dose according to defined dose limiting toxicity criteria assessed using CTCAE version 4.03. Planned AZD5363 dose levels were 320 mg (DL1), 400 mg (DL2) and 480 mg (DL3), BID, PO, 4 days on/3 days off, from day 2 of each cycle. Results 10 patients were treated. Dose limiting toxicities affected 2 patients (grade 3 rash ≥5 days; grade 3 diarrhoea) in DL2. The commonest grade 3 or 4, AZD5363 related, symptomatic adverse events were rash and diarrhoea. Hyperglycaemia affected all patients but was self-limiting. PSA reduction to <50% at 12 weeks occurred in 7 patients. Conclusions The RP2D for AZD5363 is 320 mg BID, 4 days on/3 days off, in combination with full dose DP for mCRPC.

Octenyl-succinylated inulin for the encapsulation and release of hydrophobic compounds.

Octenyl-succinylated inulins (OSA-inulin) were synthesized in aqueous solutions using inulin with varying degrees of polymerization (DP). They were characterized using 1H NMR and FTIR and their degrees of substitution were determined. All the samples formed micellar aggregates in aqueous solution above a critical aggregation concentration (CAC) and solubilized beta-carotene. The amount of beta carotene solubilized within the micelles ranged from 12 to 25 mg/g of OSA-inulin and depended on the inulin molar mass. Dynamic light scattering showed that the aggregates, with and without dissolved beta-carotene, were ∼10-15 nm in size and this was confirmed by Transmission Electron Microscopy which also indicated that the micelles had a globular shape. OSA-inulin particles containing encapsulated beta-carotene were produced by freeze-drying. The encapsulated beta-carotene was not released from the freeze-dried particles when introduced into simulated gastric fluid at pH 2.5 but was readily released in simulated small intestinal fluid at pH 7. The results demonstrate the potential application of OSA-inulin in the encapsulation, dissolution and targeted delivery of hydrophobic drug molecules for nutraceutical, pharmaceutical and medical applications.

Data presenting the synthesis of three novel stimuli responsive hyperbranched polymers synthesised via RAFT polymerisation and the bio conjugation of folic acid.

The data presented in this manuscript presents the characterisation spectra of three hyperbranched polymers as discussed in the paper "Folic Acid and Rhodamine Labelled pH Responsive Hyperbranched Polymers: synthesis, characterisation and cell uptake studies" [1]. Characterisation of polymers was performed via 1H Nuclear Magnetic Resonance (1H NMR) and Size Exclusion Chromatography (SEC). pH responsive characteristics were observed via Dynamic Light Scattering (DLS). The data for characterisation of folate conjugated hyperbranched polymer is presented as 1H NMR, Ultra Violet Visible (UV-VIS) spectra and DLS measurements. Further data is presented detailing the experiments for the synthesis of monomers 2-propyl acrylic acid (PAA) and disulfide diacrylate (DSDA), with the full synthesis of folic acid-poly (ethylene glycol) (PEG) linker, rhodamine B ethylenediamine linker and bioconjugation reactions also detailed.

COAST (Cisplatin ototoxicity attenuated by aspirin trial): A phase II double-blind, randomised controlled trial to establish if aspirin reduces cisplatin induced hearing-loss.

