The cost of treating pancreatic cancer: A pilot study

16004

Background: The treatment of pancreatic cancer (PC) is rapidly changing with the approval of new anti-cancer agents. A pilot analysis of twenty five patients treated for PC was performed to determine the cost of PC treatment. Methods: Twenty-five PC patients were selected from 1998–2004 to represent a variety of treatments, both standard and experimental. Charts were reviewed for hospitalizations, clinic visits, and medications greater than $10 in cost. Costs were determined using pharmacy and hospital billing services. Average costs per month were calculated for all 25 patients in the twelve months preceding death. Results: Mean time from diagnosis to death was 13.6 months and mean duration of treatment was 12.6 months. During the period of treatment, mean monthly anti-cancer treatment and additional pharmacotherapy costs were $3,771 and $3,196 respectively. Mean monthly cost of hospitalizations and clinic visits were $2,258 and $213. In the last twelve months of life, months -3, -5, and -2 (death = 0) were most expensive with average spending of $65,557, $58,820, $47,727 respectively. Breakdown of costs in the three most expensive months was: anti-cancer agents (82%), hospitalization (15%), additional pharmacotherapy (3.0%), and clinic visits (0.5%). Conclusions: In this pilot study, we compiled major contributors to the cost of treating PC and then focused on the twelve months preceding death. Anti-cancer agents were determined to be the largest expenditure overall, and were a greater proportion of the cost in the most expensive months before death. This remains an underestimate as surgery, radiation, and indirect costs are not included. As newer agents become incorporated into standard treatment for PC, costs are expected to rise further. This data is being used in designing a larger study comparing costs, quality of life, and survival using newer combination chemotherapy.

No significant financial relationships to disclose.

Phase I study of RX-0201 in patients with advanced or metastatic solid tumors

13102

Background: RX-0201 is a 20-mer oligonucleotide that is complementary to Akt-1 mRNA. Strong evidence exists that Akt plays a very important role in cancer progression by stimulating cell proliferation and inhibiting apoptosis. Over-expression of constitutively activated Akt in many cell types promotes cellular transformation. In addition to reducing Akt mRNA levels and inhibiting the expression of Akt protein, in vitro pharmacology studies have demonstrated that RX-0201 suppressed cell proliferation in carcinomas of the brain, breast, cervix, colon, head & neck, kidney, liver, lung, ovary, pancreas, prostate, stomach and melanoma. In vivo studies have also shown that RX-0201 significantly inhibits the growth of tumor in human prostate and brain cancer of nude mice models. This study is designed to determine the maximum tolerated RX-0201 dose in patients with advanced malignancies. Methods: Patients with solid tumors for whom no standard therapies exist, Karnofsky PS>70, adequate hepatic and renal function and normal coagulation parameters were eligible. Eligible patients were scheduled to receive 2 treatment cycles with RX-0201 via continuous infusion for 14 days with 7 days off q 21 days. Dose escalation was based on observed treatment-related toxicities. One patient was enrolled at each dose level (6 mg/m2/day - 315mg/m2/day). Tumor measurements were performed at screening and at the completion of treatment cycle 2. Tumor biopsies were obtained at screening and at the completion of treatment cycle 2 to look for inhibition of AKT in tumor cells. Plasma samples for pharmacokinetic analyses were collected. Results: To date 9 patients have been enrolled, 4 with GI malignancies, 1 with small cell lung cancer, 2 with breast cancer and 1 with locally advanced Basal Cell carcinoma. 6/9 patients were able to complete the 2 cycles.1/9 patients were taken off study because of withdrawal of consent due to grade 1 vomiting. 8 patients were taken off for disease progression. Drug related toxicities were Grade 1 and included fatigue, dizziness, cough vomiting and myalgia. Conclusions: While enrolment is still ongoing, the RX-0201 has been well tolerated upto 315mg/m2 in this previously heavily treated patient population. Once MTD is reached phase II trials will be planned. PK and PD data will be presented.

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A phase I dose escalation study of BIBW 2992, an irreversible dual EGFR/HER2 receptor tyrosine kinase inhibitor, in a 3 week on 1 week off schedule in patients with advanced solid tumors

