Setting research priorities to reduce mortality and morbidity of childhood diarrhoeal disease in the next 15 years

Zulfi Bhutta and colleagues lay out research priorities for global child diarrheal disease over the next 15 years, which they developed using the Child Health and Nutrition Research Initiative (CHNRI) method.

Please see later in the article for the Editors' Summary

Assessing the toxicity and associated costs among pediatric patients admitted with unintentional poisonings of attention-deficit/hyperactivity disorder drugs in the United States

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is widespread, with a national (United States) prevalence of nearly 10%. The 2011 changes in the diagnostic criteria will likely further increase the prevalence of this disorder. Little is known about the incidence of toxicity from unintentional poisonings of ADHD medications. This study attempted to determine the incidence of these ingestions and the corresponding financial impact in the United States.

METHODS

Four geographically different centers were chosen. Subjects with unintentional poisonings due to ADHD medications were included if the admission dates were between 2000 and 2002 (cohort A) or between 2009 and 2010 (cohort B). Using data from the participating hospitals and the number of monitored beds in each corresponding county, data were extrapolated on a national (United States) level.

RESULTS

Sixty-three subjects were admitted at four hospitals (18, cohort A and 45, cohort B). The crude incidence rate ratio increased in the later time frame as compared to that in the earlier time frame (incidence rate ratio, 3.13; 95% CI, 1.80-5.68; p < 0.0001). The median (IQR) charges per patient, adjusted for inflation, were $4780 ($3,895-$8,287) and $5912 ($3,432-$9,433) for cohorts A and B, respectively (p = 0.57). If the subjects in the participating counties were only admitted to the participating hospitals, the annual charges, extrapolated throughout the United States for the two periods, would be $2,419,016 and $8,129,538, respectively. If the subjects were evenly distributed across all pediatric monitored beds in a given county, the annual charges extrapolated throughout the United States for the two periods would be $5,694,232 and $24,126,640, respectively.

CONCLUSION

The incidence of unintentional poisonings from ADHD drugs is increasing and is associated with a significant cost.

[Uncertainty in the radiological evaluation of deformity in proximal humerus fractures]

INTRODUCTION

The accurate measurement of the deformity of proximal humerus fractures is essential for a proper treatment, particularly in the growing bone. Due to the local pain the correct projection in standard X-rays is difficult to achieve and, in contrast to other joints, cannot be verified in the X-ray. Even with the correct projections a mismeasurement can occur when the rotation is 45° to both planes. The aim of this study was to objectify the error sources and reveal starting points for an improvement.

MATERIAL AND METHODS

In a three-step study we initially developed a mathemathical formula in cooperation with the faculty of mathematics of the University of Duisburg-Essen. This formula was proved with X-ray imaging of a steel rod which was bent 120°, simulating a 60° deformity. X-ray images with different rotation and tilt were taken and compared with the values calculated with the above-mentioned formula. In the third step X-rays of a healthy shoulder in different rotation and tilt positions were presented to 2 orthopaedic and 3 radiological consultants. The aim was to determine the direction and amount of rotation and tilt.

RESULTS

The first theoretical step resulted in a mathematical formula which describes the optical deformation based on real deformation, tilt and rotation. The evaluation showed a mean difference of 0.5° (0-1.2°) between the calculated and the measured values. In the third step, evaluation of the X-rays of a shoulder showed that two in 50 (4 %) of the values were correct, in additional 28 cases (56 %) the tendency of the direction of the rotation was correct, the extent of the rotation was missed by 19.6° (0-60°). Ante- and retroversion were evaluated correctly in nine cases (18 %), the extent was missed by a mean of 23° (0-50°). In seven cases (18 %) the tendency for rotation and ante-/retroversion was correct, in 11 cases (22 %) one or both aspects could not be evaluated, in additional 8 cases (16 %) the extent could not be estimated.

DISCUSSION

Our results show that rotation and tilt of the proximal humerus cannot be estimated in shoulder X-rays and therefore a reliable measurement of the deformity of proximal humerus fractures is extremely unsafe. This problem is relevant for clinical practice because of the high likeliness of unaccurate projections in shoulder X-ray imaging after trauma. Especially for the growing bone the problem is evident, so that new ways of determining the deformity are mandatory.

