Quit attempts among tobacco users identified in the Tamil Nadu Tobacco Survey of 2015/2016: a 3 year follow-up mixed methods study

OBJECTIVES

To determine current tobacco use in 2018/2019, quit attempts made and to explore the enablers and barriers in quitting tobacco among tobacco users identified in the Tamil Nadu Tobacco Survey (TNTS) in 2015/2016.

SETTING

TNTS was conducted in 2015/2016 throughout the state of Tamil Nadu (TN) in India covering 111 363 individuals. Tobacco prevalence was found to be 5.2% (n=5208).

PARTICIPANTS

All tobacco users in 11 districts of TN identified by TNTS (n=2909) were tracked after 3 years by telephone. In-depth interviews (n=26) were conducted in a subsample to understand the enablers and barriers in quitting.

PRIMARY AND SECONDARY OUTCOMES

Current tobacco use status, any quit attempt and successful quit rate were the primary outcomes, while barriers and enablers in quitting were considered as secondary outcomes.

RESULTS

Among the 2909 tobacco users identified in TNTS 2015/2016, only 724 (24.9%) could be contacted by telephone, of which 555 (76.7%) consented. Of those who consented, 210 (37.8%) were currently not using tobacco (ie, successfully quit) and 337 (60.7%) continued to use any form of tobacco. Of current tobacco users, 115 (34.1%) have never made any attempt to quit and 193 (57.3.8%) have made an attempt to quit. Those using smoking form of tobacco products (adjusted relative risk (aRR)=1.2, 95% CI: 1.1 to 1.4) and exposure to smoke at home (aRR=1.2, 95% CI: 1.1 to 1.3) were found to be positively associated with continued tobacco use (failed or no quit attempt). Support from family and perceived health benefits are key enablers, while peer influence, high dependence and lack of professional help are some of the barriers to quitting.

CONCLUSION

Two-thirds of the tobacco users continue to use tobacco in the last 3 years. While tobacco users are well aware of the ill-effects of tobacco, various intrinsic and extrinsic factors play a major role as a facilitator and lack of the same act as a barrier to quit.

Olanzapine versus metoclopramide for the treatment of breakthrough chemotherapy-induced vomiting in children: An open-label, randomized phase 3 trial

BACKGROUND

Breakthrough chemotherapy-induced vomiting (CIV) is defined as CIV occurring after adequate antiemetic prophylaxis. Olanzapine and metoclopramide are two drugs recommended for the treatment of breakthrough CIV in children, without adequate evidence. We conducted an open-label, single-center, phase 3 randomized controlled trial comparing the safety and efficacy of olanzapine and metoclopramide for treating breakthrough CIV.

PROCEDURE

Children aged 5-18 years who developed breakthrough CIV after receiving highly emetogenic chemotherapy or moderately emetogenic chemotherapy were randomly assigned to the metoclopramide or olanzapine arm. The primary objective of the study was to compare the complete response (CR) rates between patients receiving olanzapine or metoclopramide for treating breakthrough CIV during 72 hours after the administration of the study drug. Secondary objectives were to compare CR rates for nausea and toxicities between the two arms.

RESULTS

Eighty patients were analyzed (39 in the olanzapine arm and 41 in the metoclopramide arm). CR rates were significantly higher in the olanzapine arm compared with the metoclopramide arm for vomiting (72% vs 39%, P = 0.003) and nausea (59% vs 34%, P = 0.026). Seven patients in the metoclopramide arm crossed over to the olanzapine arm and none crossed over in the olanzapine arm (P < 0.001). The mean nausea score in the olanzapine arm was significantly lower than the metoclopramide arm after the initiation of the rescue antiemetic (P = 0.01). Hyperglycemia and drowsiness were more commonly seen in the olanzapine arm.

CONCLUSION

Olanzapine is superior to metoclopramide for the treatment of breakthrough CIV in children. Drowsiness and hyperglycemia need to be monitored closely in children receiving olanzapine for breakthrough CIV.

