Management of diarrhoea cases by community pharmacies in 3 cities of Pakistan

Community pharmacies are valued for their potential role in the management of common ailments. This cross-sectional study aimed to document the management of diarrhoea by community pharmacies in 3 cities in Pakistan. Visits were performed to 371 randomly selected pharmacies to request advice for a simulated paediatric case of diarrhoea. The pharmacy's management was scored on a checklist including history taking and provision of advice and information. Customers were served by a salesperson in 97.3% of visits and by a pharmacist in only 2.2%. Medication was dispensed in 77.1% of visits. Of the medications dispensed, 58.7% were antiamoebics, 14.0% antibiotics and 18.9% antidiarrhoeals; only 8.4% were oral rehydration salts. None of the regimens matched with a standard prescription. The dosage regimen was explained to the customer in only 52.6% of cases. Drug safety, unqualified personnel, lack of history taking, inappropriate treatment and lack of counselling are concerns to be addressed.

GSTP1 methylation and polymorphism increase the risk of breast cancer and the effects of diet and lifestyle in breast cancer patients

Glutathione S-transferases (GSTs) are an important group of isoenzymes that play an essential role in the detoxification of carcinogens. Polymorphism at exon 5 of the GST π family decreases the catalytic activity and affects the detoxification ability of the enzyme, GSTP1. GSTP1 promoter hypermethylation and loss of expression are frequently observed in various types of carcinoma. We hypothesized that somatic epigenetic modification in homozygous mutants increases the degree to which breast cancer risk is affected by lifestyle factors and dietary habits. The present study used tumor biopsies and blood samples from 215 breast cancer patients and 215 blood samples from healthy donors. GSTP1 polymorphism was studied using PCR-restriction fragment length polymorphism, methylation using methylation-specific PCR and loss of expression using immunohistochemistry and western blotting. No significant increase was observed in the breast cancer risk of individuals with the mutant (Val) allele [odds ratio (OR), 1.48; 95% confidence interval (CI), 0.97–2.26 for heterozygotes; OR, 1.42; 95% CI, 0.86–2.42 homozygous mutants]. GSTP1 promoter hypermethylation was detected in one-third of tumor biopsies (74/215) and was found to be associated with a loss of expression. Genotype and tumor methylation associations were not observed. Estrogen (ER) and progesterone (PR) receptor-positive tumors had a higher methylation frequency. GSTP1 polymorphism was not associated with increased promoter hypermethylation. The results suggest that GSTP1 methylation is a major event in breast carcinogenesis and may act as a tumor-specific biomarker.

Phase II study of first-line sagopilone plus prednisone in patients with castration-resistant prostate cancer: a phase II study of the Department of Defense Prostate Cancer Clinical Trials Consortium

BACKGROUND

Preclinical studies in prostate cancer (PC) models demonstrated the anti-tumour activity of the first fully synthetic epothilone, sagopilone. This is the first study to investigate the activity and safety of sagopilone in patients with metastatic castration-resistant PC (CRPC).

METHODS

Chemotherapy-naïve patients with metastatic CRPC received sagopilone (one cycle: 16 mg m(-2) intravenously over 3 h q3w) plus prednisone (5 mg twice daily). The primary efficacy evaluation was prostate-specific antigen (PSA) response rate (≥50% PSA reduction confirmed ≥28 days apart). According to the Simon two-stage design, ≥3 PSA responders were necessary within the first 13 evaluable patients for recruitment to continue until 46 evaluable patients were available.

RESULTS

In all, 53 patients received ≥2 study medication cycles, with high compliance. Mean individual dose was 15.1±1.4 mg m(-2) during initial six cycles, mean dose intensity 94±9%. The confirmed PSA response rate was 37%. Median overall progression-free survival was 6.4 months. The most commonly reported adverse events (>10% of patients) were peripheral neuropathy (94.3%), fatigue (54.7%) and pain in the extremities (47.2%). Sagopilone was associated with very little haematological toxicity.

CONCLUSION

This study shows that first-line sagopilone has noteworthy anti-tumour activity and a clinically significant level of neuropathy for patients with metastatic chemotherapy-naïve CRPC.