Pharmacological ascorbate with gemcitabine for the control of metastatic and node-positive pancreatic cancer (PACMAN): results from a phase I clinical trial

BACKGROUND

Treatment for pancreatic cancer with pharmacological ascorbate (ascorbic acid, vitamin C) decreases tumor progression in preclinical models. A phase I clinical trial was performed to establish safety and tolerability of pharmacological ascorbate combined with gemcitabine in patients with biopsy-proven stage IV pancreatic adenocarcinoma.

DESIGN

Nine subjects received twice-weekly intravenous ascorbate (15-125 g) employing Simon's accelerated titration design to achieve a targeted post-infusion plasma level of ≥350 mg/dL (≥20 mM). Subjects received concurrent gemcitabine. Disease burden, weight, performance status, hematologic and metabolic laboratories, time to progression and overall survival were monitored.

RESULTS

Mean plasma ascorbate trough levels were significantly higher than baseline (1.46 ± 0.02 vs. 0.78 ± 0.09 mg/dL, i.e., 83 vs. 44 μM, p < 0.001). Adverse events attributable to the drug combination were rare and included diarrhea (n = 4) and dry mouth (n = 6). Dose-limiting criteria were not met for this study. Mean survival of subjects completing at least two cycles (8 weeks) of therapy was 13 ± 2 months.

CONCLUSIONS

Data suggest pharmacologic ascorbate administered concurrently with gemcitabine is well tolerated. Initial data from this small sampling suggest some efficacy. Further studies powered to determine efficacy should be conducted.

Risk of end-stage renal disease among liver transplant recipients with pretransplant renal dysfunction

Guidelines recommend restricting simultaneous liver-kidney (SLK) transplant to candidates with prolonged dialysis or estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m(2) for 90 days. However, few studies exist to support the latter recommendation. Using Scientific Registry of Transplant Recipients and Medicare dialysis data, we assembled a cohort of 4997 liver transplant recipients from February 27, 2002-January 1, 2008. Serial eGFRs were calculated from serum creatinines submitted with MELD reports. We categorized recipients by eGFR patterns in the 90 days pretransplant: Group 1 (eGFR always >30), Group 2 (eGFR fluctuated), Group 3 (eGFR always <30) and Group 4 (short-term dialysis). For Group 2, we characterized fluctuations in renal function using time-weighted mean eGFR. Among liver-alone recipients in Group 3, the rate of end-stage renal disease (ESRD) by 3 years was 31%, versus <10% for other groups (p < 0.001). In multivariable Cox regression, eGFR Group, diabetes (HR 2.65, p < 0.001) and black race (HR 1.83, p = 0.02) were associated with ESRD. Among liver-alone recipients in Group 2, only diabetics with time-weighted mean eGFR <30 had a substantial ESRD risk (25.6%). In summary, among liver transplant candidates not on prolonged dialysis, SLK should be considered for those whose eGFR is always <30 and diabetic candidates whose weighted mean eGFR is <30 for 90 days.

P2-12-27: Simply Adding Together the Diameters of Tumor Foci in Patients with Multicentric or Multifocal Disease Does Not Add Any Additional Prognostic Information: An Analysis from NCIC CTG MA.12 Randomized Placebo-Controlled Trial of Tamoxifen after Adjuvant Chemotherapy in Pre-Menopausal Women with Early Breast Cancer

Background: A common clinical conundrum in breast cancer management is whether pathologic T stage in women with multicentric or multifocal disease should be taken as the diameter of the largest focus or as the sum of all foci in the breast. Most staging systems, such as the American Joint Committee on Cancer (AJCC), simply use the largest tumor focus for staging. We examine here the impact of alternate methods of estimating tumour size including measures of total tumor size, volume and surface area.

Materials & Methods: NCIC CTG MA.12 is a randomized placebo-controlled trial of tamoxifen after adjuvant chemotherapy for pre-menopausal women with early breast cancer. Median follow up is 9.7 years. Pathologically reported patient tumor dimensions for up to 3 foci were utilized to examine the effects of tumor size on Breast-Cancer-Free-Interval (BCFI), defined as the time from randomization until recurrence (defined as first local, regional, distant, or contralateral invasive tumor or DCIS). Tumor size was estimated as 1) pathologic T stage as per AJCC criteria; 2) largest dimension of largest tumor focus (cm); 3) sum of largest dimension(s) of tumor foci (cm); 4) sum of surface area(s) of tumor foci (cm2), and 5) sum of volume of tumor foci (cm3). Step-wise forward unstratified Cox regression was used to assess the different effects of tumor size. Results: This study accrued 672 patients, 43% with T1 tumors, 51% with T2 tumors, and 6% with T3/T4 tumors; 25% were node negative and 56% had 1–3 positive lymph nodes. 75% were locally determined to have hormone receptor positive tumors. A higher number of involved lymph nodes was associated with significantly shorter BCFI (p&lt;0.0001). None of pathologic T stage (p=0.14), largest dimension of largest tumor size (p=0.14), sum of largest dimensions of tumor foci (p=0.24), sum of surface area (p=0.38), and sum of volume of foci (p=0.51) were significantly associated with BCFI. Likewise, lymphovascular invasion (p=0.08), grade (p=0.14), nor administration of anthracycline therapy (p=0.08) were associated with BCFI.