A Microfluidic MEMS-Microbalance Platform With Minimized Acoustic Radiation in Liquid

In this article, the microfluidic channels that deliver liquid to a microscale thin-film piezoelectric-on-silicon (TPoS) gravimetric resonant sensor are incorporated into the backside of the silicon-on-insulator (SOI) wafer on which the resonator is fabricated. Specifically, a microwell is embedded at the bottom of the disk -shaped TPoS resonator, while a very thin layer of parylene covering the backside of the resonator and the microwell forms an isolation layer between the liquid and the top device-layer features. In this way, the liquid is in contact with the backside of the resonator, while the device-defining trenches and the electrical connections to the resonator stay clear, thus mitigating the acoustic energy loss and undesirable feedthroughs. The impact of the parylene layer thickness on a few symmetric ( S ) and antisymmetric ( A ) Lamb wave modes of the resonator is experimentally studied, and the performance of such modes in the liquid is characterized by filling the microwells through a PDMS-based microfluidic channel. The parylene layer, while marginally affecting the resonator in the air, is found to substantially enhance its performance in the liquid media. Strong resonance peaks with high quality factors ( Q ) are observed for the S modes, among which Q values above 400 are recorded for a specific mode named S (4, 2) (among the highest ever reported). This article can potentially facilitate the realization of highly stable and sensitive resonant mass sensors (i.e., microbalance) for real-time applications. Additionally, the effect of the acoustic energy radiation in the form of evanescent shear and longitudinal waves in liquid on the Q and resonance frequency of the disk resonators is experimentally validated.

Assessment of an ensemble of machine learning models toward abnormality detection in chest radiographs

Respiratory diseases account for a significant proportion of deaths and disabilities across the world. Chest X-ray (CXR) analysis remains a common diagnostic imaging modality for confirming intra-thoracic cardiopulmonary abnormalities. However, there remains an acute shortage of expert radiologists, particularly in under-resourced settings, resulting in severe interpretation delays. These issues can be mitigated by a computer-aided diagnostic (CADx) system to supplement decision-making and improve throughput while preserving and possibly improving the standard-of-care. Systems reported in the literature or popular media use handcrafted features and/or data-driven algorithms like deep learning (DL) to learn underlying data distributions. The remarkable success of convolutional neural networks (CNN) toward image recognition tasks has made them a promising choice for automated medical image analyses. However, CNNs suffer from high variance and may overfit due to their sensitivity to training data fluctuations. Ensemble learning helps to reduce this variance by combining predictions of multiple learning algorithms to construct complex, non-linear functions and improve robustness and generalization. This study aims to construct and assess the performance of an ensemble of machine learning (ML) models applied to the challenge of classifying normal and abnormal CXRs and significantly reducing the diagnostic load of radiologists and primary-care physicians.

Capabilities and limitations of 3D printed microserpentines and integrated 3D electrodes for stretchable and conformable biosensor applications

We explore the capabilities and limitations of 3D printed microserpentines (µserpentines) and utilize these structures to develop dynamic 3D microelectrodes for potential applications in in vitro, wearable, and implantable microelectrode arrays (MEAs). The device incorporates optimized 3D printed µserpentine designs with out-of-plane microelectrode structures, integrated on to a flexible Kapton® package with micromolded PDMS insulation. The flexibility of the optimized, printed µserpentine design was calculated through effective stiffness and effective strain equations, so as to allow for analysis of various designs for enhanced flexibility. The optimized, down selected µserpentine design was further sputter coated with 7-70 nm-thick gold and the performance of these coatings was studied for maintenance of conductivity during uniaxial strain application. Bending/conforming analysis of the final devices (3D MEAs with a Kapton® package and PDMS insulation) were performed to qualitatively assess the robustness of the finished device toward dynamic MEA applications. 3D microelectrode impedance measurements varied from 4.2 to 5.2 kΩ during the bending process demonstrating a small change and an example application with artificial agarose skin composite model to assess feasibility for basic transdermal electrical recording was further demonstrated.