The vascular-disrupting agent combretastatin impairs splitting and sprouting forms of physiological angiogenesis

OBJECTIVE

Vascular-disrupting agents like combretastatin (CA-4-P), used to attenuate tumor blood flow in vivo, exert anti-mitotic and anti-migratory effects on endothelial cells in vitro. We tested whether anti-vascular or anti-angiogenic effects of CA-4-P are evident with physiological angiogenesis in skeletal muscle (EDL) due to sustained hyperemia (intraluminal splitting) and chronic muscle overload (abluminal sprouting).

METHODS

CA-4-P was given i.v. (25 mg/kg on alternate days for 14 days) to mice subjected to angiogenic stimuli (prazosin or synergist extirpation). The responses of femoral artery blood flow as well as capillarity, capillary ultrastructure, and levels of Rho GTPase were measured.

RESULTS

Blood flow was unaffected in the sprouting angiotype, but decreased in the splitting angiotype, by CA-4-P. In contrast, CA-4-P attenuated the capillarity increase in both models, associated with reduced lamellipodia and filopodia formation. Muscle overload, but not hyperemia, was accompanied by an increase in Rho GTPase with CA-4-P.

CONCLUSIONS

CA-4-P impaired the angiogenic response in both experimental models. This inhibitory effect was associated with a lower increase in femoral blood flow in splitting, whereas sprouting angiogenesis was accompanied by higher Rho activity consistent with the interruption of actin polymerization. Thus, CA-4-P may exert context-dependent anti-vascular and anti-angiogenic effects in vivo under physiological conditions.

Inhibitory effect of genistein on the invasive potential of human cervical cancer cells via modulation of matrix metalloproteinase-9 and tissue inhibitors of matrix metalloproteinase-1 expression

BACKGROUND

One of the most challenging stumbling blocks for the treatment of cancer is the ability of cancer cells to break the natural barriers and spread from its site of origin to non-adjacent regional and distant sites, accounting for high cancer mortality rates. Gamut experimental and epidemiological data advocate the use of pharmacological or nutritional interventions to inhibit or delay various stage(s) of cancer such as invasion and metastasis. Genistein, a promising chemopreventive agent, has gained considerable attention for its powerful anti-carcinogenic, anti-angiogenic and chemosensitizing activities.

METHODS

In this study, the cytotoxic potential of genistein on HeLa cells by cell viability assay and the mode of cell death induced by genistein were determined by nuclear morphological examination, DNA laddering assay and cell cycle analysis. Moreover, to establish its inhibitory effect on migration of HeLa cells, scratch wound assay was performed and these results were correlated with the expression of genes involved in invasion and migration (MMP-9 and TIMP-1) by RT-PCR.

RESULTS

The exposure of HeLa cells to genistein resulted in significant dose- and time-dependent growth inhibition, which was found to be mediated by apoptosis and cell cycle arrest at G(2)/M phase. In addition, it induced migration-inhibition in a time-dependent manner by modulating the expression of MMP-9 and TIMP-1.

CONCLUSION

Our results signify that genistein may be an effective anti-neoplastic agent to prevent cancer cell growth and invasion and metastasis. Therefore therapeutic strategies utilizing genistein could be developed to substantially reduce cancer morbidity and mortality.

Correcting photoacoustic signals for fluence variations using acousto-optic modulation

We present a theoretical concept which may lead to quantitative photoacoustic mapping of chromophore concentrations. The approach supposes a technique capable of tagging light in a well-defined tagging volume at a specific location deep in the medium. We derive a formula that expresses the local absorption coefficient inside a medium in terms of noninvasively measured quantities and experimental parameters and we validate the theory using Monte Carlo simulations. Furthermore, we performed an experiment to basically validate the concept as a strategy to correct for fluence variations in photoacoustics. In the experiment we exploit the possibility of acousto-optic modulation, using focused ultrasound, to tag photons. Results show that the variation in photoacoustic signals of absorbing insertions embedded at different depths in a phantom, caused by fluence variations of more than one order of magnitude, can be corrected for to an accuracy of 5%.