Discussion: In the MA.12 population of pre-menopausal women randomized to either tamoxifen or placebo, the sole factor significantly associated with BCFI was nodal status. No measure of tumor size in unifocal or multicentric/multifocal tumors impacted BCFI. The findings of this mature data set suggest that simply adding together the diameters of tumors in patients with multicentric or multifocal disease did not add any additional prognostic information.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-27.

P2-12-23: How Should We Assess Tumour Size (T Stage) in Patients with Multicentric/Multifocal Breast Cancer? Results from the NCIC CTG MA.5 Randomized Trial of CEF vs. CMF in Pre-Menopausal Women with Node Positive Breast Cancer

Background

A common clinical conundrum in breast cancer management is whether pathologic T stage in women with multicentric or multifocal disease should be taken as the diameter of the largest focus or as the sum of all foci in the breast. Most staging systems, such as the American Joint Committee on Cancer (AJCC), simply use the largest tumour focus for staging. We examine here the impact of alternate methods of estimating tumour size including measures of total tumour size, volume and surface area.

Methods: NCIC CTG MA.5 is a randomized trial of CEF versus CMF in pre-menopausal women with node positive breast cancer.

Median follow up is 10 years. Pathologically reported patient tumour dimensions for up to 3 foci were utilized to examine the effects of tumour size on Breast-Cancer-Free-Interval (BCFI). BCFI is defined as the time from randomization until recurrence: first local invasive or DCIS, regional, distant, contralateral invasive or DCIS. Tumour size was estimated as 1) pathologic T stage as per AJCC criteria; 2) largest dimension of largest tumour focus (cm); 3) sum of largest dimension(s) of tumour foci (cm); 4) sum of surface area(s) of tumour foci (cm2), and 5) sum of volume of tumour foci (cm3). Step-wise forward unstratified Cox regression was used to assess the different effects of tumour size.

Results: This study accrued 710 patients, 37% with T1 tumours, 52% with T2 tumours and 9% with T3 tumours; 61% had 1 to 3 positive lymph nodes. 59% hormone receptor positive. Higher pathologic T stage (p=0.001) and greater surface area (p=0.02) were associated with shorter BCFI, as was lymphovascular invasion (p=0.03), and # of lymph nodes involved (p&lt;0.0001). Administration of anthracycline therapy led to significantly longer BCFI (0.003). The sum of largest tumour sizes (p=0.33) and sum of tumour volume (p=0.34) were not significantly associated with BCFI. Additionally, when the less complete locally reported tumour grade data were included, higher tumour grade was associated with shorter BCFI (p&lt;0.0001).

Conclusions: Consideration of multicentric and multifocal disease was an important adjunct to standard pathologic tumour size as was estimation of tumour surface area in this chemotherapy trial of node positive premenopausal women. However, simply adding together the diameters of tumours in patients with multicentric or multifocal disease did not add any additional prognostic information in this high risk patient population.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-23.

P4-12-05: Impact of the Lifestyle Intervention Study in Adjuvant Treatment of Early Breast Cancer (LISA) Weight Loss Intervention upon Physical Activity

Observational evidence shows a relationship between obesity and poor prognosis in breast cancer (BC). Physical activity (PA) is an important component of weight loss and maintenance, but most large-scale interventions in BC patients have produced only modest improvements in activity. We sought to evaluate changes in PA in women participating in LISA, a randomized trial coordinated by the Ontario Clinical Oncology Group which was designed to examine the impact of a telephone-based weight loss intervention (WLI) upon disease free survival in BC patients.