Low-Power, Multimodal Laser Micromachining of Materials for Applications in sub-5 µm Shadow Masks and sub-10 µm Interdigitated Electrodes (IDEs) Fabrication

Laser micromachining is a direct write microfabrication technology that has several advantages over traditional micro/nanofabrication techniques. In this paper, we present a comprehensive characterization of a QuikLaze 50ST2 multimodal laser micromachining tool by determining the ablation characteristics of six (6) different materials and demonstrating two applications. Both the thermodynamic theoretical and experimental ablation characteristics of stainless steel (SS) and aluminum are examined at 1064 nm, silicon and polydimethylsiloxane (PDMS) at 532 nm, and Kapton^® and polyethylene terephthalate at 355 nm. We found that the experimental data aligned well with the theoretical analysis. Additionally, two applications of this multimodal laser micromachining technology are demonstrated: shadow masking down to approximately 1.5 µm feature sizes and interdigitated electrode (IDE) fabrication down to 7 µm electrode gap width.

Makerspace microfabrication of a stainless steel 3D microneedle electrode array (3D MEA) on a glass substrate for simultaneous optical and electrical probing of electrogenic cells

Microfabrication and assembly of 3D MEA based on a glass-stainless steel platform is shown utilizing non-traditional “Makerspace Microfabrication” techniques featuring cost-effective, rapid fabrication and an assorted biocompatible material palette.

A novel stacked generalization of models for improved TB detection in chest radiographs

Chest x-ray (CXR) analysis is a common part of the protocol for confirming active pulmonary Tuberculosis (TB). However, many TB endemic regions are severely resource constrained in radiological services impairing timely detection and treatment. Computer-aided diagnosis (CADx) tools can supplement decision-making while simultaneously addressing the gap in expert radiological interpretation during mobile field screening. These tools use hand-engineered and/or convolutional neural networks (CNN) computed image features. CNN, a class of deep learning (DL) models, has gained research prominence in visual recognition. It has been shown that Ensemble learning has an inherent advantage of constructing non-linear decision making functions and improve visual recognition. We create a stacking of classifiers with hand-engineered and CNN features toward improving TB detection in CXRs. The results obtained are highly promising and superior to the state-of-the-art.

Precision Vascular Delivery of Agrochemicals with Micromilled Microneedles (µMMNs)

We demonstrate use of makerspace techniques involving subtractive microtechnologies to fabricate micromilled microneedles (µMMNs) of stainless steel (SS) for precise delivery of agrochemicals into vascular bundles of plant tissue. Precision delivery is of immense importance for systemic pathogen control in specific areas of plant tissue. Optimization of the micromilling allows for selective removal of SS at the microscale and the microfabrication of a 5 × 5 array of µMMNs having both base width and height of 500 µm to enable precise puncture into the stem of citrus saplings. Atomic Absorption Spectroscopy reveals up to 7.5× increase in the uptake of a therapeutic cargo while Scanning Electron Microscopy reveals that specific sites of the vascular bundle; either xylem or the phloem can be uniquely targeted with customized µMMNs. Such rapid and cost-effective customization with intricate designs along with scalability is enabled by makerspace microfabrication. Additionally, a 19 × 20 array of micromilled mesoneedles has been fabricated and affixed to a paint roller as an applicator system for real-world field testing outside the laboratory. Initial results indicate reliable behavior of the applicator system and the technique can be applied to the systemic delivery of agrochemicals while conserving the loss of the agrochemical with increased application efficiency.

Exploratory analysis of barriers and facilitators to cervical cancer care in rural Tamil Nadu, India