3091

Background: BIBW 2992 is a highly potent irreversible dual EGFR /HER2 receptor tyrosine kinase inhibitor. This is the first trial performed in the United States with this compound. Methods: Patients with refractory solid tumors (historically known to express EGFR and/or HER2) with normal end-organ function and PS 0–1 were enrolled into a phase I dose-escalation clinical trial. After completion of eligibility and informed consent, BIBW 2992 was administered orally, once daily, for 21 days followed by a 7-day rest. Three patients were accrued in each cohort using a traditional dose escalation 3+3 trial design. After reaching DLT, the MTD dose group was expanded to 18 patients. PK sampling and skin biopsies were performed at baseline and day 21. Tumor biopsies in appropriate patients were obtained pre- and post-treatment in the final cohort to analyze inhibition of the EGFR pathway. Results: Forty-three patients were enrolled. Dose levels ranged from 10 to 65 mg daily. Tumor types included colon (10), breast (8), pancreas and ovarian (4), thyroid and esophageal (3), prostate and NSCLC (2), gastric, cholangiocarcinoma, basal cell, parotid, NPC, HCC, and mesothelioma (1 ). An interim PK analysis showed that BIBW 2992 exposure and peak plasma concentrations increased with increasing dose on day 1 and at steady state. Steady state was reached at day 8. Adverse events were diarrhea, skin rash, pruritus, mucositis, nausea, and vomiting. Doses were escalated to 65 mg/day, with two DLTs noted (skin rash and mucositis). The 40-mg dose was chosen as the recommended phase II dose based on acceptable toxicity when administered chronically. No objective responses have been observed; however, 15 of 35 evaluable patients (43%) experienced stable disease and have been on treatment for > 3 mos. Four patients have continued in an extension study. Two of these patients are still active and one has been taking BIBW 2992 for approximately 1 year. Conclusion: BIBW 2992 is well tolerated at 40 mg per day using a 21-day, 7-day off-treatment schedule. The adverse events observed were typical of receptor tyrosine kinases, including skin rash, pruritis, mucositis and GI disturbance.

[Table: see text]

A randomized trial of first-line irinotecan/fluoropymidine combinations with or without celecoxib in metastatic colorectal cancer (BICC-C)

3506

Background: This multicenter, randomized study assessed efficacy & safety for 3 irinotecan/fluoropyrimidines combinations in previously untreated mCRC. In a 3 × 2 factorial design, we also assessed whether celecoxib added to chemotherapy (CT) improved CT efficacy and/or reduced toxicity. Methods: Pts were randomized to: FOLFIRI - irinotecan (I) 180 mg/m2, leucovorin (LV) 400 mg/m2, 5-FU bolus 400 mg/m2, & infusional 5-FU 2400 mg/m2 over 46 hours q 2 wks; modified IFL (m-IFL) - I 125 mg/m2, LV 20 mg/m2, & bolus 5-FU 500 mg/m2 wkly × 2, q 3 wks; or CapeIri - I 250 mg/m2 day 1 & capecitabine 1000 mg/m2 po BID × 14 days, q 3 wks. Pts were also randomized to concurrent celecoxib (400 mg po BID) or placebo in a double-blind fashion. Time to progression (TTP) was the primary endpoint. Results: 430 pts were enrolled from 2/03 to 4/04, prior to an amendment that added bevacizumab to CT arms. Baseline characteristics were balanced. TTP for FOLFIRI (median = 8.2 mos) was significantly better than for either m-IFL (6.0 mos; p = 0.01) or CapeIri (5.7 mos; p = 0.01). Overall survival (OS) also favored FOLFIRI (median = 23.1 mos) compared to either m-IFL (17.6 mos; p=0.10) or CapeIri (18.8 mos; p = 0.19). Common grade ≥ 3 toxicities are listed below. CapeIri had the highest rates of nausea, vomiting, diarrhea, dehydration & hand-foot syndrome, whereas FOLFIRI had lower rates. Among all 430 pts, median TTP did not differ for pts randomized to celecoxib compared to placebo (6.9 vs 6.9 mos; p=0.71). Median OS was also similar for celecoxib vs placebo (19.5 vs 18.8 mos; p=0.63). CT toxicities did not differ for celecoxib vs placebo. Rates for MI/stroke were 1.5% for celecoxib and 1.9% for placebo. Conclusions: First-line FOLFIRI offers a superior TTP when compared to m-IFL or CapeIri; OS & toxicity analyses also favored FOLFIRI. Celecoxib neither improved CT efficacy nor reduced CT toxicity. Updated survival data & data on pts enrolled after the addition of bevacuzimab will be presented.

[Table: see text]

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An experimental study of the elastic properties of the human Bruch's membrane-choroid complex: relevance to ageing

AIM

To investigate the mechanical properties (stress-strain relation, elasticity, hysteresis, response to stress spikes and drops) of isolated human Bruch's membrane-choroid, as well as the effect of ageing and aged related macular degeneration (AMD).

METHODS

13 Bruch's membrane-choroid complexes were obtained from human donors (21-97 years). Two samples (aged 85 and 95) showed signs of AMD including large, soft drusen, choroidal neovascularisation, and/or disciform scars. Various hydrostatic pressures (stress) were applied to the choroidal surface of mid-peripheral samples mounted in a modified open Ussing chamber. Linear scans of the tissue were recorded by optical coherence tomography (OCT) and the pressure induced deformation (strain), elasticity, hysteresis, and response to pressure spikes and drops measured.

RESULTS

The elasticity of human Bruch's membrane-choroid complex decreased linearly with ageing (p<0.001) after the age of 21 with an approximate reduction of 1% per year. The decrease was not exaggerated in AMD. The recoil capacity of Bruch's membrane-choroid was not affected by ageing. The response to pressure spikes/drops was similar in age matched normal and AMD eyes. The results suggest that although the aged induced decrease in Bruch's membrane elasticity may contribute to breaks in this membrane in AMD leading to neovascularisation this is not sufficient. The presence of other factors is required for its development.

