Impact of the Massachusetts tobacco control programme: population based trend analysis

OBJECTIVE

To assess the impact of the Massachusetts tobacco control programme, which, since its start in January 1993, has spent over $200m-"the highest per capita expenditure for tobacco control in the world"-funded by an extra tax of 25 cents per pack of cigarettes.

DESIGN

Population based trend analysis with comparison group.

SUBJECTS

Adult residents of Massachusetts and other US states excluding California.

MAIN OUTCOME MEASURES

Per capita consumption of cigarettes as measured by states' sales tax records; prevalence of smoking in adults as measured by several population-based telephone surveys.

RESULTS

From 1988 to 1992, decline in per capita consumption of cigarettes in Massachusetts (15%) was similar to that in the comparison states (14%), corresponding to an annual decline of 3-4% for both groups. During 1992-3, consumption continued to decline by 4% in the comparison states but dropped 12% in Massachusetts in response to the tax increase. From 1993 onward, consumption in Massachusetts showed a consistent annual decline of more than 4%, whereas in the comparison states it levelled off, decreasing by less than 1% a year. From 1992, the prevalence of adult smoking in Massachusetts has declined annually by 0.43% (95% confidence interval 0.21% to 0.66%) compared with an increase of 0. 03% (-0.06% to 0.12%) in the comparison states (P<0.001).

CONCLUSIONS

These findings show that a strongly implemented, comprehensive tobacco control programme can significantly reduce tobacco use.

A genomic response of H-358 bronchiolar carcinoma cells to MK 886, an inhibitor of 5-lipoxygenase, assessed with a cDNA array

Incomplete programmed cell death is one explanation for the escape of cancer cells from therapy. Inhibitors of the enzyme 5-lipoxygenase reduce proliferation and initiate programmed cell death in many different types of malignantly transformed cells. The 5-lipoxygenase inhibitor, MK 886. induces an atypical form of programmed cell death in H-358 bronchiolar lung cancer cells. A genomic response of H-358 cells after 24 hr of culture at a 40 uM concentration that inhibited proliferation was analyzed with a Clontech human cDNA array containing 588 cDNAs corresponding to identified genes. The data grouped into 3 major categories and initial conclusions regarding countervailing, cellular stress, programmed cell death, DNA damage and repair mRNA-responses as possible reasons for escape from the antiproliferative response are discussed. The use of cDNA arrays to estimate the extent to which malignantly transformed cells respond to therapy or why they do not and so infer prognosis and identify possible therapeutic modifications is indicated.

Widespread countervailing genomic responses induced by chemotherapy or radiation as a cause of therapeutic failure

If chemotherapy or ionizing radiation induce widespread genomic responses tending to circumvent or antagonize their ability to kill malignant cells, an additional cause for therapeutic failure would be suggested. There is evidence that some agents evoke extensive countervailing genomic activity, the nature and extent of which can be assessed with the use of 'gene chips'.

Immunohistochemical analyses of focal adhesion kinase expression in benign and malignant human breast and colon tissues: correlation with preinvasive and invasive phenotypes

The focal adhesion kinase (FAK) is a protein tyrosine kinase linked to signaling events between cells and the extracellular matrix. Studies at the Western blot level have demonstrated up-regulation of FAK expression in invasive breast and colon cancers. To assess p125FAK expression at the cellular level, we developed monoclonal antibodies that specifically detected FAK in formalin-fixed, paraffin-embedded tissue sections and analyzed the levels of FAK expression in human breast and colon tissues. Monoclonal antibody 4.47 demonstrated FAK-specific focal adhesion staining by immunofluorescence assays on BT-474 breast cancer cells and detected a Mr 125,000 protein by both Western blotting and immunoprecipitation analyses. Using immunohistochemical techniques, the expression of p125FAK was analyzed in 36 normal and 43 preinvasive or invasive human breast and colon tissues from individual patients. FAK was weakly expressed in most benign breast epithelium but was up-regulated at moderate or strong levels in 14 of 18 invasive breast carcinomas. In seven samples of ductal carcinoma-in situ, FAK was overexpressed. Borderline-to-weak expression of FAK was detected in the normal colonic epithelium. In the invasive colon cancers, FAK was overexpressed at moderate or strong levels in 13 of 15 tumors. Furthermore, FAK expression was up-regulated in areas of dysplastic, premalignant colon epithelium. These results provide the first evidence at the cellular level that FAK expression is variably overexpressed in breast and colon cancer and suggest that up-regulation occurs at an early stage of tumorigenesis.