125

Background: Approximately 20% of cervical cancer deaths worldwide occur in India, most notably in rural areas. The key to addressing the cervical cancer epidemic is early detection and treatment of precancerous cervical lesions. Many studies that assess barriers to cervical cancer care in India focus on individual level factors, such as awareness and education. Given the disparities in cervical cancer in India, particularly between rural and urban settings, a comprehensive, multi-level approach to evaluating barriers and facilitators to care is needed. Methods: In December 2018, we used semi-structured interviews and direct observation of 15 community health workers, medical officers and gynecologic oncologists to explore the multi-level barriers and facilitators to cervical cancer care in rural Tamil Nadu. Data collection occurred within an existing organized cervical cancer screening program and was guided by the social-ecological model. Results: Barriers and facilitators to cervical cancer screening and treatment of precancerous lesions were identified at all levels of the social-ecological model. Barriers included fear of and travel distance to urban centers for treatment (individual), limited social support (interpersonal), lack of rural clinical facilities that provide treatment (organizational), competing community health initiatives (community), and lack of cohesive national screening and treatment guidelines (policy). Facilitators included travel distance to local screening services (individual), access to community health workers (interpersonal), institutional initiatives to increase screening access (organizational), mass awareness campaigns (community), and Tamil Nadu State priorities to improve cervical cancer care (policy). Conclusions: This assessment underscores the gap between cervical cancer screening and treatment in rural Tamil Nadu. This data will inform the development of a multi-faceted intervention, targeting all levels of the social-ecological model, to improve the linkage between cervical cancer screening and treatment for precancerous cervical lesions to decrease the burden of disease and mortality in India.

Intravenous fosaprepitant for the prevention of chemotherapy-induced vomiting in children: A double-blind, placebo-controlled, phase III randomized trial

BACKGROUND

Fosaprepitant is a neurokinin-1 receptor antagonist, approved for the prevention of chemotherapy-induced nausea and vomiting. The data on the use of fosaprepitant in children are limited and therefore we conducted a phase III randomized controlled trial.

PROCEDURE

Children aged 1-12 years scheduled to receive moderately or highly emetogenic chemotherapy were randomly assigned to arm-A (fosaprepitant) or arm-B (placebo). Children recruited to arm-A received intravenous ondansetron plus dexamethasone followed by fosaprepitant infusion. Children recruited to arm-B received the same drugs as those given to children in arm-A, except that fosaprepitant was substituted with a placebo. Ondansetron and dexamethasone were continued for 48 hours after completion of chemotherapy. The primary end point of the study was to determine the proportion of patients who achieved a complete response (CR), defined as no vomiting, no retching, and no use of rescue medication, during the 24-120 hours (delayed phase) after administration of the last dose of chemotherapy. Secondary end points were the proportion of patients who achieved a CR during the acute phase (0-24 hours) and overall after administration of the last dose of chemotherapy.

RESULTS

One-hundred-sixty-three patients were analyzed (81 in the fosaprepitant arm and 82 in the placebo arm). CR rates were significantly higher in the fosaprepitant arm compared to those in the placebo arm during the acute phase (86% vs 60%, P < 0.001), delayed phase (79% vs 51%, P < 0.001), and overall phase (70% vs 41%, P < 0.001). Three (4%) patients in the fosaprepitant arm and sixteen (20%) in the placebo arm required rescue anti-emetics (P = 0.0017).

CONCLUSION

Addition of fosaprepitant to ondansetron and dexamethasone improved chemotherapy-induced vomiting control in children treated with moderately or highly emetogenic chemotherapy.

Optimization of makerspace microfabrication techniques and materials for the realization of planar, 3D printed microelectrode arrays in under four days

Conventional two-dimensional microelectrode arrays (2D MEAs) in the market involve long manufacturing timeframes, have cleanroom requirements, and need to be assembled from multiple parts to obtain the final packaged device. For MEAs to be “used and tossed”, manufacturing has to be moved from the cleanroom to makerspaces. In order to enable makerspace fabricated MEAs comparable to conventional MEAs, the microfabrication processes must be optimized to have similar electrical properties along with biocompatibility and number of recording sites. This work presents a makerspace microfabricated 2D MEA having electrode densities up to a commercially popular 8 × 8 array, all fabricated under four days. Additive manufacturing-based realization of the MEA devices provides immense flexibility in terms of meeting distinct design requirements. A unique non-planar MEA having meso-scale electrodes on the top side of a chip transitioning to traces onto the bottom side through electrical vias is presented in this work. This allows for (a) monolithic integration of a culture well for devices having up to a 6 × 6 MEA array, (b) selective electroplating of the meso-scale electrodes (500 μm diameter) defined by silver ink casting followed by pulsed electroplating of gold or platinum without any masking procedure, (c) casting of a uniform and planar insulation layer via a novel process of confined precision spin coating (CPSC) of SU-8 which acts as a biocompatible insulation atop the meso-scale electrodes; and (d) selective laser micromachining to define the 50 μm × 50 μm microelectrodes. For an 8 × 8 array, the culture well and MEA chip framework are 3D printed as two separate parts and sealed together with a biocompatible epoxy as in commercially available MEAs. The fabricated MEAs have an average 1 kHz impedance of 36.8 kΩ/16 kΩ with a double layer capacitance of 400 nF cm⁻²/520 nF cm⁻² for nano-porous platinum/nano-gold which is comparable to the state-of-art commercially available 2D MEAs. Additionally, it was found out that our 3D printing-based process compares very favorably with traditional glass MEAs in terms of design to device while representing a dramatic reduction in cost, timeline for fabrication, reduction in the number of steps and the need for sophisticated microfabrication and packaging equipment.