CONCLUSION

The elasticity of Bruch's membrane-choroid complex decreases with age while recoil capacity does not. The decrease was not exaggerated in AMD.

CpG-C ISS-ODN activation of blood-derived B cells from healthy and chronic immunodeficiency virus-infected macaques

Cytosine-phosphate-guanine class C (CpG-C) immunostimulatory sequence oligodeoxynucleotides (ISS-ODNs) activate human B cells and dendritic cells (DCs), properties that suggest potential use as a novel adjuvant to enhance vaccine efficacy. After demonstrating that the CpG-C ISS-ODN C274 activates macaque DCs, we examined in vitro activation of macaque B cells by C274 as a prelude to evaluation of this molecule as an adjuvant in the testing of candidate human immunodeficiency virus vaccines in the rhesus macaque-simian immunodeficiency virus (SIV) model. C274 induced macaque CD20(+) B cells to proliferate more strongly than CD40 ligand or CpG-B ISS-ODN. C274 enhanced B cell survival; increased viability was most evident after 3-7 days of culture. Increased expression of CD40, CD80, and CD86 by B cells was apparent within 24 h of exposure to C274 and persisted for up to 1 week. C274-stimulated, B cell-enriched and peripheral blood mononuclear cell suspensions from naïve and immunodeficiency virus-infected monkeys secreted several cytokines [e.g., interleukin (IL)-3, IL-6, IL-12, interferon-alpha] and chemokines [e.g., monocyte chemoattractant protein-1/CC chemokine ligand 2 (CCL2), macrophage-inflammatory protein-1alpha/CCL3, IL-8/CXC chemokine ligand 8]. In comparison, exposure of macaque B cells to SIV had minimal impact on surface phenotype, despite inducing cytokine and chemokine production in cells from infected and uninfected animals. These observations emphasize the need to identify strategies to optimally boost immune function, as immunodeficiency viruses themselves only partially activate B cells and DCs. The ability of C274 to stimulate B cells and DCs in healthy and infected monkeys suggests its possible use as a broad-acting adjuvant to be applied in the rhesus macaque model for the development of preventative and therapeutic vaccines.

Alcohol intake and ovarian cancer risk: a pooled analysis of 10 cohort studies

Alcohol has been hypothesized to promote ovarian carcinogenesis by its potential to increase circulating levels of estrogen and other hormones; through its oxidation byproduct, acetaldehyde, which may act as a cocarcinogen; and by depletion of folate and other nutrients. Case–control and cohort studies have reported conflicting results relating alcohol intake to ovarian cancer risk. We conducted a pooled analysis of the primary data from ten prospective cohort studies. The analysis included 529 638 women among whom 2001 incident epithelial ovarian cases were documented. After study-specific relative risks (RR) and 95% confidence intervals (CI) were calculated by Cox proportional hazards models, and then were pooled using a random effects model; no associations were observed for intakes of total alcohol (pooled multivariate RR=1.12, 95% CI 0.86–1.44 comparing ⩾30 to 0 g day⁻¹ of alcohol) or alcohol from wine, beer or spirits and ovarian cancer risk. The association with alcohol consumption was not modified by oral contraceptive use, hormone replacement therapy, parity, menopausal status, folate intake, body mass index, or smoking. Associations for endometrioid, mucinous, and serous ovarian cancer were similar to the overall findings. This pooled analysis does not support an association between moderate alcohol intake and ovarian cancer risk.

Predictors of success and failure in pulmonary rehabilitation

The purpose of the present study was to identify prognostic features of chronic obstructive pulmonary disease (COPD) associated with success or failure in pulmonary rehabilitation. Patients were stratified according to the Medical Research Council (MRC) dyspnoea score. A total of 74 stable COPD patients (mean+/-sd age 68+/-10 yrs), 21 MRC dyspnoea score grade 1/2, 29 grade 3/4 and 24 grade 5, with a mean forced expiratory volume in one second of 1.1+/-0.6 L, attended for rehabilitation. Assessments consisted of the following: quadriceps torque, 6-minute walking distance (6MWD), Brief Assessment Depression Cards and St George's Respiratory Questionnaire (SGRQ). Predictors of drop-out and of response (a change in SGRQ of four points or 6MWD of 54 m) were tested using binary logistic regression. In total, 51 patients completed the study. Of these, 39 (77%) showed a clinically significant benefit in either 6MWD or SGRQ. Baseline variables were poor predictors of response in each case. Significant differences were seen between MRC dyspnoea score groups for change in 6MWD and SGRQ Score. Only grade 1/2 and 3/4 patients improved. Depression was a risk factor for subject drop-out compared with nondepressed patients. Baseline state is a poor predictor of response to rehabilitation, although Medical Research Council dyspnoea score grade 5 patients showed smaller magnitudes of improvement than patients with less severe Medical Research Council dyspnoea score grades. Risk of drop-out is significantly greater in depressed compared with nondepressed patients.