Methods: Participants were randomized 1:1 to the WLI or educational control (EC) group. Eligibility included diagnosis of Stage I-III BC, BMI ≥24 kg/m2, and treatment with letrozole. The WLI, based on the Diabetes Prevention Program, focused on weight reduction through calorie restriction and increased physical activity. Delivery involved 19 calls, mailings and a participant manual. The PA goal was 150 minutes/week. PA was measured using the International Physical Activity Questionnaire (Short Form) at baseline, 6, 12, and 18 months. Changes in time (minutes/week) spent sitting and engaging in moderate, vigorous, and walking activities were compared between groups.

Results 338 women were randomized to WLI (n=171) or EC (n=167) from 20 centers in Canada and the USA. The study was discontinued due to loss of funding. The WLI arm lost significantly more weight than EC arm, with mean weight loss of 6.1% of body weight vs. 0.6% at 12 months (p&lt;0.001). Activity data are presented in Table 1. At baseline, participants were inactive; median vigorous activity was zero minutes/week and median time spent sitting was more than 35 hours/week. WLI participants reported significantly higher participation in vigorous, moderate and walking activities, and lower levels of sedentary behavior, compared to controls at 6 and 12 months. Higher levels of PA were significantly associated with increased weight loss at all time periods. Factors associated with increases in activity included higher baseline BMI (p=0.014), lower baseline activity (p&lt;0.001) and assignment to the WLI arm (p=0.02). Women assigned to WLI increased their PA during the intervention period (p=0.017) even after adjusting for other significant baseline factors.

Conclusion Participants in the LISA WLI reported significantly higher levels of PA compared with controls. Activity increased most in women who were heavier and less active at baseline. Further study of this WLI as a potential means to improve BC outcomes is warranted.

Maximum smoothed likelihood for multivariate mixtures

We introduce an algorithm for estimating the parameters in a finite mixture of completely unspecified multivariate components in at least three dimensions under the assumption of conditionally independent coordinate dimensions. We prove that this algorithm, based on a majorization-minimization idea, possesses a desirable descent property just as any em algorithm does. We discuss the similarities between our algorithm and a related one, the so-called nonlinearly smoothed em algorithm for the non-mixture setting. We also demonstrate via simulation studies that the new algorithm gives very similar results to another algorithm that has been shown empirically to be effective but that does not satisfy any descent property. We provide code for implementing the new algorithm in a publicly available R package.

The chemotherapy metabolite acrolein upregulates thrombin generation and impairs the protein C anticoagulant pathway in animal-based and cell-based models

BACKGROUND

Thrombosis is a common complication in cancer patients receiving chemotherapy regimens that include cyclophosphamide. However, the mechanisms by which these agents increase this risk are largely uncharacterized.

OBJECTIVES

To examine the effects of cyclophosphamide and its metabolite acrolein on procoagulant and anticoagulant pathways in both cell-based and animal-based models.

METHODS

Thrombin and activated protein C (APC) generation were measured in defibrinated plasma exposed to acrolein-treated endothelial and smooth muscle cells. Tissue factor (TF) activity was measured on acrolein-treated cells. Cell surface levels of phosphatidylserine, TF, endothelial protein C receptor and thrombomodulin were measured. Healthy BALB/c mice received injections of saline (control), acrolein, or cyclophosphamide; blood was collected, and plasma thrombin-antithrombin (TAT) complex, protein C and APC levels were analyzed.

RESULTS

Exposure of acrolein-treated endothelial and smooth muscle cells to defibrinated plasma increased thrombin generation in the plasma. This was associated with enhanced phosphatidylserine exposure and/or increased TF activity on acrolein-treated cells. Despite elevated levels of thrombin generation, plasma APC levels were not elevated. In vivo, treatment of mice with cyclophosphamide and acrolein resulted in elevations of plasma TAT complex levels, whereas APC levels remained low.

CONCLUSIONS

This is the first study to examine thrombin generation and the APC pathway in chemotherapy-treated mice. Cyclophosphamide and acrolein appear to upregulate procoagulant pathways, while impairing endogenous anticoagulant pathways. This may explain, in part, the increased risk of thrombosis observed in cancer patients receiving cyclophosphamide-containing chemotherapy.