BACKGROUND: Cisplatin is one of the most ototoxic chemotherapy drugs, resulting in a permanent and irreversible hearing loss in up to 50% of patients. Cisplatin and gentamicin are thought to damage hearing through a common mechanism, involving reactive oxygen species in the inner ear. Aspirin has been shown to minimise gentamicin-induced ototoxicity. We, therefore, tested the hypothesis that aspirin could also reduce ototoxicity from cisplatin-based chemotherapy. METHODS: A total of 94 patients receiving cisplatin-based chemotherapy for multiple cancer types were recruited into a phase II, double-blind, placebo-controlled trial and randomised in a ratio of 1:1 to receive aspirin 975 mg tid and omeprazole 20 mg od, or matched placebos from the day before, to 2 days after, their cisplatin dose(s), for each treatment cycle. Patients underwent pure tone audiometry before and at 7 and 90 days after their final cisplatin dose. The primary end-point was combined hearing loss (cHL), the summed hearing loss at 6 kHz and 8 kHz, in both ears. RESULTS: Although aspirin was well tolerated, it did not protect hearing in patients receiving cisplatin (p-value = 0.233, 20% one-sided level of significance). In the aspirin arm, patients demonstrated mean cHL of 49 dB (standard deviation [SD] 61.41) following cisplatin compared with placebo patients who demonstrated mean cHL of 36 dB (SD 50.85). Women had greater average hearing loss than men, and patients treated for head and neck malignancy experienced the greatest cHL. CONCLUSIONS: Aspirin did not protect from cisplatin-related ototoxicity. Cisplatin and gentamicin may therefore have distinct ototoxic mechanisms, or cisplatin-induced ototoxicity may be refractory to the aspirin regimen used here.

Self-assembly and emulsification properties of hydrophobically modified inulin.

A series of alkenylated inulin samples were synthesized in aqueous solution using alkenyl succinic anhydrides with varying alkenyl chain lengths (C8-C18). The inulin derivatives (ASA-inulins) were characterized using NMR and FTIR and their degree of substitution determined. The solution properties of ASA-inulins were investigated using dye solubilization, surface tension, and dynamic light scattering, and all three techniques confirmed that the molecules aggregated in solution above a critical concentration (critical aggregation concentration, CAC). The value of the CAC was found to be reasonably consistent between the different techniques and was shown to decrease with increasing alkenyl chain length, from 0.08% for the octenyl succinylated sample to 0.005% for the octadecenyl succinylated sample. The hydrodynamic diameter of ASA-inulins above the CAC was determined from dynamic light scattering studies and was shown to increase with alkenyl chain length, from 4 nm for the octenyl derivative to 55 nm for the hexadecenyl derivative. All ASA-inulins were shown to be able to produce oil-in-water emulsions with a droplet size similar to that of emulsions prepared using Tween 20 on storing for 21 days. The fact that the derivatives are able to form micellarlike aggregates and stabilize emulsions makes them suitable candidates for the encapsulation and delivery of water-insoluble active compounds, with potential application in food, cosmetic, personal care, and pharmaceutical formulations.

The clinical effectiveness and cost-effectiveness of STeroids Or Pentoxifylline for Alcoholic Hepatitis (STOPAH): a 2 × 2 factorial randomised controlled trial.