Bone metastasis (BM) based on SEER registry versus Medicare claims among metastatic prostate cancer (PCa) patients (pts) in SEER-Medicare

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Background: There is questionable reliability of administrative claims data to identify BM, yet historically such claims were the only source for identifying BM in SEER-Medicare (SM). Starting in 2004, SEER provided tumor registry information on incident BM. We compared frequencies of BM using registry and claims data among men diagnosed with PCa. Methods: We analyzed pts aged 66 and older from the linked SM database. Pts with stage IV (M1) PCa diagnosed between 2004 and 2007 were followed until death or censoring. Identifying pts with BM using claims required at least one inpatient or outpatient claim with a diagnosis code of 198.5 within (i.e., +/-) 1 month of the SEER diagnosis month (designated BMclaims-90) or at any time during follow up (designated BMclaims-ever). BM identified using SEER was based on an indicator for bone metastasis at diagnosis using the AJCC M1b classification (designated BMseer). We calculated the sensitivity and specificity of BM at diagnosis in claims (BMclaims-90) with respect to the incident BM data in SEER, assuming BMseer to be the gold standard. Results: Application of inclusion/exclusion criteria resulted in 3,664 stage IV (M1) PCa pts. Average age was 79 years, 13% were African American, and 61% had poorly/un-differentiated tumors. BMseer (n=2,301; 63%) was higher than BMclaims-90 (n=1,979; 54%) and lower than BMclaims-ever (n=2,878; 79%). Assuming BMseer as the standard measure of BM at diagnosis, BMclaims-90 had 58.8% sensitivity (n=1,353), 54.1% specificity (n=737), and 68.4% positive predictive value for identifying BM at diagnosis. Among men with BM identified using BMseer, 84% (1,931) had BMclaims-ever and the median (min; max; average) time to the first BM claim was 0.9 (-2.6; 57.1; 3.9) months. Among men with BM identified using BMclaims-90, the median (min; max; average) time to the first BM claim was 0.6 (-1.0; 2.0; 0.7) months. Conclusions: The incidence of BM in PCa pts differs between a commonly-used algorithm to identify BM in claims data and the AJCC staging information in tumor registry data. There was moderate concordance between the claims-based measure and the SEER-based measure of BM at diagnosis.

Heterogeneity of treatment effects (HTE) in stage IV prostate cancer (S4PC)

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Background: HTE occurs when patient factors modify a treatment’s effect on health outcomes so patients in the same study have different responses to a specific treatment. Variation in outcomes is caused by interactions between the factors causing HTE and the treatment. HTE may explain some of the heterogeneity in S4PC prognosis. The HTE literature is evolving; hence some factors causing HTE in S4PC are not yet documented. Methods: A systematic literature review (1946-2011) of published trials and observational studies identified evidence of statistically significant factors influencing HTE in S4PC. Inclusion criteria required that articles examine the impact of HTE factors on survival (OS, DSS, PFS) or health-related quality-of-life measures among S4PC patients. Factors that influenced outcomes but were not specifically evaluated in the context of HTE were excluded. Results: Of 398 articles that included key words, 33 met inclusion/exclusion criteria. Treatments included chemotherapy, radiation, hormonal therapy and bone-modifying agents. Both biologic and non-biologic factors (Table) were found to be associated with HTE in S4PC. Evidence was mixed regarding whether HTE in S4PC is influenced by race or by confounding factors correlated with race or both. As no articles examined prognostic factors such as bcl2, PTEN, p53, Pgp and EGFR status in the context of a specific treatment, such factors were excluded. Conclusions: Current evidence reveals diverse factors influencing HTE in S4PC.Ultimately, such knowledge can help oncologists prescribe more personalized medicine, help patients make more informed treatment choices, and aid policy making and treatment coverage decisions. [Table: see text]

Pharmacokinetics of samarium-153-EDTMP (153Sm) prior to and following zoledronic acid (ZA) in prostate cancer (PC) patients with bone metastases (BM)