Abstract P5-10-18: Echocardiography on Neonates Exposed to Anthracycline Therapy In Utero for Maternal Breast Cancer

Background: Anthracycline therapy carries a risk for cardiac toxicity in pediatric and adult populations. It is unknown if this risk also applies to fetuses exposed in utero. The objective of this study is to evaluate the cardiac function of neonates exposed to anthracyclines in utero. Materials and Methods: This was an observational study. Pregnant women diagnosed with breast cancer who underwent anthracycline based chemotherapy and delivered a liveborn infant after 24 weeks, were offered enrollment. Patients provided written consent to obtain doses and dates of chemotherapy treatment. Echocardiograms were offered to all newborns exposed as fetuses to anthracyclines. Women chose to perform this echocardiogram locally or at the institution of the primary investigator. Baseline fetal cardiac evaluation was reportedly normal on ultrasound prior to starting chemotherapy.

Chemotherapy Regimens:

Adriamycin/Cytoxan (n=20).

5-Fluorouracil/Adriamycin/Cytoxan (n=3)

There were no cases of exposure to epirubicin or idarubicin.

Mean dosage of Adriamycin was 57/m2 +/−8.0.

Results: Twenty three neonates participated.

Neonatal echocardiograms done at a mean age of 15 +/−26 months, (range 3 days of life to 9.75 years). RV wall, IVS and LV posterior wall diastolic and systolic thickness measurements were within normal limits for age and BSA. Mean shortening fraction was 41+/−10%. (normal 33 +/− 3%). In all 23, AV and semilunar valves were normal. Great arteries were normal in 22/23, with one case of a small pulmonary artery fistula. At 2 years of age, this was not hemodynamically significant. Patent foramen ovale was noted in 4 cases, all in children less than 2.0 months of age. Two children ages 3 days to 1.4 months had a PDA. One child at 1 year of age had an ASD. No structural or functional heart defects were diagnosed in any of these children.

Discussion:

Cardiac function appears to be preserved in neonates exposed to adriamycin chemotherapy in utero.

Any toxic effects on fetal myocytes was not evident in postnatal echocardiograms.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-10-18.

Dalteparin low molecular weight heparin (LMWH) in ovarian cancer: A phase II randomized study

e16529

Background: Up to 17% of women with ovarian cancer (OC) develop venous thromboembolism (VTE). LMWH reduces the risk of VTE and may have antineoplastic effects because tissue factor on OC cells stimulates tumor growth. A multicentre, open-label phase II randomized trial was undertaken to identify a potentially efficacious and safe dose of dalteparin to investigate its antineoplastic potential in OC. Methods: Women with newly diagnosed epithelial OC were randomized to receive taxane and platinum chemotherapy (CT) and one of 3 doses of dalteparin (50 IU/kg, 100 IU/kg, or 150 IU/kg) subcu daily during the first 3 cycles of CT. With each cycle of CT, patients had a CA125 and were assessed for bleeding or VTE. A response was defined as a ≥50% reduction in CA125 from baseline sustained for at least 28 days (according to GCIG criteria). To select the best LMWH group with a ≥ 80% response rate (RR) {vs. 60% with CT alone} with 90% probability, 39 patients per group were needed. Patients were followed until the end of CT. Results: 77 women were randomized and 72 of them completed follow-up. Compliance with injections was > 80%. There were no major bleeding events and 3 patients in the highest dose group had minor bleeding. There were no VTEs while on or within 7 days of finishing LMWH. There were 2 deaths attributed to the underlying OC. A 50% drop in CA125 by the start of cycle 4 was seen in 87% of the 50 IU/kg group, 92% of the100 IU/kg group, and 84% of the 150 IU/kg group, respectively. The corresponding RRs by the end of cycle 6 were 91%, 92% and 92%. Conclusions: Use of dalteparin is safe and well tolerated in women who are receiving CT for newly diagnosed OC. This therapy was effective in preventing VTE. A dose response effect on CA125 levels was not identified.

[Table: see text]

PET-CT compared to invasive mediastinal staging in non-small cell lung cancer (NSCLC)

