From big to small: a process for developing policy-relevant research summaries

Government departments and not-for-profit agencies expend significant resources commissioning and conducting research, only to find their resulting lengthy reports shelved and unused. In this case study, we describe a project that developed short, policy-relevant research summaries of topics prioritized by the Ontario Women's Health Council, an advisory body to the province's Minister of Health and Long-Term Care. These products were created based on an understanding of policy makers' needs and work contexts and were designed to help users find, understand and utilize research evidence to inform their clinical, programmatic and policy decision-making.

Self-Collected Samples for Testing of Oncogenic Human Papillomavirus: A Systematic Review

BACKGROUND

To investigate the role of self-sampling for human papillomavirus (HPV) testing as an alternative to cervical cancer screening by clinicians (i.e., Papanicolaou [Pap] test).

METHODS

A systematic search of MEDLINE, EMBASE, Cochrane Library, and other sources for evidence related to the efficacy and feasibility of HPV DNA self-collection.

RESULTS

A total of 25 studies were identified. In 22 comparisons across 19 studies, the concordance between samples collected by patients and those obtained by clinicians was reasonably high in the majority of cases. Women in many countries across wide age ranges were successful in collecting samples for HPV DNA testing. In four studies, the quality of the cytology from patient samples was as good as clinician samples, with more than 95% of samples yielding HPV DNA results. The studies that examined acceptability found that women were generally very positive about collecting their own samples, although some concerns were noted. No study evaluated the effect of HPV DNA self-sampling on screening participation rates, early detection, survival, or quality of life.

CONCLUSIONS

Self-sampling for HPV DNA testing is a viable screening option, but there is insufficient evidence to conclude that self-sampling for HPV DNA testing is an alternative to the Pap test. Although HPV DNA testing using self-collected samples holds promise for use in under-resourced areas or for women who are reluctant to participate in Pap testing programs, the evidence supporting it is limited. Further definitive research is needed to provide a solid evidence base to inform the use of self-sampling for HPV DNA testing for the purpose of increasing screening rates, especially in women who are never or seldom screened.

Formation of compartments in the neck to facilitate suction drainage during transfer of free flaps

A method of surgical compartmentalisation of the neck is reported. This technique can be used in order to maintain suction drainage without compromising the flow of the anastomoses when an end-to-side technique in the internal jugular vein is used.

Non-malignant disease mortality in meat workers: a model for studying the role of zoonotic transmissible agents in non-malignant chronic diseases in humans

BACKGROUND

Current research efforts have mainly concentrated on evaluating the role of substances present in animal food in the aetiology of chronic diseases in humans, with relatively little attention given to evaluating the role of transmissible agents that are also present. Meat workers are exposed to a variety of transmissible agents present in food animals and their products. This study investigates mortality from non-malignant diseases in workers with these exposures.

METHODS

A cohort mortality study was conducted between 1949 and 1989, of 8520 meat workers in a union in Baltimore, Maryland, who worked in manufacturing plants where animals were killed or processed, and who had high exposures to transmissible agents. Mortality in meat workers was compared with that in a control group of 6081 workers in the same union, and also with the US general population. Risk was estimated by proportional mortality and standardised mortality ratios (SMRs) and relative SMR.

RESULTS

A clear excess of mortality from septicaemia, subarachnoid haemorrhage, chronic nephritis, acute and subacute endocarditis, functional diseases of the heart, and decreased risk of mortality from pre-cerebral, cerebral artery stenosis were observed in meat workers when compared to the control group or to the US general population.

CONCLUSIONS

The authors hypothesise that zoonotic transmissible agents present in food animals and their products may be responsible for the occurrence of some cases of circulatory, neurological and other diseases in meat workers, and possibly in the general population exposed to these agents.