“Makerspace microfabrication” with the use of simple tools and materials is used to demonstrate the realization of 2D microelectrode arrays (MEAs) having a density of up to 8 × 8 MEAs in under four days which are comparable to conventional MEAs.

Fiber-Type Solar Cells, Nanogenerators, Batteries, and Supercapacitors for Wearable Applications

Wearable electronic devices represent a paradigm change in consumer electronics, on-body sensing, artificial skins, and wearable communication and entertainment. Because all these electronic devices require energy to operate, wearable energy systems are an integral part of wearable devices. Essentially, the electrodes and other components present in these energy devices should be mechanically strong, flexible, lightweight, and comfortable to the user. Presented here is a critical review of those materials and devices developed for energy conversion and storage applications with an objective to be used in wearable devices. The focus is mainly on the advances made in the field of solar cells, triboelectric generators, Li-ion batteries, and supercapacitors for wearable device development. As these devices need to be attached/integrated with the fabric, the discussion is limited to devices made in the form of ribbons, filaments, and fibers. Some of the important challenges and future directions to be pursued are also highlighted.

Long-term outcome of diffuse large B-cell lymphoma: Impact of biosimilar rituximab and radiation

INTRODUCTION

Rituximab (R)-CHOP improves survival over CHOP in diffuse large B-cell lymphoma (DLBCL). The availability of biosimilar rituximab in India has increased access of this drug. We report on the impact of treatment on outcomes with special emphasis on the impact of biosimilar rituximab and radiation.

METHODS

Outcomes of adults (age 15-60 years) treated with CHOP+/- Rituximab radiation were analyzed retrospectively to look at baseline features, treatment, and event-free and overall survival (EFS and OS).

RESULTS

In the period 2000-2013, 444 patients (median age 47 years: 15-60; males: 288 [65%]; Stage III/IV: 224 [50%]; age-adjusted international prognostic index [aaIPI] Score 2 or 3 in 50%) received either CHOP (n = 325 [73%]) or RCHOP (n = 119 [27%]) therapy. Biosimilar rituximab and the original were used in 95 (80%) and 24 (20%) patients, respectively. Radiation was given in 134 (30%) patients (Stages I and II, 100/220 [45%] and Stages III and IV, 34/224 [15%]). After a median follow-up of 46 (0.2-126) months, the 5-year EFS and OS were 59% and 68%, respectively. The factors predicting inferior EFS and OS were age> 40 years, performance status 2-4, Stage III/IV, hemoglobin <12 g/dL, the aaIPI Score 2 or 3, and nonuse of rituximab and radiation. Radiation used in early stage disease benefitted all subgroups regardless of bulky disease, use of rituximab, or the number of cycles of chemotherapy. Addition of rituximab improved survival across all categories of aaIPI.

CONCLUSION

Availability of biosimilar rituximab has increased access and survival of patients with DLBCL in India. Radiotherapy improved outcomes in early stages.