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Background: In patients with NSCLC, preoperative staging tests including mediastinoscopy (M) are important in defining which patients are surgical candidates. 18FDG PET-CT is useful in identifying patients with mediastinal disease not evident by CT. Alternatively, M may not be required if PET-CT is negative. We have previously reported reduced rates of unnecessary thoracotomy (T) in the PET-CT arm of a trial which compared staging with PET-CT versus conventional imaging (bone scan and CT liver and adrenals) in patients with clinical stage I, II, or IIIA NSCLC being considered for surgery (J Clin Oncol 26 May 20 suppl: abstr 7502). Methods: In this analysis, we determined the accuracy of PET-CT in mediastinal staging compared to invasive surgical staging either by M alone or by M and T. Patients in the PET-CT arm had invasive mediastinal staging either by M or mediastinal nodal sampling at T. PET-CT was considered positive if N2 or N3 nodes exhibited increased 18FDG uptake. Results: M was performed in 81 of 143 patients in the PET-CT arm; the remainder had mediastinal nodal staging at T. Combining M with T, the sensitivity and specificity of PET-CT were 0.70 [95% CI: 0.48–0.85] and 0.94 [95%CI: 0.89–0.97], respectively. Of 21 patients with a positive PET-CT, 7 did not have tumor. The positive predictive value (PPV) and negative predictive value (NPV) were 0.67 [95% CI: 0.45–0.83] and 0.95 [95% CI: 0.90–0.98], respectively. The results for PET-CT versus M alone were: sensitivity, 1.0 [95% CI: 0.76–1.0]; specificity, 0.88 [95%CI: 0.79–0.94]; PPV, 0.60 [95%CI: 0.39–0.78]; NPV, 1.0 [95% CI: 0.94–1.0]. Based on PET-CT alone, 7 patients would have been denied T if PET-CT abnormalities had not been evaluated with invasive mediastinal staging. Conclusions: Mediastinal abnormalities on PET-CT should be confirmed by invasive mediastinal staging because of the risk of a false positive test. Patients should not be denied potentially curative therapy based on PET-CT alone. If PET-CT is negative in the mediastinum, the likelihood of occult metastatic disease in the mediastinum is very low and invasive staging may not be required depending on the clinical context.

No significant financial relationships to disclose.

Predictors of recurrent thrombosis and anticoagulant-related bleeding in patients with cancer

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Background: Anticoagulant therapy is treatment of choice for cancer-associated thrombosis. However, the risk of symptomatic recurrent thrombosis (RT) is approximately 9% on low molecular weight heparin (LMWH) and 17% on vitamin K antagonist (VKA) therapy, while the risk of anticoagulant-related major bleeding is about 5%. Given such complications are associated with morbidity and increased resource utilization, prognostic factors that identify patients at high risk for RT or bleeding would be useful for individualizing therapy. We performed a post-hoc analysis of the CLOT study (N Eng J Med 2003;349,146–53) for predictors of RT and bleeding in patients with proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) who were randomized to receive either dalteparin LMWH or VKA for 6 months. Methods: Cox proportional hazards modeling analyses were performed using prospectively collected data from the CLOT study database. Potential baseline factors associated with RT and bleeding examined in the models were identified a priori based on published literature. Factors for RT were: dalteparin, age, gender, ECOG status, smoking status, presence of metastases, tumor site, history of DVT or PE, recent surgery, cancer treatment and body mass index. Factors for bleeding were: dalteparin, age, gender, ECOG, tumor type, major surgery, cancer treatment, platelet count, body mass index, creatinine, and concurrent use of antiplatelet agents. Results: Data from 673 cancer patients were available for the analysis. There were 80 patients with RT, 31 with major bleeds and 77 with minor bleeds. Three statistically significant predictors for RT were identified (with their hazard ratio and corresponding 95% CI): dalteparin (0.52; 0.32–0.82), every 10 year increase in age (0.77; 0.66–0.90) and presence of metastases (2.59; 1.20–6.60). Of the tumour sites investigated, lung (3.51; 1.62–7.62) and unknown primaries (3.63; 1.36–1.90) were predictive of RT. None of the factors examined in the models were found to be predictive of bleeding. Conclusions: Baseline factors may identify cancer patients with a higher risk of RT despite anticoagulant therapy. The risk of anticoagulant-related bleeding is not predictable at treatment onset.

[Table: see text]

Impact of positron emission tomography (PET) in stage III non-small cell lung cancer (NSCLC): A prospective randomized trial (PET START)