Phase 1 study of CP-868,596 an oral, highly specific PDGFR inhibitor

3524

Background: CP-868,596 is an orally available, highly specific inhibitor of platelet-derived growth factor receptors (PDGFR). PDGF and its receptor play an important role in angiogenesis, modulation of tumor interstitial fluid pressure (IFP), and influence cell growth, migration, and survival through signal-transduction pathways. Methods: The safety, tolerability and pharmacokinetics (PK) of daily oral CP-868,596 administered in 4-week cycles were assessed in patients with advanced solid malignancies. Original dose escalation cohorts were 100, 200, 280 and 340 mg QD administered on an empty stomach. Prevalence of persistent Grade 1 nausea and vomiting led to amendments that include “with food” cohorts. Safety assessments included adverse events (AEs), clinical laboratories, and ECG monitoring. PK blood samples were collected after a single dose and at steady state. PK parameters were estimated by non compartmental techniques. Results: Data is available for all 59 patients enrolled in the trial [(29 M/30F); mean age (range): 58.6 (18–80)]. The most common treatment related AEs were nausea (67.8%), vomiting (55.9%) and diarrhea (25.4%). The MTD with coadministration of anti-emetics on an empty stomach was 200 mg/day. Coadministration of CP-868,596 with food resulted in a decrease of nausea and vomiting. The recommended phase 2 dose is 100 mg BID given with food. CP-868,596 was rapidly absorbed after oral administration. Median Tmax ranged from 1 to 4 hours. Cmax and AUC of CP-868,596 increased with dose more-than proportionally. Moderate accumulation occurred with a mean AUC accumulation ratio of 1.4–4.0. The mean terminal t1/2 ranged from 11.6 to 16.8 hours and was similar across all dose levels. The effect of food on PK appeared to be dose-dependent in this parallel cohort design with a limited number of patients (n=3–8). Analysis of safety data showed increasing liver enzymes with increasing PK exposures. No objective responses were seen. Conclusion: Daily administration of CP-868,596 appears to be safe and well tolerated. DLTs were: N/V (2), elevated ALT/GGT (2/2), increased Mg (1), Hematuria (1), and Insomnia (1). Mean steady state serum concentrations in all dose cohorts exceeded the preclinically predicted minimal efficacious exposure (16 ng/mL).

No significant financial relationships to disclose.

Phase I experience with an anti-glycotope monoclonal antibody, RAV12, in recurrent adenocarcinoma

14017

Background: RAV12 is a high affinity, internalizing, chimeric IgG1 monoclonal antibody (MAb) that binds RAAG12, a novel primate-restricted N-linked carbohydrate epitope present on multiple cell-surface proteins. RAAG12 is variably expressed on normal non-keratinizing epithelia, particularly those of GI origin (cytoplasm and apical membrane), and is not expressed on human tissues from the cardiovascular, endocrine, hematolymphatic, neuromuscular, and central nervous systems. IHC studies demonstrated diffuse membrane staining on > 90% of human colorectal, gastric, and pancreatic adenocarcinoma samples. RAAG12 is distinct from previously reported mucin or Lewis blood group carcinoma-associated carbohydrates. In vitro, RAV12 kills tumor cells by oncosis and facilitates ADCC. Methods: In December 2004, a phase I dose-escalation safety and pharmacokinetics (PK) trial was begun in patients with recurrent (1 to 3 prior treatments) adenocarcinoma. RAV12 was administered weekly x 4, twenty-eight patients have received treatment in the following cohorts: 0.3 mg/kg qw (6), 1.0 mg/kg qw (8), 1.5 mg/kg qw (7), 0.5 mg/kg biw (3), 0.75 mg/kg biw (2), and 0.5 mg/kg tiw (2). Sixteen patients had colorectal, 5 gastroesophageal, 4 pancreatic, 2 lung cancer, and 1 breast cancer. Responses were evaluated on day 42. Results: Preliminary analysis demonstrated dose-dependent PK. Three clinical syndromes associated with drug administration have been observed to date: 1) abdominal cramping pain (21 patients) and diarrhea (18 patients) particularly at the higher doses, 2) asymptomatic, self-limited, generally rapidly reversible excursions of liver function tests (16 patients), and 3) asymptomatic, self-limited, rapidly reversible excursions of pancreatic enzymes (6 patients). One patient (0.3 mg/kg qw), with advanced pancreatic cancer, had a > 50% reduction in CA19–9, continued treatment, and had TTP > 5 months. One patient with colorectal cancer (1.5 mg/kg qw) experienced a durable partial remission, continued treatment, and had TTP > 8 months. Conclusions: RAV12 has activity in recurrent adenocarcinoma. Side effects uncommonly have been dose limiting. The trial continues to define dose/schedule to be recommended for phase 2 testing.

