Physical environmental correlates of childhood obesity: a systematic review

Increasing rates of childhood obesity in the USA and other Western countries are a cause for serious public health concern. Neighborhood and community environments are thought to play a contributing role in the development of obesity among youth, but it is not well understood which types of physical environmental characteristics have the most potential to influence obesity outcomes. This paper reports the results of a systematic review of quantitative research examining built and biophysical environmental variables associated with obesity in children and adolescents through physical activity. Literature searches in PubMed, PsychInfo and Geobase were conducted. Fifteen quantitative studies met the inclusion criteria for this systematic review. The majority of studies were cross-sectional and published after 2005. Overall, few consistent findings emerged. For children, associations between physical environmental variables and obesity differed by gender, age, socioeconomic status, population density and whether reports were made by the parent or child. Access to equipment and facilities, neighborhood pattern (e.g. rural, exurban, suburban) and urban sprawl were associated with obesity outcomes in adolescents. For most environmental variables considered, strong empirical evidence is not yet available. Conceptual gaps, methodological limitations and future research directions are discussed.

Secondary creatine deficiency in ornithine delta-aminotransferase deficiency

AIMS

Ornithine delta-aminotransferase (OAT) deficiency causes gyrate atrophy (GA) of the retina, as a consequence of high plasma ornithine concentrations. Because creatine synthesis requires the conversion of arginine and glycine into ornithine and guanidinoacetate, high ornithine concentration inhibits this reaction thus causing secondary creatine deficiency. The aim of this study was to evaluate the neuropsychological features and creatine metabolism in patients with GA.

METHODS

The study involved 7 GA patients, aged from 11 to 27 years who underwent neuropsychological evaluation and cerebral proton magnetic resonance spectroscopy (MRS).

RESULTS

Neurocognitive impairment was found in 5/7 patients, including mental retardation (3/7), school failure (1/7), major visuospatial dyspraxia (1/7), aggressive behavior (3/7) and epilepsy (2/7). Two patients had normal neuropsychological evaluation. Cerebral proton magnetic resonance spectroscopy revealed a profound creatine deficiency in all patients. MRS data were confirmed by decreased levels of creatine and/or guanidinoacetate in plasma and urine in all patients.

CONCLUSIONS

In our group of patients with GA, we found a high prevalence of neurological impairment, not reported so far, and possibly related to secondary creatine deficiency and hyperornithinemia. We propose to treat mentally retarded GA patients with high doses of creatine, as it may normalize brain creatine levels and help to reduce ornithine levels.

Multiple OXPHOS deficiency in the liver of a patient with CblA methylmalonic aciduria sensitive to vitamin B(12)

An adult patient with methylmalonic aciduria due to defective cobalamin synthesis (CblA) responsive to vitamin B(12) presented suddenly with severe visual impairment ascribed to optic atrophy followed by a fatal multiorgan failure and lactic acidosis but low methylmalonic acid in plasma and urine. Multiple deficiency of oxidative phosphorylation was found in the patient's liver. We suggest that patients with B(12)-sensitive methylmalonic aciduria who have a milder clinical course should be carefully monitored for long-term complications.

Prevalence of glaucoma in patients with obstructive sleep apnoea--a cross-sectional case-series

AIM

To determine the prevalence of glaucoma in patients with obstructive sleep apnoea.

DESIGN

Cross-sectional case series.

PARTICIPANTS

One hundred patients with moderate to severe obstructive sleep apnoea.

TESTING

Within 48 h of the polysomnographic diagnosis of obstructive sleep apnoea, patients underwent the following tests: intraocular pressure, gonioscopy, automated perimetry, stereoscopic biomicroscopy, and fundascopic assessment for the presence of glaucomatous optic nerve changes.

MAIN OUTCOME MEASURES

The prevalence of glaucoma in patients with obstructive sleep apnoea and the associations between patient characteristics and both glaucoma and intraocular pressure.

RESULTS

Glaucoma was diagnosed in 27 of 100 patients yielding an estimated prevalence of 27% (95% CI 19-37%). The presence of glaucoma did not correlate with sex, body mass index (BMI), or AHI, but did appear to be associated with age (P=0.014). There was no evidence of a relationship between intraocular pressure and either the apnoea plus hypopnoea index or age.

CONCLUSION

The prevalence of glaucoma in patients with obstructive sleep apnoea is an estimated 27%. Sex, age, body mass index or apnoea plus hypopnoea index are not factors influencing the presence of glaucoma in this population of patients.