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Background: 153Sm and ZA are often employed to manage complications related to BM. Although 153Sm and ZA bind to overlapping sites within the bone, there is a paucity of information on potential pharmacokinetic (PK) and pharmacodynamic interactions between the two. In this study we report the pharmacokinetics of 153Sm when administered in combination with ZA. Methods: The study was carried out as two independent phase I trials assessing the effects of escalating dose 153Sm (0.5, 0.75, 1.0, and 1.25 µCi/kg) administered prior to or immediately after intravenous ZA 4 mg. Study 1 recruited 12 ZA-naive PC pts, while Study 2 enrolled 10 PC pts who had received at least 3 months of ZA prior to trial entry. On study, pts received 2 doses of 153Sm given 3 months apart and 6 doses of ZA given monthly. In Cycle 1 of both trials, 153Sm was administered on day1 and ZA on day 2. In Cycle 2, ZA was administered 1 hour prior to 153Sm on the same day. Blood samples for radioactive analysis were obtained at 5 min, and 0.5, 1, 2, 4, and 24 h post 153Sm dosing. PK analysis was performed by both model independent and PK modeling methods using WinNonlin. Results: The PK parameters of 153 Sm were highly variable between patients. The coefficient of variation of the Cmax/Dose was greater than 50% in all subgroups. A dose related increase in exposure to 153Sm was observed with high variability as well. The estimated terminal half-life (t1/2) was similar across all dose levels within each study. The t1/2 for Cycle 1 was 4.73 ± 1.27 for Study 1 and 6.73 ± 3.92 h for Study 2. The dose normalized Cmax (Cmax/Dose) was 0.068 ± 0.036 and 0.061 ± 0.043 µCi/mL for Study 1 and Study 2, respectively. Pharmacokinetic parameters for Cycle 2 were similar to those calculated for Cycle 1 within each study. Conclusions: The Cmax and t1/2 reported here are similar to previous studies of 153Sm with doses ranging from 1.0 to 3.0 µCi/kg in ZA-untreated pts. Although not statistically significant, the subtle differences in the pharmacokinetics of 153Sm merit further investigation.

Characteristics of stage III and IV M0 prostate cancer (PCa) patients in SEER-Medicare who develop bone metastasis (BM) following diagnosis

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Background: BM is diagnosed in 70-80% of men with metastatic PCa. Less is known about the timing of BM diagnosis following incident non-metastatic PCa and associated patient characteristics. In this study, we determined the incidence and timing of post-diagnosis BM (BMpd) among PCa patients (pts) by incident stage, age, race and year of diagnosis using a large observational dataset. Methods: We analyzed pts aged 66 or older from the linked Surveillance, Epidemiology, and End Results and Medicare (SEER-Medicare) database. Pts with PCa were identified between 2000 and 2007 and were followed until death, Medicare disenrollment, HMO enrollment, or end of the study (December 31, 2009). The cohort included incident stage III and IV(M0) PCa in SEER, and identified BM occurring either within (i.e., +/-) 1 month of the SEER diagnosis month (BM90) or beyond the initial 90-day window (BMgt90) based on the presence of at least one inpatient or one outpatient claim with a diagnosis code of 198.5. We calculated summary and chi-square statistics to examine BMpd, BM90, and BMgt90 by incident stage, age, race and year of PCa diagnosis. Results: Among 9,188 Stage III (72%) and IV(M0) (28%) PCa pts who met inclusion/exclusion criteria, 14.6% (n=1,345) had BMpd: 2.3% (n= 217) had BM90 and 12.3% (n=1,128) had BMgt90. Average age was 72 years and 9% were African American (AA). Incidence of BMpd varied by stage (stage III: 11%; stage IV/M0: 25%; p<0.001) and by age group (66-74 years: 13%; 75-84 years: 19%; >85 years: 22%; p<0.001) but not by race (White: 15%; AA: 16%; Other: 13%; p=0.49). The diagnosis BM90 and BMgt90 varied with stage (stage III: 2% and 9%; stage IV(M0): 4% and 21%; p<0.0001) and age (66-74 years: 2% and 11%; 75-84 years: 3% and 16%; >85 years: 5% and 17%; p<0.001). The incidence of BM decreased over time whether considering BMpd (19% in 2000 to 9% in 2007; p<0.001), BM90 (4% in 2000 to 2% in 2007; p=0.03) or BMgt90 (16% in 2000 to 6% in 2007; p<0.001). Conclusions: BM occurred in only 2% of incident stage III/IV(M0) PCa pts within 1 month of diagnosis, but nearly 15% were diagnosed with BM during a median follow-up of 57 months. Prevalence of BM was highest in stage IV(M0) and older pts.