A randomised, prospective study comparing selective laser trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma

AIM

To compare 90 degrees , 180 degrees , and 360 degrees selective laser trabeculoplasty (SLT, 532 nm Nd:YAG laser) with latanoprost 0.005% for the control of intraocular pressure (IOP) in ocular hypertension (OHT) and open angle glaucoma (OAG).

METHODS

A prospective, randomised clinical trial in the Department of Ophthalmology, St Thomas's Hospital, London, and Clayton Eye Centre, Wakefield, West Yorkshire. 167 patients (167 eyes) with either OHT or OAG were randomised to receive 90 degrees , 180 degrees , and 360 degrees SLT or latanoprost 0.005% at night and were evaluated at 1 hour, 1 day, 1 week and 1, 3, 6, and 12 months.

RESULTS

The mean follow up was 10.3 months (range 1--12 months). Early, transient, complications such as postoperative ocular pain, uveitis, and 1 hour IOP spike occurred in a number of eyes after SLT, with pain being reported more frequently after 360 degrees than 90 degrees treatments (p>0.001). Success rates defined in terms of both a 20% or more and a 30% or more IOP reduction from baseline measurements with no additional antiglaucomatous interventions were better with latanoprost than 90 degrees (p<0.001) and 180 degrees SLT (p<0.02) treatments. Differences in success rates between latanoprost and 360 degrees SLT did not reach statistical significance (p<0.5). Success rates were greater with 180 degrees and 360 degrees compared to 90 degrees SLT (p<0.05). With 360 degrees SLT, 82% of eyes achieved a >20% IOP reduction and 59% a >30% reduction from baseline. Although success rates were better with 360 degrees than 180 degrees SLT treatments, differences did not reach statistical significance. There were no differences with regard to age, sex, race, pretreatment IOP, OHT versus OAG, laser power settings, and total laser energy delivered between eyes which responded, in terms of a >20% and a >30% IOP reduction, and those that did not respond with 180 degrees and 360 degrees SLT treatments.

CONCLUSIONS

Success rates were higher with latanoprost 0.005% at night than with 90 degrees and 180 degrees SLT treatments. 90 degrees SLT is generally not effective. 360 degrees SLT appears to be an effective treatment with approximately 60% of eyes achieving an IOP reduction of 30% or more. Transient anterior uveitis with associated ocular discomfort is not unusual in the first few days after SLT. Late complications causing ocular morbidity after SLT were not encountered.

Sgbeta1, a novel locust (Schistocerca gregaria) non-alpha nicotinic acetylcholine receptor-like subunit with homology to the Drosophila melanogaster Dbeta1 subunit

The cloning, sequencing and functional expression of Sgbeta1, a novel locust (Schistocerca gregaria) non-alpha nicotinic acetylcholine receptor (nAChR) subunit is described. This subunit shows 80% identity with the Drosophila melanogaster Dbeta1 and 92% identity with the Locusta migratoria beta1, non-alpha subunits but only 38% identity to Sgalpha1 (also referred to as alphaL1), a previously cloned S. gregaria nAChR alpha-subunit. When expressed in Xenopus laevis oocytes, Sgbeta1 does not respond to nicotine. Responses to nicotine are observed, however, in oocytes co-expressing Sgalpha1 and Sgbeta1, but the pharmacology is indistinguishable from that of currents produced by expressing Sgalpha1 alone. We conclude that either Sgbeta1 does not co-assemble with Sgalpha1, or that it is unable to contribute to the functional properties of the receptor, in the Xenopus oocyte expression system.

Improving hospital doctors' working lives: online questionnaire survey of all grades

BACKGROUND

In 2001, the Department of Health produced the Improving Working Lives (IWL) for Doctors document. This is the first national survey which asks hospital doctors what changes are needed to improve their working lives.

METHODS

An online questionnaire was run over a period of six weeks and was open to all doctors of all grades. Doctors were asked to choose their top five factors from a list of 35 diverse choices or to provide alternatives in free text. Demographic data were also collected.

RESULTS

1603 hospital doctors working in the UK completed the online questionnaire. Improved secretarial or managerial support was the first IWL choice for consultants, with different aspects of clinical and non-clinical support representing their top four choices. Junior hospital doctors and staff and associate specialist grades (staff grades, associate specialists, and clinical assistants) identified improved support for education and training as their first choice, while among the female specialist registrars, it was improved support for childcare. Greater opportunities to develop new skills was an important issue for doctors in the surgical specialties and improved access to mentoring was important for all junior doctors, staff and associate specialist grades, and doctors from black and ethnic minority groups.