Phase I trial of a histone deacetylase inhibitor (HDACI) and retinoid acid (RA) in patients (pts) with advanced solid tumor malignancies

13114

Background: Transcription of RA responsive genes is inhibited by co-repressor complexes which have HDAC activity. Pre-clinical data demonstrates that addition of an HDACI to RA enhances transcription of genes that augment anti-tumor and differentiation response, and results in tumor inhibition in a RCC model (Clin Cancer Res. 2005;11:3558). Valproic Acid (VPA) has potent HDCAI activity and ATRA-IV is a liposomal RA with excellent bioavailability. The objective of this trial is to determine safety, pharmacokinetics (PK) of combination therapy, as well as correlative studies of RA receptor expression and histone acetylation status. Methods: Adults with a refractory metastatic solid tumor malignancy, KPS >60%, adequate organ function, life expectancy >3 months are eligible. 3-pt cohorts in a 2-step dose escalation: Oral VPA (Abbott Pharmaceutical) is dosed (starting at 10 mg/kg/d every 8 hrs) until trough VPA serum concentration of 50–80; 80–100 and 100–120 μg/ml. IV ATRA (Antigenics) is then administered at 60mg/m2 IV weekly. Once VPA MTD is determined, ATRA-IV is then escalated to 90, 120 and 140 mg/m2 unless DLT’s are seen. Dose levels are escalated in cohorts of 3–6 pts and cycle length is 4 weeks. Results: 9 pts have been enrolled and 5 are evaluable for toxicity of both drugs (renal cell, prostate, GE junction, bladder and small blue cell tumor). 4 pts withdrew from VPA toxicity prior to ATRA-IV. Median age 67 (range 26–79), pts received between 1–4 prior therapies (non-palliative surgery, chemotherapy, radiation, PBSCT). VPA did not alter ATRA-IV pharmacokinetics. The MTD of VPA has not yet been reached and the ATRA escalation phase has not yet been initiated. Most common toxicities observed were pain, dyspnea, gastrointestinal and neurologic. One grade 3 neurotoxic event occurred related to POD. 1 pt had a transient decline in PSA. Correlative studies are ongoing. Conclusions: Epigenetic modifications induced by HDACIs may allow the anti-tumor effects of retinoids to be realized. Toxicity of VPA has limited the addition of RA to this HDACI. HDACI + RA is a rationale approach to treat progressive RCC and future studies will incorporate more potent and less toxic HDACI + RA to treat RCC.

No significant financial relationships to disclose.

Surgical salvage of pelvic recurrences from colorectal tumors

13580

Background: The morbidity of pelvic recurrences from colorectal tumors (PRCT) represents a challenge for the oncology multidisciplinary team. Surgical treatment is the best option for palliation and in several series it offers long term local control in 30% of the cases. Objective: To perform a retrospective analysis of patients (pts) surgically resected for PRCT in terms of: time to progression after surgical salvage (TP) and specific suvival (SS). Correlatives studies were performed with clinic and pathologic factors, surgical procedures (SP), and postoperative complications in terms of TP and SS. Methods: 64 pts treated (June 1994 - February 2005) were identified (women: 30), median age 63 years, site of the primary: rectum 48, sigmoid 16; Median number of resected nodes: 8 (r: 2 - 20) in pts with negative nodes and 15 (r: 6 - 42) in pts with positive nodes; primary treatment: surgery (S): 22 pts, S + chemotherapy (CT): 18, S + radiotherapy (RT): 4, S + CT/RT: 17, CT + S: 2 pts, QT/RT + CX: 1; in 7/64 a Miles procedure was performed as primary therapy, median disease free interval: 15 months; site of initial recurrence: locoregional 58 (90%), locoregional + systemic 10%. Pain and bleeding were the most frecuent symptoms. Results: The strategy in PRCT was: S: 29 pts, S + RT: 15, S + CT/RT: 9, CT/RT + S: 7, S + CT: 2, CT + S: 1, RT + S:1; IORT: 18/64; external beam RT: 17/64, 6 pts required Miles; type of resection: R0: 50/64 (78%), R1: 8/64 (12%), R2: 3/64 (5%) and 3 (5%) unknown. Median duration of surgery: 4 hours, abscesses and fistulas were the complications most frequently observed. Median time to progression (TP): 12 months, site of recurrence (56/64 pts) post salvage surgery: pelvic: 22 pts, extrapelvic: 6 pts, combined: 10 and unknown 18. Eleven pts are free of disease. In 16 pts more than one surgical salvage was perfomed. The specific survival was 21 months (IC 95% 37 - 61 m). Conclusions: In this serie surgical salvage of PRCT showed one year of local control disease, even in pts with R2 and with moderate morbidity. The surgical decision must be individualized and in the context of a trained surgical team.

No significant financial relationships to disclose.