No significant financial relationships to disclose.

Chemotherapy plus cyclosporine A for the treatment of intraocular retinoblastoma: The University of Miami Miller School of Medicine experience

20005

Background: In the past decade chemotherapy and focal control became the standard of care in retinoblastoma. The ideal chemotherapy regimen has not yet been determined. We analyzed the results of treatment at the University of Miami Miller School of Medicine using the regimen carboplatin (20 mg/kg, day 1), vincristine (0.05 mg. /kg, day 1), etoposide (5 mg / kg, days 1 and 2) with or without cyclosporine A (10 mg. /kg over 2 hours followed by 45 mg/kg over 31 hours) every 3–4 weeks. We attempted to maintain peak CSA levels between 2,400 and 6,000 and steady state levels between 2,400 and 4,200 ng/ml. When CSA was given, vincristine was started at 0.0125 mg /kg. The dose was escalated by 25% with each cycle of therapy, as tolerated. Methods: A retrospective analysis was performed in 41 patients diagnosed with bilateral retinoblastoma from Dec 1996 to Jan 2006. Only eyes with intraocular disease (76 eyes) were included in this analysis. Before each cycle of chemotherapy ophthalmologic examination under anesthesia was performed and active tumor and seeding were treated with local ablation using laser therapy. Eyes in which enucleation was planned at diagnosis were excluded from this analysis. Results: Most patients received 9 cycles of chemotherapy. Sixty percent (46/76) of the eyes were treated with chemotherapy and CSA. The eye salvage rate for eyes classified by the International Classification of Retinoblastoma (ICRB) as groups A, B, C and D was 100%. The eye salvage rate for the 21 eyes classified as ICRB group E was 29%. No difference in salvage rate was observed in eyes treated with or without CSA. One patient died from disease progression. Only one patient required radiation therapy to both eyes. To date there have been no reports of development of secondary malignancies. Conclusion: The addition of CSA to the treatment of the eyes classified as ICRB groups A, B, C and D made no difference in the eye salvage rate. Also, we were not able to demonstrate any benefit from the addition of CSA in patients with stage E eyes- although our sample size was quite small. Aggressive focal control and chemotherapy beginning at diagnosis may be the reason for the excellent EFS in group A, B, C and D eyes.

No significant financial relationships to disclose.

A phase Ib study to assess the safety of lexatumumab, a human monoclonal antibody that activates TRAIL-R2, in combination with gemcitabine, pemetrexed, doxorubicin or FOLFIRI