CONCLUSIONS

Hospital doctors in the UK need more support to improve their working lives. The principle needs are better secretarial and managerial support for consultants; education, training, and mentoring for junior doctors and staff and associate specialist grades; and improved opportunities to develop new skills for those in surgical specialties. Support with childcare is an important issue for female specialist registrars. The Department of Health, NHS trusts, deaneries, and Royal Colleges need to endorse policies that promote a training and working environment that will improve working lives for all hospital doctors, ensuring that appropriate and continuing support is available from the time doctors enter the new foundation programmes and proposed run-through grades, to their time spent as consultants in today's NHS.

Topical fusidic acid/betamethasone-containing gel compared to systemic therapy in the treatment of canine acute moist dermatitis

The efficacy of a topical preparation containing 0.5% fusidic acid and 0.1% betamethasone-17-valerate was compared to a systemic therapy (comprising a combination of parenteral dexamethasone and oral clavulanate-potentiated amoxycillin) in the treatment of 104 dogs with acute moist dermatitis. Significant improvement was evident after seven days in both treatment groups in all clinical parameters assessed and there was no significant difference in the overall response between the two treatment groups. Staphylococcus intermedius was the most frequently isolated organism from swabs at the first visit (Day 0). No resistance to fusidic acid or clavulanate-potentiated amoxycillin was encountered. The study demonstrates no difference in the clinical improvement achieved in canine acute moist dermatitis following topical or systemic therapy and that both treatment regimes represent effective treatment options for the condition.

Five-year follow-up of women with borderline and mildly dyskaryotic cervical smears

This study investigated the 5-year follow-up status of women with cervical smears showing borderline nuclear changes (BNC) or mild dyskaryosis and the effect of koilocytosis on the outcome. Thirteen per cent of women with cervical smears showing BNC had high-grade cervical intraepithelial neoplasia (CIN). In contrast, 28% of women with cervical smears showing mild dyskaryosis had high-grade CIN. The presence of koilocytosis (24% for borderline smears and 34% for mild dyskaryotic smears) did not appear to influence the risk of developing high-grade CIN. Our results suggest that the simultaneous implementation of the British Society for Clinical Cytology proposed terminology and the colposcopy guidelines from the British Society for Colposcopy and Cervical Pathology could have an impact on colposcopy services.

Row configuration as a tool for managing rain-fed cotton systems: review and simulation analysis

Rain-fed cotton production can be a significant proportion (average 17%) of the Australian Cotton Industry. One of the management techniques that rain-fed cotton growers have is to modify row configuration. Configurations that have entire rows missing from the sowing configuration are often referred to as ‘skip row’. Skip configurations are used to: increase the amount of soil water available for the crop, which can influence the potential lint yield; reduce the level of variability or risk associated with production; enhance fibre quality; and reduce input costs. Choosing the correct row configuration for a particular environment involves many, often complex, considerations. This paper presents an examination of how rain-fed cotton production in Australia is influenced by row configuration with different management and environmental factors. Data collated from field experiments and the cotton crop simulation model OZCOT, were used to explore the impact of agronomic decisions on potential lint yield and fibre quality and consequent economic benefit. Some key findings were: (i) soil water available at sowing did not increase the advantage of skip row relative to solid configurations; (ii) reduced row spacing (75 cm) did not alter lint yield significantly in skip row crops; (iii) skip row, rain-fed crops show reasonable plasticity in terms of optimum plant spacing within the row (simular to irrigated cotton); (iv) sowing time of rain-fed crops would appear to differ between solid and skip row arrangements; (v) skip row configurations markedly reduce the risk of price discounts due to short fibre or low micronaire and this should be carefully considered in the choice of row configuration; and (vi) skip configurations can also provide some savings in variable costs. In situations where rain-fed cotton sown in solid row configurations is subject to water stress that may affect lint yield or fibre quality, skip row configurations would be a preferential alternative to reduce risk of financial loss.

A phase I trial of a Bcl-2 antisense (G3139) and weekly docetaxel in patients with advanced breast cancer and other solid tumors

PURPOSE

Expression of the Bcl-2 protein confers resistance to various apoptotic signals. G3139 [oblimersen sodium (Genasense)] is a phosphorothioate antisense oligodeoxynucleotide that targets Bcl-2 mRNA, downregulates Bcl-2 protein translation, and enhances the antitumor effects of subtherapeutic doses of docetaxel (Taxotere).

PATIENTS AND METHODS

We performed a phase I trial to determine the maximum tolerated dose (MTD) and safety profile of combined therapy with G3139 and weekly docetaxel in patients with advanced Bcl-2-positive solid tumors. Cohorts of three to six patients were enrolled to escalating doses of G3139 and a fixed dose of weekly docetaxel using either of two schedules. In part I, G3139 was administered by continuous infusion for 21 days (D1-22), and docetaxel (35 mg/m2) was given weekly on days 8, 15 and 22. In part II, G3139 was given by continuous infusion for 5 days before the first weekly dose of docetaxel, and for 48 h before the second and third weekly docetaxel doses. For both schedules, cycles were repeated every 4 weeks.