A phase II study of gemcitabine and 5-fluorouracil in metastatic pancreatic cancer: an Eastern Cooperative Oncology Group Study (E3296)

Gemcitabine has recently been compared favorably to 5-fluorouracil (5-FU) as the standard chemotherapy for advanced pancreas cancer. Based on phase I data that combining gemcitabine with 5-FU is safe and has evidence for clinical activity, a phase II trial was conducted by the Eastern Cooperative Oncology Group (ECOG). Patients with metastatic disease, good performance status and organ function were eligible and enrolled after providing informed consent. Patients were given gemcitabine (1,000 mg/m(2)) followed by 5-FU (600 mg/m(2)) weekly for 3 weeks of every 4. Of 37 patients enrolled over a 3-month period, 36 were eligible. Partial responses were seen in 5 patients (14%). Median survival was 4.4 months with a 1-year survival rate of 8.6%. A randomized trial of the combination of 5-FU and gemcitabine versus gemcitabine alone is currently accruing patients in ECOG.

High yield criteria for emergency cranial computed tomography in adult patients with no history of head injury

OBJECTIVES

A recent American study identified clinical factors which effectively predicted those patients who would have significant findings on cranial computed tomography. It was proposed to apply these criteria in a UK setting and to determine whether modifications could be made to improve their efficiency.

METHODS

A prospective observational study was conducted over a four month period including all non-trauma adult patients referred from the accident and emergency (A&E) department for urgent cranial computed tomography. Presenting symptoms and signs were analysed for ability to predict clinically significant computed tomography findings, namely: acute infarct, malignancy, acute hydrocephalus, intracranial haemorrhage, or intracranial infection.

RESULTS

Sixty two patients were included; 22 (35%) had significant findings on computed tomography. Applying the original criteria (any of: age 60 years or older, focal neurology, headache with nausea or vomiting, altered mental status) to the study population showed that no clinically significant tomograms would have been omitted but only 11% fewer performed. Modifying the criteria by removing "age 60 years or older" and replacing "altered mental status" with a Glasgow coma score <14, still ensured 100% sensitivity and would have resulted in 19% fewer scans being performed.

CONCLUSION

Simple clinical criteria can be usefully applied to patients presenting to an A&E department in this country to target patients most likely to have clinically significant findings on urgent cranial computed tomography.

Adjuvant active specific immunotherapy for stage II and III colon cancer with an autologous tumor cell vaccine: Eastern Cooperative Oncology Group Study E5283

PURPOSE

A randomized phase III clinical trial of adjuvant active specific immunotherapy (ASI) with an autologous tumor cell-bacillus Calmette-Guérin (BCG) vaccine was conducted to determine whether surgical resection plus ASI was more beneficial than resection alone in stage II and III colon cancer patients.

PATIENTS AND METHODS

Patients (n = 412) with colon cancer (297 with stage II disease, 115 with stage III disease) were randomly allocated to an observation arm or to a treatment arm in which they received three weekly intradermal vaccine injections of 10(7) irradiated autologous tumor cells beginning approximately 4 weeks after surgery. The first two weekly injections also contained 10(7) BCG organisms. Patients were observed for determination of time to recurrence and disease-free and overall survival.

RESULTS

This was a negative study in that after a 7.6-year median follow-up period, there were no statistically significant differences in clinical outcomes between the treatment arms. However, there were disease-free survival (P =.078) and overall survival (P =.12) trends in favor of ASI when treatment compliance was evaluated, ie, patients who received the intended treatment had a delayed cutaneous hypersensitivity (DCH) response to the third vaccination (induration >/=5 mm). Also, the magnitude of the DCH response correlated with improved prognosis. The 5-year survival proportion was 84.6% for those with indurations greater than 10 mm, compared with 45.0% for those with indurations less than 5 mm.

CONCLUSIONS

When all randomized patients were evaluated, no significant clinical benefit was seen with ASI in surgically resected colon cancer patients with stage II or III colon cancer. However, there was an indication that treatment compliance with effective immunization results in disease-free and overall survival benefits.