14006

Background: Lexatumumab (HGS-ETR2) is a fully-human agonistic monoclonal antibody that targets and activates the Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor 2 (TRAIL-R2). TRAIL-R2 is a member of the Tumor Necrosis Factor Receptor (TNFR) superfamily that, when activated, induces apoptosis via the extrinsic pathway. Lexatumumab shows promising anti-tumor activity in preclinical models, particularly in combination with chemotherapeutic agents. Single-agent lexatumumab was well-tolerated in phase I trials. This is the first study of the safety of a TRAIL-R2 agonist in combination with chemotherapy. Methods: Patients for whom gemcitabine, pemetrexed, doxorubicin or FOLFIRI was considered an appropriate treatment received one of the full-dose chemotherapy regimens plus lexatumumab every 2 weeks (for gemcitabine and FOLFIRI) or 3 weeks (for pemetrexed and doxorubicin). Four to 6 patients were treated with 5 mg/kg lexatumumab in each chemotherapy cohort prior to dose escalation to 10 mg/kg. Results: To date, 41 patients with a wide range of cancer types have received 164 courses of lexatumumab over the 2 dose levels. The majority (33/41) received at least 2 courses (range 1 to 19). Lexatumumab was well-tolerated; no dose reductions of lexatumumab were required. Severe adverse events considered at least possibly related to lexatumumab included anemia, fatigue and dehydration. Tumor shrinkage has been observed, including confirmed partial responses (PRs) in the FOLFIRI and doxorubicin arms. Eight patients continue on study. Conclusions: Lexatumumab can be safely administered in combination with a wide range of chemotherapeutic agents. Evaluation of the efficacy of lexatumumab in combination with chemotherapy in Phase 2 trials is warranted.

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A Phase I/II study of GTI-2040 and capecitabine in patients with renal cell carcinoma

BACKGROUND

Fluoropyrimidine based therapy has modest activity in patients with metastatic renal carcinoma and inhibition of ribonucleotide reductase is synergistic in model systems. GTI-2040 is a 20-mer phosphorothioate oligonucleotide complimentary to the R2 component of ribonucleotide reductase that has activity in renal cancer models.

METHODS

Metastatic renal carcinoma patients without prior fluoropyrimidine therapy and normal organ function were treated with oral capecitabine 880 mg/m(2) twice daily along with continuous infusion GTI-2040 starting at 148 mg/m(2)/day for 21 days, for each 28-day cycle. After completion of the phase I portion, the phase II study portion sought to rule out a null hypothesized 10% response rate versus an alternative 25% response rate utilizing alpha and beta errors of 0.05 and 0.2, respectively. GTI-2040 pharmacokinetics and effects on ribonucleotide reductase expression in peripheral mononuclear cells were evaluated in a subset of patients.

RESULTS

Based on one dose limiting toxicity in nine patients in the phase I portion, the phase II portion was conducted using the previously recommended 185 mg/m(2)/day dose of GTI-2040. Twenty-six patients were enrolled in the phase II portion to obtain 18 fully evaluable for response. Only one patient, treated at a GTI 2040 dose of 185 mg/m(2)/day in the phase I portion of the protocol, responded. Toxicities and GTI-2040 pharmacokinetics were consistent with previously reported results. R2 expression in peripheral mononuclear cells was too variable for accurate interpretation.

CONCLUSION

Further study of GTI-2040 and capecitabine in metastatic renal cancer at this dose and schedule is not indicated. Further study is necessary to determine whether lack of activity is due to inadequate target inhibition or inadequate effect of appropriate targeting.

Phase I trial of preoperative hypofractionated intensity-modulated radiotherapy with incorporated boost and oral capecitabine in locally advanced rectal cancer

PURPOSE

To determine the safety and efficacy of preoperative hypofractionated radiotherapy using intensity-modulated radiotherapy (IMRT) and an incorporated boost with concurrent capecitabine in patients with locally advanced rectal cancer.

METHODS AND MATERIALS

The eligibility criteria included adenocarcinoma of the rectum, T3-T4 and/or N1-N2 disease, performance status 0 or 1, and age > or =18 years. Photon IMRT and an incorporated boost were used to treat the whole pelvis to 45 Gy and the gross tumor volume plus 2 cm to 55 Gy in 25 treatments within 5 weeks. The study was designed to escalate the dose to the gross tumor volume in 5-Gy increments in 3-patient cohorts. Capecitabine was given orally 825 mg/m(2) twice daily for 7 days each week during RT. The primary endpoint was the maximal tolerated radiation dose, and the secondary endpoints were the pathologic response and quality of life.