3D Printing, Ink Casting and Micromachined Lamination (3D PICLμM): A Makerspace Approach to the Fabrication of Biological Microdevices

We present a novel benchtop-based microfabrication technology: 3D printing, ink casting, micromachined lamination (3D PICLμM) for rapid prototyping of lab-on-a-chip (LOC) and biological devices. The technology uses cost-effective, makerspace-type microfabrication processes, all of which are ideally suited for low resource settings, and utilizing a combination of these processes, we have demonstrated the following devices: (i) 2D microelectrode array (MEA) targeted at in vitro neural and cardiac electrophysiology, (ii) microneedle array targeted at drug delivery through a transdermal route and (iii) multi-layer microfluidic chip targeted at multiplexed assays for in vitro applications. The 3D printing process has been optimized for printing angle, temperature of the curing process and solvent polishing to address various biofunctional considerations of the three demonstrated devices. We have depicted that the 3D PICLμM process has the capability to fabricate 30 μm sized MEAs (average 1 kHz impedance of 140 kΩ with a double layer capacitance of 3 μF), robust and reliable microneedles having 30 μm radius of curvature and ~40 N mechanical fracture strength and microfluidic devices having 150 μm wide channels and 400 μm fluidic vias capable of fluid mixing and transmitted light microparticle visualization. We believe our 3D PICLμM is ideally suited for applications in areas such as electrophysiology, drug delivery, disease in a dish, organ on a chip, environmental monitoring, agricultural therapeutic delivery and genomic testing.

Awareness and Perception About Cancer Among the Public in Chennai, India

PURPOSE

Cancer-related stigma influences the way people perceive cancer, which renders cancer control-beginning with prevention and proceeding to palliation-a challenging task. This study aimed to assess the current levels of awareness and perceptions about cancer among people with various socioeconomic status and diverse backgrounds in the city of Chennai, India.

PATIENTS AND METHODS

The sample population (N = 2,981; 18 to 88 years of age) was stratified into four groups: patients (n = 510), caregivers (n = 494) consulting at the Cancer Institute (Women Indian Association), college students (n = 978), and general public (n = 999). Fourteen statements related to cancer stigma or myths were identified and categorized by awareness (10 items) or perception (4 items). Responses to those statements were recorded by using a Likert scale (yes, no, and don't know). The data were described by frequency analysis and χ2 test using SPSS Version 13 (SPSS, Chicago, IL).

RESULTS

More than 70% of the study participants were aware that cancer is curable, that cancer is not contagious, and that cancer is not a curse or a death sentence. However, only approximately half believed that surgery or biopsy do not cause cancer to spread to other organs or that radiation therapy does not consist of receiving an electric shock. Higher education, younger age, male sex, personal experience with cancer (either as a patient or caregiver), and high socioeconomic status were the categories of people with increased awareness about cancer.

CONCLUSION

These factors need to be taken into consideration in tailoring information, education, and communication campaigns. Resource allocation for these campaigns is an investment in cancer control.

Microneedle cuff electrodes for extrafascicular peripheral nerve interfacing

OBJECTIVE

The work presented here describes a new tool for peripheral nerve interfacing, called the microneedle cuff (μN-cuff) electrode.

APPROACH

μN arrays are designed and integrated into cuff electrodes for penetrating superficial tissues while remaining non-invasive to delicate axonal tracts.

MAIN RESULTS

In acute testing, the presence of 75 μm height μNs decreased the electrode-tissue interface impedance by 0.34 kΩ, resulting in a 0.9 mA reduction in functional stimulation thresholds and increased the signal-to-noise ratio by 9.1 dB compared to standard (needle-less) nerve cuff electrodes. Preliminary acute characterization suggests that μN-cuff electrodes provide the stability and ease of use of standard cuff electrodes while enhancing electrical interfacing characteristics.

SIGNIFICANCE

The ability to stimulate, block, and record peripheral nerve activity with greater specificity, resolution, and fidelity can enable more precise spatiotemporal control and measurement of neural circuits.