Evaluation of mitoguazone in patients with refractory chronic lymphocytic leukemia: a phase II study (P-H482) of the Eastern Cooperative Oncology Group

Mitoguazone is a unique antitumor agent that interferes with polyamine synthesis that has been reported to have activity against AIDS-related malignant lymphoma. We, therefore, tested this agent for activity against chronic lymphocytic leukemia (CLL) in this phase II study. Mitoguazone, 500 mg/M2 was given intravenously weekly to 13 patients with relapsed or refractory, previously treated Rai stages 2-4 CLL. There were no complete or partial responses as judged by standard criteria. Toxicity was acceptable. Mitoguazone in the dose and schedule employed in this study has no significant activity as a single agent in patients with relapsed or refractory CLL.

Altered oncogene, tumor suppressor and cell-cycle gene expression in PANC-1 cells cultured with the pleiotrophic 5-lipoxygenase inhibitor, MK886, assessed with a gene chip

We describe a genomic response of mRNAs associated with a subset of oncogenes, tumor suppressor and cell cycle-related genes in proliferating human Panc-1 pancreatic cancer cells after 24 hours of culture with MK886, a pleotrophic 5-lipoxygenase inhibitor. Ninety-eight of these cDNAs are represented in one of the sub-arrays included in the Clontech Human cDNA Expression Array. In this initial analysis, control cells exhibited apparent widespread low levels of disparate mRNA synthesis. In cells cultured with 40 microM MK886 for 24 hr, while most expressed genes, including a number of specific proliferation-enhancing genes such as c-myc were inhibited, 19 other ones including some countervailing genes including tyrosine SRC protein kinase, cyclins B1 and D1, CDC25B phosphatase and 40s ribosomal S19, amounting to 19 percent of the cDNAs resident on the chip were up-regulated at > 1.10 experimental/control values. Therapy-induced activation of compensatory proliferative genomic responses provides an additional explanation why malignant cells can fail therapy. Among their many future uses, gene chips clearly will be an extremely powerful tool for identifying relationships between the hierarchical linear and non-linear control and implementation-related cellular events and for identifying potential molecular targets tor cancer therapy.

Osteopathic family physicians' attitudes, knowledge, and self-reported practices regarding obesity

The study's purpose was to examine attitudes, knowledge, and self-reported practices of osteopathic family physicians regarding obesity. A survey was developed and administered to osteopathic family physicians. Respondents were predominantly male (76%), and their mean age was 44.6 years. Most had been in practice for fewer than 10 years. Physicians surveyed used diet, exercise, and behavior modification most often in treating obese patients. They were reluctant to suggest medications for treatment of obesity. The physicians also displayed a lack of understanding of the proper assessment of obese patients. These family physicians admitted that medical journals and continuing education were their major sources of information about obesity. Most agreed that their medical school training was deficient in regard to the treatment of obesity, but a majority wished further training. Most of the physicians surveyed had a desire to collaborate on obesity-related research projects. These trends appeared not to be related to physician gender, age, years in practice, or weight. The results of this survey indicated that osteopathic family physicians desire to be updated on current research regarding obesity and use of interdisciplinary modalities. Additional access to training could make an impact on these attitudes and thereby influence their patient management.

Induction of type 1 programmed cell death in U937 cells by the antioxidant, butylated hydroxy-toluene or the free radical spin trap, NTBN

Oxidative stress can initiate programmed cell death and contributes to the patho-physiology of a number of diseases. Low micromolar to millimolar concentrations of various antioxidants or free radical scavengers promote cell growth and reduce cellular suicide induced by several functionally distinct agents, including some known to produce oxidative stress. Severe anoxia or inhibitors of oxidative phosphorylation also initiate programmed cell death. These results seem paradoxical. In order to compare the response of U937 monoblastoid cells to higher concentrations of an antioxidant or a free radical-spin trap, cells were cultured with 20-80 microM concentrations of butylated hydroxy-toluene or with 5 to 60 mM concentrations of the free radical spin trap, N-tertiary butyl phenyl-nitrone. At these concentrations, both agents inhibited cellular proliferation and induced oligosomic DNA, detected by its 'laddering' after electrophoresis on agarose, confirmed by TUNEL (BHT) or flow cytometric (NTBN) evidence of hypodiploid DNA and ultrastructural evidence of a type 1 programmed cell death. The ability of hydroxy-toluenes to oxidize DNA and promote carcinogenesis and whether free radical spin traps could augment or interfere with the response of malignantly transformed cells to chemotherapy or ionizing radiation provide the raison d'etre of these studies.