RESULTS

Twenty-two patients were enrolled. Thirteen patients were treated on the part I schedule with doses of G3139 escalated from 1 to 4 mg/kg/day. Nine patients were on the part II schedule of shorter G3139 infusion at G3139 doses of 5-9 mg/kg/day. Hematologic toxicities were mild, except for one case of persistent grade 3 thrombocytopenia in part I. The most common adverse events were cumulative fatigue and transaminase elevation, which prevented further dose escalation beyond 4 mg/kg/day for 21 days with the part I schedule. In part II of the study, using the abbreviated G3139 schedule, even the highest daily doses were tolerated without dose-limiting toxicity or the need for dose modification. Objective tumor response was observed in two patients with breast cancer, including one whose cancer previously progressed on trastuzumab plus paclitaxel. Four patients had stable disease. Pharmacokinetic results for G3139 were similar to those of other trials.

CONCLUSIONS

G3139 in combination with standard-dose weekly docetaxel was well tolerated. The shortened and intermittent G3139 infusion had less cumulative toxicities and still allowed similar total G3139 delivery as the longer infusion. Further studies should examine the molecular effect of the regimen, as well as clinical activities in malignancies for which taxanes are indicated.

The Relationship Between a Urinary Cachectic Factor and Weight Loss in Advanced Cancer Patients

A 24K glycoprotein, the proteolysis-inducing factor (PIF), has been identified in mice and humans with cancer cachexia. Clinical cross-sectional studies found an association between the presence of PIF in urine and tumors of patients and weight loss. For the first time, we report results from a longitudinal study establishing the relationship between a urinary PIF pattern and persistent weight loss. Over time, cancer patients positive for the PIF pattern experienced weight loss, whereas those with a negative test gained weight.

Do blue light filters confer protection against age-related macular degeneration?

Age-related macular degeneration (AMD) is a major health problem in the developed world accounting for approximately half of all blind registrations. Current treatment options are unsuitable for the majority of patients and therefore the identification of modifiable risk factors that may inform disease prevention programmes is a priority. This review evaluates the long-held belief that blue light exposure has a role in the pathogenesis of AMD. Laboratory evidence has demonstrated that photochemical reactions in the oxygen-rich environment of the outer retina lead to the liberation of cytotoxic reactive oxygen species (ROS). These ROS cause oxidative stress which is known to contribute to the development of AMD. The precise chromopore that may be involved in the pathogenesis of AMD is unclear but the age pigment lipofuscin is a likely candidate. Its aerobic photoreactivity and adverse effects on antioxidant activity combined with its gradual accumulation over time suggests that its in vivo phototoxicity increases with age despite changes in the absorption characteristics of the crystalline lens. Evidence from animal studies confirms blue light's damaging potential but the results are not directly applicable to macular degeneration in humans. Studies of human macular pigment density and the risk of AMD progression following cataract surgery lend further weight to the hypothesis that blue light exposure has a role in the pathogenesis of AMD but the epidemiological evidence is equivocal. On balance the evidences suggests but does not yet confirm that blue light is a risk factor for AMD. Given the socio-economic impact of this disease and urgent need to identify modifiable risk factors, future work should include a large-scale clinical trial to evaluate the effect of blue blocking filters on AMD progression rates.

Strategies for consulting with the community: the cases of four large-scale genetic databases

Large-scale genetic databases are being developed in several countries around the world. However, these databases depend on public participation and acquiescence. In the past, information campaigns have been waged and little attention has been paid to dialogue. Nowadays, it is important to include the public in the development of scientific research and to encourage a free, open and useful dialogue among those involved. This paper is a review of community consultation strategies as part of four proposed large-scale genetic databases in Iceland, Estonia, United Kingdom and Quebec. The Iceland Health Sector Database and Estonian Genome Project have followed a "communication approach" in order to address public concerns, whereas, UK Biobank and Quebec CARTaGENE have chosen a "partnership approach" to involve the public in decision-making processes. Following a comparison of community consultation strategies, the main concerns of the public are examined as well as the challenges of involving communities. Importantly, reported across all groups is the concern for confidentiality, respect of the individual, transparency, and the donor's right to access to their own result. However, even if researchers demonstrate a willingness to respect values such as fair representation, transparency and accountability, there is still a risk that the public will mistrust researchers and simply will not participate in sufficient numbers. Complications may arise when individual and community interests conflicts. The implementation of a partnership approach is definitely involving and costly; however, if used properly, this method can improve both participation and so database development.

A phase I and pharmacokinetic study of irinotecan in patients with hepatic or renal dysfunction or with prior pelvic radiation: CALGB 9863

BACKGROUND

To ascertain if hepatic or renal dysfunction or prior pelvic radiation (XRT) leads to increased toxicity at a given dose of irinotecan and to characterize the pharmacokinetics of irinotecan and its major metabolites in patients with hepatic or renal dysfunction.