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Background: Patients with stage III NSCLC are potentially curable using combined modality therapy (CMT) with chemotherapy and radical radiation (RT). The use of PET-CT rather than conventional imaging (CI) may better identify patients for CMT by enhanced tumor staging and improved definition of RT treatment volumes. Methods: Patients with stage III NSCLC (based on histology/cytology, brain CT/MRI, CT thorax, CT/US abdomen, and bone scan) who were considered candidates for CMT were randomized to either PET-CT or CT for RT treatment planning. The primary outcome was the proportion of patients who did not receive CMT because their tumor was upstaged to Stage 4 or their intrathoracic tumor was too extensive for radical RT. Overall survival (OS) and alteration of RT treatment planning volume were secondary outcomes. Target sample size was 400 patients based on a hazard rate reduction of 30% in OS at 2 years in favor of PET-CT with 2-sided alpha = 0.05 and 80% power. We also postulated that 200 patients would be required to detect a 20% difference between arms for the primary endpoint. 5 centers in Ontario participated. Results: The trial commenced in August 2004. In November 2008 after a planned interim analysis for the primary outcome, the Data Safety Monitoring Board recommended stopping recruitment because of superior efficacy with PET-CT. 304 patients were randomized and 289 had analyzable data. 25 patients were unsuitable for CMT: 21 in the PET-CT arm (16 upstaged to Stage 4 and 5 unsuitable for radical RT) and 4 in the CT arm (unsuitable for radical RT). Thus, 21 of 140 (15%) patients in the PET-CT arm achieved the primary outcome compared with 4 of 149 (2.7%) in the CT arm, P= 0.0002. Conclusions: This is the first randomized trial in stage III NSCLC showing that PET-CT is superior to CT planning alone in selecting appropriate patients for CMT. Longer patient follow-up will determine potential impact on OS.

No significant financial relationships to disclose.

Dehydroascorbate and glucose are taken up into Arabidopsis thaliana cell cultures by two distinct mechanisms

The possible involvement of glucose (Glc) carriers in the uptake of vitamin C in plant cells is still a matter of debate. For the first time, it was shown here that plant cells exclusively take up the oxidised dehydroascorbate (DHA) form. DHA uptake is not affected by 6-bromo-6-deoxy-ascorbate, an ascorbate (ASC) analogue, specifically demonstrating ASC uptake in animal cells. There is no competition between Glc and DHA uptake. Moreover, DHA and Glc carriers respond in the opposite manner to different inhibitors (cytochalasin B, phloretin and genistein). In conclusion, the plant plasma membrane DHA carrier is distinct from the plant Glc transporters.

Phase I clinical trial of i.v. ascorbic acid in advanced malignancy

BACKGROUND

Ascorbic acid is a widely used and controversial alternative cancer treatment. In millimolar concentrations, it is selectively cytotoxic to many cancer cell lines and has in vivo anticancer activity when administered alone or together with other agents. We carried out a dose-finding phase I and pharmacokinetic study of i.v. ascorbic acid in patients with advanced malignancies.

PATIENTS AND METHODS

Patients with advanced cancer or hematologic malignancy were assigned to sequential cohorts infused with 0.4, 0.6, 0.9 and 1.5 g ascorbic acid/kg body weight three times weekly.

RESULTS

Adverse events and toxicity were minimal at all dose levels. No patient had an objective anticancer response.

CONCLUSIONS

High-dose i.v. ascorbic acid was well tolerated but failed to demonstrate anticancer activity when administered to patients with previously treated advanced malignancies. The promise of this approach may lie in combination with cytotoxic or other redox-active molecules.

Perception of sweet taste is important for voluntary alcohol consumption in mice

To directly evaluate the association between taste perception and alcohol intake, we used three different mutant mice, each lacking a gene expressed in taste buds and critical to taste transduction: alpha-gustducin (Gnat3), Tas1r3 or Trpm5. Null mutant mice lacking any of these three genes showed lower preference score for alcohol and consumed less alcohol in a two-bottle choice test, as compared with wild-type littermates. These null mice also showed lower preference score for saccharin solutions than did wild-type littermates. In contrast, avoidance of quinine solutions was less in Gnat3 or Trpm5 knockout mice than in wild-type mice, whereas Tas1r3 null mice were not different from wild type in their response to quinine solutions. There were no differences in null vs. wild-type mice in their consumption of sodium chloride solutions. To determine the cause for reduction of ethanol intake, we studied other ethanol-induced behaviors known to be related to alcohol consumption. There were no differences between null and wild-type mice in ethanol-induced loss of righting reflex, severity of acute ethanol withdrawal or conditioned place preference for ethanol. Weaker conditioned taste aversion (CTA) to alcohol in null mice may have been caused by weaker rewarding value of the conditioned stimulus (saccharin). When saccharin was replaced by sodium chloride, no differences in CTA to alcohol between knockout and wild-type mice were seen. Thus, deletion of any one of three different genes involved in detection of sweet taste leads to a substantial reduction of alcohol intake without any changes in pharmacological actions of ethanol.