Free radicals and reactive oxygen species in programmed cell death

Oxidative stress, originating from reactive oxygen species and free radicals provides a constant challenge to eukaryotic cell survival. While implicated in a number of degenerative diseases, some associated with aging and with aging itself, the manner and extent to which oxidative stress contributes to the initiation or implementation of programmed-cell death is problematic. If oxidative stress is an important modulator of programmed-cell death, any ability intentionally to augment or inhibit it might ameliorate diseases in which the process is abnormally underactive or overactive.

The role of physical activity in the management of obesity

Sedentary lifestyle is associated with obesity and obesity-related chronic diseases. Increased physical activity can produce clinically significant changes in body composition and a reduction in risk of obesity-related chronic diseases in obese people. Because a great proportion of a primary care physician's patient population will be obese, it is essential that physicians know the scientific facts about the role of physical activity in the treatment of obesity and how to effectively prescribe it. This article summarizes significant research conclusions about the relationship between physical activity, obesity, and health. It also provides practical strategies for helping obese patients integrate physical activity into their lives.

Does maximizing programmed cell death necessarily yield an optimum clinical advantage?

Generally it has been believed that a maximum therapeutic induction of programmed cell death in cancer cells is universally desirable. As a corollary, the presence of Bcl-2, a major anti-programmed cell death protein, is considered an unfavorable prognostic sign. The latter is not and the former may not be universally true.

Conventional dose melphalan is inactive in metastatic melanoma: results of an Eastern Cooperative Oncology Group Study (E1687)

Despite reports that i.v. melphalan is active in the settings of conditioning regimens utilizing high-dose chemotherapy for autologous bone marrow transplantation and in isolated limb perfusion for the treatment of malignant melanoma, its activity at conventional doses has never been defined in this disease. We conducted a phase II study of conventional-dose i.v. melphalan (30 mg/m2) in 17 patients with metastatic melanoma. All patients were previously untreated with chemotherapy with performance status 0, 1 or 2. Forty-seven cycles were given with a median of two cycles. One patient was not evaluable due to early death. There were no responses in the 16 patients, resulting in a 0% response rate (95% confidence interval = 0-17%). We conclude that conventional-dose melphalan by i.v. administration has no appreciable activity in patients with metastatic malignant melanoma.

The continuum-of-addiction: cigarette smoking in relation to price among Americans aged 15-29

We studied the relationship between current cigarette smoking and price among 34145 respondents, aged 15-29 years, to the 1992-1993 Tobacco Use Supplements to the Current Population Survey. The price elasticity of current smoking varied inversely with age: -0.831 (S.E. 0.402) for ages 15-17; -0.524 (S.E. 0.256) for ages 18-20; -0.370 (S.E. 0.188) for ages 21-23; -0.202 (S.E. 0.175) for ages 24-26; and -0.095 (S.E. 0.157) for ages 27-29. In response to higher prices, older youth were more likely to reduce the number of cigarettes smoked per day than to quit entirely. Among 15-17-year-olds, smoking cigarettes 'some days' was more sensitive to price than smoking 'every day'. Cigarette smoking was inversely related to the prices of premium brands, but not discount brands.

Free radical spin traps as adjuncts for the prevention and treatment of disease

Free radical spin traps exhibit properties consistent with a role in the prevention or amelioration of diseases mediated by the formation of free radical species in excess of optimum constitutive requirements. At first view, it may be surprising that they have not found a place in clinical medicine. Some studies of diseases in which free radicals and oxidative stress are aberrantly over- or underabundant and which might be ameliorated by inhibiting or augmenting their formation have been reported. A number of pathophysiologic categories in which such agents have been or might be employed are briefly summarized.

Do lipoxygenases modulate normal or aberrant lympho-hematopoiesis?

Whether 5- (and the 12- or 15-) lipoxygenases participate in normal or malignantly transformed hematopoietic cell proliferation and differentiation, or contribute to programmed or necrotic cell death has been difficult to decide. Recent evidence concerning these questions is reviewed and some reasons for these difficulties are considered.