PATIENTS AND METHODS

Adults with tumors appropriate for irinotecan therapy and who had abnormal liver or renal function tests or had prior radiation to the pelvis were eligible. Patients were assigned to one of four treatment cohorts: I, aspartate aminotransferase (AST) > or = 3x upper limit of normal and direct bilirubin <1.0 mg/dl; II, direct bilirubin 1.0-7.0 mg/dl; III, creatinine 1.6-5.0 mg/dl with normal liver function; IV, prior pelvic XRT with normal liver and renal function. Starting with reduced doses of either 145 or 225 mg/m(2), irinotecan was administered every 3 weeks to at least three patients within each cohort. Irinotecan and its metabolites in the blood were measured in all patients.

RESULTS

Thirty-five patients were evaluable for toxicity. No dose-limiting toxicity was seen in cohort I, although only three patients were treated and at a dose of 225 mg/m(2). Patients with elevations of direct bilirubin had dose-limiting toxicities, even though the starting dose was 145 mg/m(2). These same patients appeared to have comparable exposure to the active metabolite SN-38 as normal patients treated with full-dose irinotecan. Patients with elevations of creatinine or with prior pelvic radiotherapy did not appear to have increased risk of toxicity at the doses explored in this study.

CONCLUSIONS

Patients with elevated bilirubin treated with irinotecan have an increased risk of toxicity and a dose reduction is recommended. Patients with elevated AST, creatinine or prior pelvic radiation do not appear to have increased sensitivity to irinotecan, but the data are not adequate to support a specific dosing recommendation.

Histopathological observations on the activity of diclazuril (Vecoxan) against the endogenous stages of Eimeria crandallis in sheep

Doses of sporulated oocysts of Eimeria crandallis were administered to 60 housed lambs aged 3-4 weeks that had been raised coccidia-free. Thirty of the lambs were medicated with diclazuril at intervals over a 20-day period post-infection with the remaining lambs serving as untreated controls. Lambs were euthanased between 5 and 22 days post-infection (dpi) and sections of the small intestine and caecum examined histologically. Untreated lambs showed loss of surface epithelial cells and villous atrophy associated with first-generation meronts, crypt destruction and crypt hyperplasia associated with pro-gamont stages. Diclazuril appeared to have a direct effect on several stages of the parasite life cycle, in particular, the large first-generation meront. Indications were that the drug also had an effect on second-generation meronts and gamont stages. Therapeutic benefits of diclazuril treatment appeared greatest when given early in the infection before damage to the intestine occurs although removal of coccidial stages did appear to reduce the pathology of the disease.

A mathematical model of factors that influence the performance of accommodative intraocular lenses

In this work a mathematical model of capsule movement during pseudophakic accommodation is described to allow identification and evaluation of factors that may explain the variation in effect of accommodative intraocular lenses (IOLs) between patients. The model assumes that increasing vitreous pressure pushes the lens capsule forward as a circular diaphragm and that this movement is from a fixed fulcrum. With an IOL in situ, the capsule is taken to have a non-uniform thickness due to the presence of the anterior capsulorhexis. The model assumes a uniform capsular elasticity and ignores contributions from cellular elements such as posterior capsule opacification. Using our model and a regression formula to calculate capsular bag size, taking into account axial length and keratometry values, we are able to predict accommodative effect in individual patients. By simple geometry we have developed a mathematical model to identify variables that are important in pseudophakic accommodation. It provides the basis for the development of a more complex model that would address the movement of a lens taking into account the influence of the zonular system during accommodation.

Hypertriglyceridaemia in Alström's syndrome: causes and associations in 37 cases

OBJECTIVE

To document frequency of severe hypertriglyceridaemia in Alström's syndrome (AS) and its relationship to hepatic and renal function, glycaemia and insulin resistance.

PATIENTS AND METHODS

Thirty-seven subjects with AS aged 5-35 years, 51% male, were assessed at multidisciplinary clinics in Canada, UK and Italy. Diagnostic criteria were: severe cone/rod dystrophy leading to severe visual impairment in early childhood, sensorineural deafness, moderate overall obesity and normal intelligence. Three patients were treated with thyroxine for primary hypothyroidism and one female patient for secondary amenorrhoea with 20 micro g ethinyloestradial combined oral contraceptive. Two male patients were receiving monthly intramuscular testosterone enanthate for secondary hypogonadism. Fasting bloods were taken for serum insulin, serum glucose, serum triglycerides, hepatic and renal function and glycosylated Hb. Triglyceride levels > 8 mmol/l and fasting serum insulin levels > 16 microunits/ml were considered to represent severe hypertriglyceridaemia and severe insulin resistance, respectively. All subjects with (23) hypertriglyceridaemia also had high insulin resistance, as measured by HOMA modelling. However, there was no significant correlation between log tyriglyceride and log serum insulin or HOMA in the whole group (P = 0.2 and 0.14, respectively). There was no clear relationship between serum triglyceride levels and age, body mass index (BMI), hepatic or renal impairment or glycaemia.

CONCLUSION

The first overview of serum triglyceride levels in a significant number of reported cases of Alström Syndrome shows an overlap between severe hypertriglyceridaemia and severe hyperinsulinism, but not a direct correlation between the two nor with insulin resistance measured by HOMA. Triglyceride levels were not related to glycaemia, hepatic or renal dysfunction.