RESULTS

Eight patients completed RT at the initial dose level of 55 Gy. The study was discontinued because of toxicity-six Grade 3 toxicities occurred in 3 (38%) of 8 patients. All patients went on to definitive surgical resection, and no patient had a pathologically complete response.

CONCLUSION

This regimen, using hypofractionated RT with an incorporated boost, had unacceptable toxicity despite using standard doses of capecitabine and IMRT. Additional research is needed to determine whether IMRT is able to reduce the side effects during and after pelvic RT with conventional dose fractionation.

The prevalence of marijuana smoking in young adults with sickle cell disease: a longitudinal study

BACKGROUND

The active ingredients of marijuana may have beneficial properties in the treatment of chronic pain and inflammation and is being used by sufferers of chronic pain and arthritis in some settings. Anecdotally, marijuana is believed by some sickle cell disease (SCD) patients to improve their health. This study aimed to determine the prevalence of marijuana smoking in the Jamaica Sickle Cell Cohort Study (JSCCS) in the years 2000 and 2004. The perception that marijuana use ameliorated the complications of SCD was also investigated.

METHODS

All patients in the JSCCS were invited to attend an annual review, and during the 2000 and 2004 reviews, participants with homozygous sickle cell (SS) disease and sickle cell haemoglobin-C (SC) disease were asked whether they smoked marijuana, and if they smoked, whether it was used for medicinal purposes related to SCD. The authors compared smoking prevalence by gender, disease, and year of review. The association of smoking with a measure of pain frequency was also examined.

RESULTS

The prevalence of marijuana smoking was higher among men and among SC participants. The proportion of either gender reporting smoking of marijuana increased in 2004 compared to 2000, and this use was not related to a simple measure of clinical severity of SCD.

CONCLUSIONS

Marijuana smoking is common in adults with SCD but its usage is unrelated to clinical severity of the disease.

Skin test reactivity to aeroallergens in Jamaicans: relationship to asthma

BACKGROUND

Asthma causes significant morbidity and mortality in the developing world. It is thus important to identify modifiable risk factors.

OBJECTIVES

To undertake a cross-sectional study to determine the prevalence of skin test reactivity to aeroallergens in Jamaican children and adults and the relationship of the diagnosis of asthma to the pattern of skin test positivity.

METHODS

One hundred and sixty subjects without the sickle cell gene (genotype AA), eighty adults and eighty children, were recruited. Skin testing to seven aeroallergens was undertaken (atopy being diagnosed if there were at least one positive reaction). Asthma status was determined by a questionnaire and/or medical records.

RESULTS

Twenty-seven (34%) of the children and forty-one (51%) of the adults were skin test positive to at least one aeroallergen. The most common positive responses in both age groups were to Dermatophagoides farinae, Dermatophagoides pteronyssinus and cockroach mix-(German and American). All adult asthmatics with current symptoms reacted to cockroach allergen.

CONCLUSIONS

Appropriate steps to reduce cockroaches and cockroach sensitization might positively impact on asthma morbidity in Jamaica.

Biosynthesis of 13-Desmethyl Spirolide C by the Dinoflagellate Alexandrium ostenfeldii

Biosynthetic origins of the cyclic imine toxin 13-desmethyl spirolide C were determined by supplementing cultures of the toxigenic dinoflagellate Alexandrium ostenfeldii with stable isotope-labeled precursors [1,2-13C2]acetate, [1-13C]acetate, [2-13CD3]acetate, and [1,2-13C2,15N]glycine and measuring the incorporation patterns by 13C NMR spectroscopy. Despite partial scrambling of the acetate labels, the results show that most carbons of the macrocycle are polyketide-derived and that glycine is incorporated as an intact unit into the cyclic imine moiety. This work represents the first conclusive evidence that such cyclic imine toxins are polyketides and provides support for biosynthetic pathways previously defined for other polyether dinoflagellate toxins.