5-Lipoxygenase inhibitors reduce PC-3 cell proliferation and initiate nonnecrotic cell death

BACKGROUND

Products of the arachidonic acid-metabolizing enzyme, 5-lipoxygenase, stimulate the growth of several cell types. Selective inhibitors of the enzyme, including SC41661A and MK886, reduce PC-3 prostate cell proliferation. With continued culture, cells die, but the mode of death, necrotic or nonnecrotic, has not been established.

METHODS

Flow cytometry, laddering after agarose electrophoresis of DNA from inhibitor-treated cells, and light and electron microscopy were employed to examine the type of death in PC-3 prostate cells cultured with either 5-lipoxygenase inhibitor.

RESULTS

The inhibitors induced nonnecrotic, programmed cell death. SC41661A-treated cells exhibited "foamy," vacuolated cytoplasm and mitochondria with disrupted cristae and limiting membranes, while some cells contained numerous polysomes and extended hypertrophic Golgi and secretory cisternal networks. A proportion of the treated cells detached and the nuclei of these cells were characteristic of type 1 "apoptotic" programmed cell death. MK886, a 5-lipoxygenase-inhibitor with a different mechanism of action, induced nonnecrotic changes largely confined to the cytoplasm, most consistent with type 2 "autophagic" programmed cell death. In preliminary studies of mechanism, we demonstrated that PC-3 cells express mRNA for 5-lipoxygenase and for 5-lipoxygenase-activating protein. The less active inhibitor, SC45662 neither reduced proliferation nor induced DNA laddering. The antioxidant, N-acetyl-l-cysteine but not butylated hydroxy toluene or alpha tocopherol, partially reduced the inhibition of proliferation from SC41661A.

CONCLUSIONS

SC41661A and MK886 inhibit PC-3 cell proliferation and induce a form of type 1 or type 2 programmed cell death, respectively. PC-3 cells contain messenger RNA for 5-lipoxygenase and 5-lipoxygenase-activating proteins. Drug-induced changes included altered redox potential, inferred from the increased survival due to the antioxidant and glutathione precursor, N-acetyl-l-cysteine. PC-3 cells are an appropriate model for studying the mechanism responsible for 5-lipoxygenase inhibitor-induced cellular suicide.

NTBN, a free radical spin trap induces programmed cell death in human pancreatic cancer (PANC-1) cells

N-tertiary butyl-a-phenylnitrone, a free radical spin trap at > or = 10 mM concentration, inhibited proliferation and reduced the viability of human pancreatic cancer (Panc-1) cells. The drug concentration determined the extent of inhibition, and with continued culture a proportion of the cells detached, most of which stained with trypan blue. Although hypodiploid cells were detected by flow cytometry of cells cultured with 20 mM NTBN, DNA laddering was absent and the TUNEL reaction negative. "Dark" cells present in samples cultured with 10 mM NTBN exhibited decreased cytoplasmic volume and increased staining with methylene blue and azure II, but lacked characteristic nuclear changes of type 1 programmed cell death. Cells cultured with > 10 mM of the spin trap exhibited nuclear and cytoplasmic changes more consistent with a non-type 1, type 2 variant of PCD with extensive cytoplasmic vacuolization. Careful analysis revealed evidence of marked pinocytosis in some cells. In view of the spin-trap associated pinocytosis, augmented uptake of chemotherapy in affected cells might be anticipated, but additive, synergistic or antagonistic interactions between NTBN and 5-fluorouracil were not observed.

Phase II study of mitoguazone, cyclophosphamide, doxorubicin, vincristine and prednisone for patients with diffuse histologic subtypes of non-Hodgkin's lymphoma: an Eastern Cooperative Oncology Group Study (PE481)

Mitoguazone, an investigational agent with significant activity in advanced lymphoma, was added to a modified CHOP regimen (COPA) in an effort to improve the activity of standard therapy in 66 previously untreated patients with stages II-IV lymphoma and diffuse histology of intermediate or high grade other than lymphoblastic in this phase II pilot study. The regimen was well tolerated and the complete response rate in diffuse large cell lymphoma was 55%. Sixty-five percent of all complete responders were in complete response for at least one year. Despite these excellent results. it is unlikely that the addition of mitoguazone improved results compared with those obtained with standard therapy alone, since similar results have been frequently reported with the latter.