Chronic Physical Exercise Reduces Anxiety-Like Behavior In Rats

While many individuals with anxiety disorders receive drug therapy, many do not respond or adversely respond to drugs. An alternative treatment, exercise, has been shown to relieve negative feelings and induce positive shifts in mood. The purpose of this study was to establish an animal model to specifically test the effects of chronic physical exercise on anxiety-related behaviors. Thirty-two male Sprague Dawley rats were divided into two groups: runners (R) and nonrunners (NR). Runners ran on a treadmill for 45 minutes a day, five days a week, for ten weeks at a moderate intensity. Nonrunners remained in their cages in the treadmill room during the running period and were handled for an equal amount of time. After ten weeks of training, two behavioral tests were administered including the elevated plus maze and open field tests. Results comparing R and NR showed higher responses by R in percent open arm time and center square time during the elevated plus maze test, as well as in number of entries into the center, number of rears, and lower fecal boli count during the open field test, p < 0.05. In addition, there were no differences in total activity levels between groups as indicated by similar closed arm entries in the elevated plus maze test and total lines crossed in the open field test. These results indicate that treadmill training reduces anxiety-like behaviors in two animal tests of anxiety, without a significant change in total activity levels. These data are in support of treadmill training as a model to test the anxiolytic effects of exercise.

Outcome of women with inadequate cervical smears followed up for five years

BACKGROUND

The clinical and prognostic significance of "inadequate" cervical smear is unknown, even though women with repeated inadequate smears are referred for colposcopy in the National Health Service (NHS) Cervical Screening Programme.

AIM

To follow up a cohort of women with inadequate cervical smears over the following five years to examine outcomes, including detection of high grade cervical intraepithelial neoplasia (CIN).

METHODS

The study comprised 1972 women with an inadequate cervical smear reported at Walsall Hospitals NHS Trust between 1 April 1995 and 31 March 1996. Results of cervical smears and biopsies taken over the following five years were reviewed to confirm the outcome.

FINDINGS

Within five years, 2.2% of women with an inadequate cervical smear developed histologically confirmed high grade CIN, which was higher than the 1.3% seen among all women with cervical smear tests reported at the same laboratory over the same period, although the difference was not significant at the 95% level of confidence. Where inadequacy resulted from or was contributed to by "polymorphs obscuring", the risk of subsequent development/detection of high grade CIN was 2.6%.

CONCLUSIONS

Women with inadequate cervical smears had an increased risk of detection of high grade CIN in the following five years compared with "all women". This increased risk was not significant, although if a larger number of women had been studied significance may have been reached, so that further studies are needed. The increased risk appeared to be at least partially dependent on the reason for inadequacy.

Molecular characterisation of the 22q13 deletion syndrome supports the role of haploinsufficiency of SHANK3/PROSAP2 in the major neurological symptoms

METHODS

The 22q13 deletion syndrome (MIM 606232) is characterised by moderate to profound mental retardation, delay/absence of expressive speech, hypotonia, normal to accelerated growth, and mild dysmorphic features. We have determined the deletion size and parent of origin in 56 patients with this syndrome.

RESULTS

Similar to other terminal deletion syndromes, there was an overabundance of paternal deletions. The deletions vary widely in size, from 130 kb to over 9 Mb; however all 45 cases that could be specifically tested for the terminal region at the site of SHANK3 were deleted for this gene. The molecular structure of SHANK3 was further characterised. Comparison of clinical features to deletion size showed few correlations. Some measures of developmental assessment did correlate to deletion size; however, all patients showed some degree of mental retardation and severe delay or absence of expressive speech, regardless of deletion size.

CONCLUSION

Our analysis therefore supports haploinsufficiency of the gene SHANK3, which codes for a structural protein of the postsynaptic density, as a major causative factor in the neurological symptoms of 22q13 deletion syndrome.

Screening for problem drinking in older people referred to a mental health service: a comparison of CAGE and AUDIT

The aim of the study was to evaluate the validity of the Alcohol Use Disorders Identification Test (AUDIT), the five-item version (AUDIT-5) and the CAGE as screening tests for problem drinking in mentally ill older people. The study was of prospective cross-sectional design with questionnaire survey and interview and included all consecutive referrals to an old age psychiatry service fulfilling inclusion criteria. Sensitivity, specificity and positive predictive values and areas under the receiver operating characteristic curves (AUROC) for the AUDIT, AUDIT-5, and CAGE were the primary outcome measures. Using clinical criteria as the gold standard, the AUDIT, AUDIT-5 and CAGE had AUROCs of 0.961, 0.964, and 0.780 respectively. The AUDIT-5 performed best of the three scales with a sensitivity of 75.0%, specificity of 97.2% and positive predictive value of 83.3% when using a 4/5 cut-point. The AUDIT-5 performed as well as the AUDIT and better than the CAGE in identifying problem drinking in this sample. The AUDIT-5 may be a useful addition to the specialist mental health assessment of older people.