BACKGROUND: Alcoholic hepatitis (AH) is a distinct presentation of alcoholic liver disease arising in patients who have been drinking to excess for prolonged periods, which is characterised by jaundice and liver failure. Severe disease is associated with high short-term mortality. Prednisolone and pentoxifylline (PTX) are recommended in guidelines for treatment of severe AH, but trials supporting their use have given heterogeneous results and controversy persists about their benefit. OBJECTIVES: The aim of the clinical effectiveness and cost-effectiveness of STeroids Or Pentoxifylline for Alcoholic Hepatitis trial was to resolve the clinical dilemma on the use of prednisolone or PTX. DESIGN: The trial was a randomised, double-blind, 2 × 2 factorial, multicentre design. SETTING: Sixty-five gastroenterology and hepatology inpatient units across the UK. PARTICIPANTS: Patients with a clinical diagnosis of AH who had a Maddrey's discriminant function value of ≥ 32 were randomised into four arms: A, placebo/placebo; B, placebo/prednisolone; C, PTX/placebo; and D, PTX/prednisolone. Of the 5234 patients screened for the trial, 1103 were randomised and after withdrawals, 1053 were available for primary end-point analysis. INTERVENTIONS: Those allocated to prednisolone were given 40 mg daily for 28 days and those allocated to PTX were given 400 mg three times per day for 28 days. OUTCOMES: The primary outcome measure was mortality at 28 days. Secondary outcome measures included mortality or liver transplant at 90 days and at 1 year. Rates of recidivism among survivors and the impact of recidivism on mortality were assessed. RESULTS: At 28 days, in arm A, 45 of 269 (16.7%) patients died; in arm B, 38 of 266 (14.3%) died; in arm C, 50 of 258 (19.4%) died; and in arm D, 35 of 260 (13.5%) died. For PTX, the odds ratio for 28-day mortality was 1.07 [95% confidence interval (CI) 0.77 to 1.40; p = 0.686)] and for prednisolone the odds ratio was 0.72 (95% CI 0.52 to 1.01; p = 0.056). In the logistic regression analysis, accounting for indices of disease severity and prognosis, the odds ratio for 28-day mortality in the prednisolone-treated group was 0.61 (95% CI 0.41 to 0.91; p = 0.015). At 90 days and 1 year there were no significant differences in mortality rates between the treatment groups. Serious infections occurred in 13% of patients treated with prednisolone compared with 7% of controls (p = 0.002). At the 90-day follow-up, 45% of patients reported being completely abstinent, 9% reported drinking within safety limits and 33% had an unknown level of alcohol consumption. At 1 year, 37% of patients reported being completely abstinent, 10% reported drinking within safety limits and 39% had an unknown level of alcohol consumption. Only 22% of patients had attended alcohol rehabilitation treatment at 90 days and 1 year. CONCLUSIONS: We conclude that prednisolone reduces the risk of mortality at 28 days, but this benefit is not sustained beyond 28 days. PTX had no impact on survival. Future research should focus on interventions to promote abstinence and on treatments that suppress the hepatic inflammation without increasing susceptibility to infection. TRIAL REGISTRATION: This trial is registered as EudraCT 2009-013897-42 and Current Controlled Trials ISRCTN88782125. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 102. See the NIHR Journals Library website for further project information. The NIHR Clinical Research Network provided research nurse support and the Imperial College Biomedical Research Centre also provided funding.

Small strain deformation measurements of konjac glucomannan solutions and the influence of borate cross-linking.

The dynamic rheology of aqueous solutions of konjac glucomannan has been evaluated over a range of concentrations up to 2.35%, and the effect of borate cross-linking of such solutions evaluated in the range 0.02-40 mM borate. In preliminary work, conventional parallel plate geometries were employed and in situ cross-linking was investigated. For borate cross-linked samples a superior method, however, was found to be measurement of pre-formed cores of cross-linked polymer into which a four-bladed vane geometry was introduced. In order to compare with other associating polymer systems, rheological data were analysed by defining plateau moduli, corresponding relaxation times and zero shear viscosities and the scaling behaviour of these parameters with polymer and cross-linker concentrations was established. Maxwell fits and time-concentration superposition procedures were investigated. The rheological properties of the cross-linked polymer were shown to be the result of both increased network connectivity and retarded network dynamics.

Physicochemical characterization of konjac glucomannan.

Four commercial konjac glucomannan (KGM) samples and a glucomannan derived from yeast were characterized by aqueous gel permeation chromatography coupled with multi angle laser light scattering (GPC-MALLS). Disaggregation of aqueous glucomannan solutions through controlled use of a microwave bomb facilitated reproducible molar mass distribution determination alleviating the need for derivatization of the polymer or the use of aggressive solvents. Further characterization was undertaken by use of capillary viscometry and photon correlation spectroscopy (PCS). The weight average molecular masses (M(w)) determined were in the region of 9.0 +/- 1.0 x 10(5) g mol(-1) for KGM samples and 1.3 +/- 0.4 x 10(5) g mol(-1) for the yeast glucomannan. The values determined for KGM in aqueous solution are in agreement with those reported for KGM in aqueous cadoxen. The degradation of samples observed upon autoclaving has been quantified by GPC-MALLS and intrinsic viscosity determination, allowing comparison with reported Mark-Houwink parameters. Shear flow experiments were undertaken for a range of KGM solutions of concentration 0.05 to 2.0% using a combination of controlled stress and controlled strain rheometers. The concentration dependence of the zero shear specific viscosity was determined by analysis of the data using the Ellis model. The dependence of the zero shear specific viscosity on the coil overlap parameter was defined and interpretation discussed in terms of the Martin and Tuinier equations.