Sentinel lymph node biopsy (SLNB) in melanoma and a simple prognostic score in a prospective cohort with long term follow-up

8058

Background: Outcome of early stage melanoma is related to pathological and clinical findings like SLNB status, but a systematic approach to risk stratification is lacking. Objectives: To assess outcome, and clinico-pathological criteria associated to recurrence and death of patients (pts) who underwent SLNB Methods: From 11/1994 to 5/2005, 286 clinical stages I/II melanoma pts underwent SLNB in our Institution. Median follow up was 38 months. Prognostic factors were analysed with Logranktest and proportional hazard regression. Survival curves with Kaplan-Meier method. A score was derived from coefficients of multivariate analysis and evaluated with ROC curves on 259 pts with complete data. Results: Median age: 48yr; male sex: 54%; median Breslow (Br): 1.8mm. SLNB +: 46 pts (16.1%). Ulcerated: 31%. 5-yr overall survival was 56% in SLNB+ vs 84% in SLNB-, p=0.0002. Five-yr relapse free survival was 52% in SLNB+ vs 73% in SLNB-, p=0.0017. SLNB status, Br, Clark level, Age>50yr, male sex, and ulceration were related to death by univariate analysis, but in multivariate analysis, only SLNB status (HR 2.36), Br (HR 1.66 for each T level of TNM staging) and ulceration (HR 2.35) remained. The score derived from the model was: 5 points (p) for SLNB +; 4p for ulceration; and 0p for Br<1mm, 2p for Br 1–2mm, 4p for Br 2–4mm, and 6p for Br>4mm. Conclusions: SLNB status, Br, and ulceration were, in concordance with literature, statistically significant prognostic factors. This allowed us to build a simple score with good correlation with prognosis (c index: 0.79). This score could be a useful tool for clinical practice and for future clinical trials, but validation in different populations is required.

[Table: see text]

No significant financial relationships to disclose.

[Leber congenital amaurosis: comprehensive survey of genetic heterogeneity. A clinical definition update]

Leber congenital amaurosis (LCA) is the earliest and most severe form of all inherited retinal dystrophies, responsible for congenital blindness. Disease-associated mutations have been hitherto reported in seven genes. These genes are all expressed preferentially in the photoreceptor cells or the retinal pigment epithelium, but they are involved in strikingly different physiologic pathways, resulting in an unforeseeable pathophysiologic variety. This broad genetic and physiologic heterogeneity, which could greatly increase in the coming years, hinders molecular diagnosis in LCA patients. Genotyping is, however, required to establish genetically defined subgroups of patients ready for therapy. Here we report a comprehensive mutational analysis of all the known genes in 179 unrelated LCA patients, including 52 familial and 127 sporadic (27/127 consanguineous) cases. Mutations were identified in 47.5% of patients. GUCY2D accounted for by far the largest part of the LCA cases in our series (21.2%), followed by CRB1 (10%), RPE65 (6.1%), RPGRIP1 (4.5%), AIPL1 (3.4%), TULP1 (1.7%) and CRX (0.6%). The clinical history of all patients with mutations was carefully revisited in the search for phenotype variations. Genotype-phenotype correlations were found that made it possible to divide patients into two main groups. The first one includes patients whose symptoms fit the traditional definition of LCA, i.e., congenital or very early cone-rod dystrophy, while the second group gathers patients affected with severe yet progressive rod-cone dystrophy. In addition, objective ophthalmologic data subdivided each group into two subtypes. Based on these findings, we have drawn decisional flowcharts directing the molecular analysis of LCA genes in a given case. These flowcharts will hopefully lighten the onerous task of genotyping new patients, but only if the most precise clinical history since birth is available.

Preliminary treatment planning and dosimetry for a clinical trial of neutron capture therapy using a fission converter epithermal neutron beam

A Phase I/II clinical trial of neutron capture therapy (NCT) was conducted at Harvard-MIT using a fission converter epithermal neutron beam. This epithermal neutron beam has nearly ideal performance characteristics (high intensity and purity) and is well-suited for clinical use. Six glioblastoma multiforme (GBM) patients were treated with NCT by infusion of the tumor-selective amino acid boronophenylalanine-fructose (BPA-F) at a dose of 14.0 g/m(2) body surface area over 90 min followed by irradiation with epithermal neutrons. Treatments were planned using NCTPlan and an accelerated version of the Monte Carlo radiation transport code MCNP 4B. Treatments were delivered in two fractions with two or three fields. Field order was reversed between fractions to equalize the average blood boron concentration between fields. The initial dose in the dose escalation study was 7.0 RBEGy, prescribed as the mean dose to the whole brain volume. This prescription dose was increased by 10% to 7.7 RBEGy in the second cohort of patients. A pharmacokinetic model was used to predict the blood boron concentration for determination of the required beam monitor units with good accuracy; differences between prescribed and delivered doses were 1.5% or less. Estimates of average tumor doses ranged from 33.7 to 83.4 RBEGy (median 57.8 RBEGy), a substantial improvement over our previous trial where the median value of the average tumor dose was 25.8 RBEGy.