Micromachining on and of Transparent Polymers for Patterning Electrodes and Growing Electrically Active Cells for Biosensor Applications

We report on microfabrication and assembly process development on transparent, biocompatible polymers for patterning electrodes and growing electrically active cells for in vitro cell-based biosensor applications. Such biosensors are typically fabricated on silicon or glass wafers with traditional microelectronic processes that can be cost-prohibitive without imparting necessary biological traits on the devices, such as transparency and compatibility for the measurement of electrical activity of electrogenic cells and other biological functions. We have developed and optimized several methods that utilize traditional micromachining and non-traditional approaches such as printed circuit board (PCB) processing for fabrication of electrodes and growing cells on the transparent polymers polyethylene naphthalate (PEN) and polyethylene terephthalate (PET). PEN-based biosensors are fabricated utilizing lithography, metal lift-off, electroplating, wire bonding, inkjet printing, conformal polymer deposition and laser micromachining, while PET-based biosensors are fabricated utilizing post-processing technologies on modified PCBs. The PEN-based biosensors demonstrate 85⁻100% yield of microelectrodes, and 1-kHz impedance of 59.6 kOhms in a manner comparable to other traditional approaches, with excellent biofunctionality established with an ATP assay. Additional process characterization of the microelectrodes depicts expected metal integrity and trace widths and thicknesses. PET-based biosensors are optimized for a membrane bow of 6.9 to 15.75 µm and 92% electrode yield on a large area. Additional qualitative optical assay for biomaterial recognition with transmitted light microscopy and growth of rat cortical cells for 7 days in vitro (DIV) targeted at biological functionalities such as electrophysiology measurements are demonstrated in this paper.

Phase II study of interim PET-CT-guided response-adapted therapy in advanced Hodgkin's lymphoma

BACKGROUND

Combination chemotherapy ABVD (doxorubicin, bleomycin, vinblastine and dacarabazine) cures ∼70% of patients with advanced Hodgkin's lymphoma (aHL, stages IIB, III and IV) while more toxic escalated BEACOPP (EB, combination of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisolone) increases cure rates to 85%. Patients with a positive interim positron emission tomography-computerized tomography (PET-CT) scan after two cycles (PET-2) of ABVD have very poor outcomes with continued ABVD. Intensifying therapy with EB in PET-2-positive patients ('response-adapted therapy') may improve cure rates, whereas the negative patients can continue ABVD alone.

PATIENTS AND METHODS

Eligible patients with newly diagnosed aHL received two cycles of ABVD and underwent PET-2 (scored with semi-quantitative 5-point visual criteria, 'Deauville score'). PET-2-negative patients continued four additional cycles of ABVD, whereas PET-2-positive patients received four cycles of EB. A phase II sample size of 50 was estimated keeping the lower and higher proportion of rejection of the event-free survival (EFS) as 70% and 85%, respectively.

RESULTS

Fifty patients [median age 28 (12-60) years; male : female: 39 : 11; stages: IIB-3 (6%), III-29 (58%) and IV-18 (36%); International Prognostic Score (IPS): 0-3: 34 (68%); 4-7: 16 (32%)] were enrolled; 49 underwent PET-2. Eight (16%) were PET-2-positive, whereas 41 (84%) were negative. Forty-seven were evaluable for EFS and all 50 for overall survival (OS). The 2-year EFS was 76% (95% CI: 68-83) and OS was 88% (95% CI: 82-94). PET-2 was strongly prognostic-2-year EFS, negative versus positive: 82% versus 50%; P = 0.013.

CONCLUSION

PET-2 response-adapted strategy could not achieve EFS of 85% in aHL. However, escalated therapy improved outcomes in PET-2-positive patients compared with historical data.

TRIAL REGISTRATION

CTRI/2012/06/002741 (http://www.ctri.nic.in) and NCT01304849 (http://www.clinicaltrials.gov).

Effects of parathyroid hormonal peptides on the gut

Our previous studies have shown PTH to be an effective relaxant of smooth muscle throughout the mammalian tract. Recently, we found PTHrP to be equally as potent and effective on the gut as PTH, and we hypothesized that PTHrP, rather than PTH, might be the natural ligand for the gut receptors which mediate GI smooth muscle relaxation. To approach this question, we asked whether rat GI tissue expresses mRNA for PTHrP. Using selective reverse transcription and PCR we have found PTHrP mRNA in smooth muscle throughout the rat GI tract and in gastric and colonic mucosa as well. Our findings support the idea that PTHrP can be produced by GI tissues and that it may function there as an autocrine or paracrine factor. One of its actions may involve regulation of GI muscle tone.