Telomere and microtubule targeting in treatment-sensitive and treatment-resistant human prostate cancer cells

Modulating telomere dynamics may be a useful strategy for targeting prostate cancer cells, because they generally have short telomeres. Because a plateau has been reached in the development of taxane-based treatments for prostate cancer, this study was undertaken to evaluate the relative efficacy of targeting telomeres and microtubules in taxane-sensitive, taxane-resistant, androgen-sensitive, and androgen-insensitive prostate cancer cells. Paclitaxel- and docetaxel-resistant DU145 cells were developed and their underlying adaptive responses were evaluated. Telomere dynamics and the effects of targeting telomeres with sodium meta-arsenite (KML001) (an agent undergoing early clinical trials), including combinations with paclitaxel and docetaxel, were evaluated in parental and drug-resistant cells. The studies were extended to androgen-sensitive LNCaP cells and androgen-insensitive LNCaP/C81 cells. Both P-glycoprotein (Pgp)-dependent and non-Pgp-dependent mechanisms of resistance were recruited within the same population of DU145 cells with selection for drug resistance. Wild-type DU145 cells have a small side population (SP) (0.4-1.2%). The SP fraction increased with increasing drug resistance, which was correlated with enhanced expression of Pgp but not breast cancer resistance protein. Telomere dynamics remained unchanged in taxane-resistant cells, which retained sensitivity to KML001. Furthermore, KML001 targeted SP and non-SP fractions, inducing DNA damage signaling in both fractions. KML001 induced telomere erosion, decreased telomerase gene expression, and was highly synergistic with the taxanes in wild-type and drug-resistant DU145 cells. This synergism extended to androgen-sensitive and androgen-insensitive LNCaP cells under basal and androgen-deprived conditions. These studies demonstrate that KML001 plus docetaxel and KML001 plus paclitaxel represent highly synergistic drug combinations that should be explored further in the different disease states of prostate cancer.

Recommendations for Clinical Trials of Off-Label Drugs Used to Treat Advanced-Stage Cancer

Purpose

To provide recommendations to trialists and sponsors that guide the design and implementation of prospective postapproval clinical trials for oncology drugs used outside US Food and Drug Administration–labeled indications for treatment of late-stage cancers.

Methods

A meeting was hosted by the Center for Medical Technology Policy in Baltimore, MD, on November 12, 2009. Discussions during the meeting and key informant interviews were conducted before and after this stakeholder meeting. Peer review by multidisciplinary stakeholders was followed by a public comment period. Input was received from patient advocacy groups, medical oncologists, pharmaceutical companies, the US Food and Drug Administration, Centers for Medicare and Medicaid Services, the National Cancer Institute, foreign government agencies involved in health technology assessment, public and private payers, drug compendia, clinical research entities, statisticians, academics, and the American Society of Clinical Oncology.

Results

To address the needs of patients and their clinical providers, compendia, payers, and policy makers, recommendations are proposed to guide the design of future prospective trials for off-label use of oncology drugs across four areas: trial design and data analysis, patient and site recruitment, comparators, and outcomes.

Conclusion

The US Food and Drug Administration provides guidance to the pharmaceutical industry and others designing randomized clinical trials for regulatory approval. However, a gap exists for postregulatory decision makers, including patients, prescribers, and payers, because regulatory trials do not answer the questions most relevant to them. Therefore, guidance is needed for trials performed in the postapproval environment for these postapproval decision makers.